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Psychosocial Disorders

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A 31-year-old woman presents to the emergency department (ED) 20 minutes after the sudden onset of chest pain, palpitations, and shortness of breath. She also reports numbness of her mouth, fingers, and toes. She also feels like she has a lump in her throat. Her medical history includes multiple visits to the ED over a period of 6 months with a similar presentation. Her only medication is an oral contraceptive. She occasionally drinks a glass of wine after a busy day of work or when she feels stressed. She tells you that her mom takes medication for anxiety. Her blood pressure (BP) is 125/75 mm Hg, heart rate (HR) 88 beats/minute, and oxygen saturation is 99% on room air. An electrocardiogram (ECG) shows a sinus rhythm. Her symptoms resolve while in the ED. Which of the following is the most likely diagnosis?

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a. Paroxysmal atrial tachycardia

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b. Hyperthyroidism

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c. Major depressive disorder

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d. Panic disorder

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e. Posttraumatic stress disorder

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The answer is d. A person with panic attacks will often present to multiple EDs and be discharged after a workup is normal. A panic attack is a discrete period of intense fear or discomfort in which four or more of the following symptoms develop acutely and peak within 10 minutes: accelerated HR, palpitations, pounding heart, diaphoresis, trembling or shaking, sensation of shortness of breath or a choking feeling, chest pain, nausea, dizziness, light-headedness, paresthesias, fear of dying, chills, or hot flushes.

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Paroxysmal atrial tachycardia (a) is a conduction defect of the heart characterized by random episodes of tachycardia. This disorder is seen on an ECG and her ECG is normal. Hyperthyroidism (b) can mimic a panic attack, but there is usually greater autonomic hyperactivity. In addition, thyroid hormone levels are increased. There are no symptoms of depression (c) described in the patient's presentation. Nonetheless, panic attacks can occur with major depressive disorder. The diagnosis of posttraumatic stress disorder (e) cannot be made with the patient's history.

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A 23-year-old woman is brought to the ED for vision loss in her left eye that began shortly after waking up in the morning. She states that she is very depressed since her father was diagnosed with terminal cancer. She was supposed to visit her father on the day of presentation in the hospital but is now in your ED because of her vision loss. Your physical examination is unremarkable. An evaluation by the ophthalmologist is also normal. A computed tomographic (CT) scan of her head is normal. Which of the following is the most likely diagnosis?

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a. Somatization ...

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