Panic Attack Differential Diagnosis: Clinical Case Study

Differential Diagnoses Overview

Chief Complaint: "I am scared. I feel like I can't catch my breath and my chest hurts."

There are a number of differential diagnoses for these presenting symptoms. The major ones are explored below.

Myocardial Infarction (MI), Angina, and Acute Coronary Syndrome

History: Prodromal symptoms include fatigue, chest discomfort, or malaise in the days before the MI. A typical STEMI may occur without warning. Onset is not directly associated with severe exertion but may be concomitant with exertion. Other symptoms include anxiety, light-headedness with or without syncope, nausea or indigestion, cough, diaphoresis, and/or wheezing.

Physical Exam: Physical symptoms can be variable. The typical chest pain of an acute myocardial infarction is intense and continuous for 30–60 minutes, retrosternal, and may radiate to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm. It may be described as burning, squeezing, aching, or sharp. Sometimes the main symptom is epigastric with indigestion. Hypertension or hypotension may be present depending on the focus of the MI. Acute valvular dysfunction may be present. Other symptoms such as confusion, anxiety, a sense of impending doom, profound restlessness, diaphoresis, weakness, presyncope, hiccupping (which reflects irritation of the diaphragm or phrenic nerve), vomiting, and palpitations may also be present. Atypical presentations may include abdominal discomfort, jaw pain, altered mental status (more common in elderly patients), or atypical chest pain. Nearly half of MIs are clinically silent, as they are not associated with the symptoms described above and may go unrecognized.

Diagnostic Testing: Blood pressure monitoring, ECG/EKG, cardiac imaging, cardiac catheterization, coronary artery calcium scoring, cardiac biomarkers/enzymes, troponin levels, creatine kinase levels, myoglobin levels, kidney function and electrolyte levels, and medication review.

Atrial Fibrillation (AF)

History: Clinical presentation can be variable, ranging from asymptomatic atrial fibrillation with rapid ventricular response to cardiogenic shock or cerebrovascular accident (CVA). The majority of AF episodes are asymptomatic. Three patterns of AF are recognized: paroxysmal AF, which terminates spontaneously within seven days (with most episodes lasting less than 24 hours); persistent AF, which lasts more than seven days and often requires pharmacologic or electrical intervention; and permanent AF, which has persisted for greater than one year.

Physical Exam: An AF diagnosis is based on the physical finding of an irregular heart rhythm.

Diagnostic Testing: A 12-lead ECG is appropriate.

Atrial Flutter

History: Palpitations, a "fluttering" sensation in the chest, shortness of breath, anxiety, and general weakness.

Physical Exam: Typically a macro-reentrant arrhythmia with atrial rates between 240 and 400 beats per minute.

Diagnostic Testing: ECG.

Mitral Valve Prolapse (MVP)

History: Symptomatic MVP is divided into three categories: symptoms related to autonomic dysfunction; symptoms related to the progression of mitral regurgitation; and symptoms that occur as a consequence of another complication such as CVA. Symptoms related to autonomic dysfunction (usually congenital) include anxiety, panic attacks, fatigue, arrhythmia, atypical chest pain, orthostasis, syncope, and/or neuropsychiatric symptoms.

Physical Exam: The classic auscultatory finding in MVP is a mid-to-late systolic click and/or murmur.

Diagnostic Testing: Physical examination and echocardiography.

Acute Respiratory Distress Syndrome (ARDS)

History: Characterized by the development of acute hypoxemia and dyspnea, typically 12–48 hours following a precipitating event (though it may occur even later). Triggering events include trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. The event may be obvious or difficult to identify depending on the case.

Physical Exam: Often presents with nonspecific symptoms such as tachypnea, tachycardia, and the need for a high fraction of inspired oxygen (FiO2) to maintain oxygen saturation. The patient may be febrile or hypothermic. Examination of the lungs may reveal bilateral rales. If ARDS occurs as a result of sepsis, there may be hypotension and peripheral vasoconstriction with cold extremities and possible cyanosis of the lips and nail beds. If sepsis is not readily apparent, attention should be paid to signs of lung consolidation or findings consistent with an acute abdomen. Any recent wounds, drain sites, and decubitus ulcers should be examined for infection. Subcutaneous air, a manifestation of infection or barotrauma, should also be noted.

