CCS Interactive Case 13

Question 1

25 y/o M, no PMHx, presents to ED w/palpitations, chest tightness, shortness of breath, sweating, nausea, anxiety, fear of dying that began abruptly 30 minutes ago while at work. Afebrile, HDS w/borderline tachycardia.

First step?

Answer 1

Emergency orders to r/o potentially life-threatening conditions (cardiac arrhythmia, CAD, PE, asthma, hyperthyroidism, hypoglycemia, drug intoxocation or withdrawal)

Pulse ox
O2 therapy
IV access
EKG
Cardiac monitor
Glucose level

Question 2

EKG shows sinus tachycardia

Exam steps?

Answer 2

Focused - general, HEENT/neck, heart, lungs, abdomen, extremities

Question 3

Anxious, diaphoretic, tachycardic young man, otherwise normal

Next steps?

Answer 3

CBC
BMP
TSH
CXR
UA
UTox

Question 4

Management of panic attack?

Answer 4

Benzodiazepines (SL, PO, IV)
Reassurance
Slow breathing
Send home when improved
Office f/u and patient education

Question 5

Long-term management of panic disorder?

Answer 5

CBT

SSRIs

Question 6

Sequence

Answer 6

Order: pulse ox, O2, IV access, cardiac monitor, 12 lead EKG, glucometer glucose (all stat)
Exam: focused (general, HEENT/neck, chest/lung, CV, abdominal, extremities/spine)
Clock: advance to obtain EKG results, note normal O2 saturation, ECG shows tachycardia, no ST-T wave abnormality
Order: CBC, BMP, CXR, TSH, UA, UTox, Troponin
Alprazolam, sublingual x1 (again, all stat)
ClocK: advance clock to obtain results except for TSH. Patient has improved. Order interval follow-up, psychological, and general/CV/lung exam
Order: cancel pulse ox, O2, cardiac monitor. Reassurance. Counseling - patient counseling, no caffeine, no nicotine, no alcohol
Location: home
Clock: schedule appointment in 2 weeks
Case ends
Final orders: none
Dx: acute episode of panic attack