Snapshot A 30-year-old man arrives at the ED stating in distress that he believes that he had a heart attack. He says the episode started suddenly and was associated with sweating, chest pain, palpitations, and shallow breathing. Troponins within normal limits and ECG shows sinus tachycardia with no remarkable findings. Upon further questioning, he reports that he has been having such episodes every few days. He denies recreational or illicit drug use. He further shares that he is recently divorced and has had no social support. Recent lab results have been normal, including TSH and vitamin B12. The patient is reassured that he does not have a heart attack and is discharged with recommendations to follow up with the hospital primary care clinic in 1 week. Introduction Overview panic disorder is characterized by recurrent panic attacks associated with > 1 month of subsequent persistent worry about having another panic attack or behavioral changes related to the attack Epidemiology prevalence 2-6% of adults in the US demographics women are 2-3 times more likely to have panic disorder most commonly develops between 18-45 years of age risk factors asthma linked to a 4.5 ↑ in risk of developing panic disorder Pathophysiology panic disorder is a psychiatric disorder that may be caused by neurochemical dysfunction symptoms arise from sympathetic overdrive Genetics study of panic disorder in first-degree relatives revealed heredity of ~43% Associated conditions major depression and anxiety schizophrenia obsessive-compulsive disorder phobias (i.e., agoraphobia) cluster C personality disorders Prognosis long-term prognosis is good with ~65% of patients achieving remission within 6 months negative prognostic variables low socioeconomic status severe illness at time of initial assessment high interpersonal sensitivity Presentation Symptoms 4 or more panic attacks in a 4-week period, or ≥ 1 panic attacks followed by at least 1 month of fear of another panic attack panic attack symptoms may include: intense fear of dying and discomfort sympathetic overdrive sweating palpitations abdominal distress/nausea hyperventilation paresthesias light-headedness chest pain chills choking disconnectedness/loss of reality shaking panic attack symptoms have no precipitating stimulus and often peak within 10 minutes and last 20-30 minutes from onset panic attacks may be triggered by injury, illness, interpersonal conflict or loss, cannabis use, or stimulants (i.e., caffeine or decongestants) Physical exam anxious mood nonspecific signs of ↑ sympathetic state hypertension tachycardia mild tachypnea mild tremors cool and clammy skin Studies ECG rule out ischemia, infarction, or pericarditis in patients with chest pain TSH, T3, and T4 rule out hyperthyroidism Urine toxicology screen screen for amphetamines, cannabis, cocaine, and phencyclidine in patients suspected of intoxication from substance use Differential Acute coronary syndrome key distinguishing factor ECG changes i.e., ST elevation, Q waves, and T-wave inversion Asthma key distinguishing factor wheezing on physical examination Hyperthyroidism key distinguishing factor ↑ levels of thyroid hormones Treatment Lifestyle psychotherapy cognitive-behavioral therapy (CBT) treatment of choice consider for all patients Medical benzodiazepines (i.e., alprazolam or clonazepam) indications providing a few doses for emergency or for urgent/as-needed use may ↑ patient confidence avoid in patients with known history of substance use disorder or alcoholism selective serotonin reuptake inhibitors (i.e., escitalopram or sertraline) indications longer-term pharmacological management Complications Noncompliance or adverse medication effects ↑ 4-fold in patients with panic disorder treatment expectations and concerns should be discussed with the patient
QUESTIONS 1 of 3 1 2 3 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.PY.16.50) A 26-year-old female with no significant past medical history presents to the emergency department complaining of chest pain. She states that she was visiting her boyfriend in the hospital and, approximately 10 minutes ago, she developed chest pain associated with sweating, palpitations, nausea, and chills. She appears very nervous and states that she is scared that she is dying. Vital signs reveal tachycardia, hypertension, and tachypnea. An EKG is obtained that is unremarkable besides tachycardia. TSH and free T4 are within normal limits. A urine drug screen is obtained and it is negative. What is the best immediate treatment for this patient? Review Topic | Tested Concept QID: 103341 Type & Select Correct Answer 1 Morphine, oxygen, nitrogylcerin, aspirin, beta blockers, ACE inhibitor, and heparin 0% (0/8) 2 Alprazolam, reassurance, encouraging patient to slow breathing 100% (8/8) 3 Albuterol breathing treatment 0% (0/8) 4 SSRI therapy 0% (0/8) 5 Cognitive behavioral therapy 0% (0/8) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2
All Videos (1) Podcasts (0) Login to View Community Videos Login to View Community Videos Panic Disorder Thomas Heineman Psychiatry - Panic Attack / Panic Disorder 11/9/2012 50 views (0)