Diagnostic Testing: ARDS is a clinical diagnosis; an acute onset of symptoms is noted along with chest radiograph, hemodynamic monitoring, and/or bronchoscopy.

Pulmonary Embolism (PE)

History: The classic presentation is sudden onset of pleuritic chest pain, shortness of breath, and hypoxia. However, many patients do not display these symptoms; people who have died from pulmonary embolism have often complained of nagging symptoms for weeks before death.

Physical Exam: Nonspecific clinical signs and symptoms. Sometimes dyspnea, tachypnea, or chest pain are present.

Diagnostic Testing: Can be extensive. Pulse oximetry with mild exertion (such as walking) will typically identify suspect cases.

Hyperthyroidism

History: Anxiety, increased perspiration, heat intolerance, hyperactivity, tremor, palpitations, unexplained weight loss, and oligomenorrhea.

Physical Exam: Hyperactivity; atrial arrhythmia or tachycardia; systolic hypertension; warm, moist, smooth skin; lid lag; tremor; and sometimes muscle weakness.

Diagnostic Testing: TSH and thyroid hormone levels; scintigraphy if needed.

Diabetes

History: Polydipsia, polyuria, and polyphagia, along with lassitude, nausea, and blurred vision.

Physical Exam: Polyuria and associated complaints of nocturnal enuresis, thirst, weakness or fatigue, muscle cramps, and blurred vision.

Diagnostic Testing: Plasma glucose levels, hemoglobin A1c, fructosamine levels, and WBC.

Seizure Disorder (Epilepsy)

History: Recurrent blackouts, staring episodes, frequent lapses of concentration, and missed periods of time.

Physical Exam: Information gathered from the patient concerning auras, preservation of consciousness, and postictal states.

Diagnostic Testing: Two imaging studies are required: a neuroimaging evaluation (MRI or CT) and an EEG.

Drug or Alcohol Intoxication or Withdrawal; Caffeine Intoxication; Medication Side Effects

History: Repeated or intermittent use of drugs or alcohol to cope with or escape from stress.

Physical Exam: Slurring of words, balance difficulties, hyper- or hypoactivity, over- or underarousal, drowsiness, autonomic signs, and nausea.

Diagnostic Testing: Urinalysis and chemistry panel analysis. Cardiac markers, measurement of prothrombin time, or toxicology screening may be indicated.

Psychiatric Disorders

History: The history will depend on the specific disorder in question. Panic attacks are associated with a number of psychiatric disorders, including panic disorder, obsessive-compulsive disorder, schizophrenia, bipolar disorder, major depressive disorder, posttraumatic stress disorder, phobic disorders, and somatization disorder.

Physical Exam: Interview with the patient. Look for signs of psychosis (loose associations, delusions, or hallucinations), mania (pressured speech, hyperactivity), and depression (decreased affect, amotivation, slowed responses).

Diagnostic Testing: Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I).

History of Present Illness

The patient is a 19-year-old Caucasian female who presents to the university health center with the chief complaint: "I am scared. I feel like I can't catch my breath and I have chest pain." She states that she began feeling nervous approximately 10–15 minutes ago. Her pulse then started racing and she experienced moderate chest pain (6/10 on the pain scale), followed by shortness of breath. She stated she "felt like she couldn't get air in or out, she started having chest pain and her heart felt as though it was going to jump out of her chest." She stated that she felt as though she was "going to lose control."

Prior to "feeling a little nervous," she had been sitting in the library studying for her chemical engineering final examination scheduled for the following morning. She stated she has never had any breathing difficulties or chest pain in the past. She noted that "her heart does race right before she starts her exams" but that it has "not stopped her from taking exams and usually resolves after she answers a few questions." She admits to "feeling a sense of doom."

While sitting in the waiting room, another student advised her to breathe in through her nose and out through her mouth slowly. She reports that after doing so for approximately two minutes, she experienced some relief of her symptoms and was able to breathe normally. She still feels a little faint and scared, with mild residual chest pain (3/10). She denies tingling or numbness of the hands and fingers, visual disturbances, diaphoresis, trembling, nausea, vomiting, abdominal pain, and pain radiating to the jaw or down the left arm. She denies smoking, drug use, and caffeine use. She has no history of hypertension, MI, hyperlipidemia, asthma, bronchitis, pneumonia, pulmonary emboli, obesity, poor physical conditioning, pneumothorax, foreign body aspiration, or phobias. She denies experiencing symptoms like these before. She admits to having obsessive-compulsive tendencies.

Past Medical History and Social History

Past Medical History

Allergies: No known drug allergies (NKDA).

Medications (Prescription): Lo/Ovral, one tablet orally once daily.

Medications (OTC): Tylenol Extra Strength, two tablets orally every 4–6 hours as needed for headache. Systane lubricant eye drops, one or two drops in each eye as needed for dryness.

Vitamins/Herbs/Supplements: One-A-Day multivitamin, one capsule daily.

Last Exams: Primary care/family physician (6/7/12) for routine gynecological checkup and birth control prescription — normal exam, current LMP. Optometrist (5/25/12) — normal exam, no need for glasses. Dentist — approximately six months ago for routine cleaning, no cavities; due to return next month. Psychologist (PhD) — seen as needed to follow up on management of obsessive-compulsive tendencies. Dermatologist — every six months for mole check; last visit approximately three months ago, normal.

Childhood Illnesses: Denies measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, and scarlet fever. Hospitalizations for acute bronchitis at age 5 and appendectomy at age 14.

Surgical History: Appendectomy (2005) with no complications; three impacted wisdom teeth extracted (2006) with no complications; LASIK surgery bilaterally (2007) with no complications except for the onset of dry eye syndrome.

Psychiatric History: Admits to obsessive-compulsive tendencies but has not been formally diagnosed with obsessive-compulsive disorder (OCD).

Vaccinations: Tetanus (2006); declines both flu and pneumococcal vaccines. All required and recommended childhood immunizations completed on schedule per records. Gardasil, meningococcal, hepatitis B series, and varicella vaccines completed. Two-step PPD was negative upon university admission.

Family History

Father — 50 years old; history of hypertension. Paternal grandfather — 72 years old; history of hypertension and diabetes. Paternal grandmother — 70 years old; history of uterine cancer and hypertension. Mother — 48 years old; history of spinal surgery at L5-S1 and hypertension. Maternal grandfather — deceased at 68; malignant melanoma. Maternal grandmother — 68 years old; major depressive disorder and hypertension. One sister — 17 years old; no known medical problems. One brother — 16 years old; asthma and ADHD.

Social History

The patient lives on campus in a suite with three other women. During the summer she lives on campus and works in a genetic research laboratory. She has a wide social network and strong parental support. She participates on the track team and volunteers in a tutoring program at a local church. She is currently sexually active with one male partner of two years. She does not consume alcohol. She denies any use of tobacco products. She limits caffeine intake to one 8-ounce caffeinated beverage per day.

Exercise History

The patient has participated on both high school and collegiate track teams. She runs approximately four miles per day, three days per week, and has done so for approximately six years. She uses the weight room two days per week and has done so for approximately two years.

Nutrition

The patient follows a healthy, low-fat diet. A 24-hour dietary recall includes: breakfast — low-fat French toast with strawberries and sliced almonds, skim milk; morning snack — two cups air-popped popcorn with a small sprinkle of Parmesan cheese and ten dry-roasted pecan halves, water; lunch — tuna salad on spinach with diced apple and low-calorie mayonnaise, water; afternoon snack — 100-calorie ice cream bar, water; dinner — veggie burger with portobello mushroom, tomato, and onion on multigrain flatbread, water.

Height: 5'8"   Weight: 132 lbs   BMI: 19.8