Panic attack Flashcards
HPC
Explore symptoms and when getting them?
How long do the panic attacks last?
Anxious all the time or only sometimes?
Symptoms to ask about:
- Sweating
- Tremor
- Dry mouth
- Palpitations
- Chest pain
- SOB
- Nausea
Stress in life atm?
Screen for depression - felt low, depressed or hopeless recently
RISK ASSESS
Questions to rule out organic causes or other serious problems
Any heat intolerance, weight loss or oligomenorrhoea (hyperthyroid?)
If getting chest pain, is this crushing chest pain or worse on doing exercise? (ACS, or stable angina)
Do you get flashbacks to traumatic events of the past? (PTSD)?
Do you get repetitive thoughts which you can’t resist acting on? (OCD)
Are the panic attacks only in response to certain situations? (Phobic disorder, agoraphobia, social anxiety)
PMH
Any thyroid problems?
Or problems with your heart such as angina or arrhythmias?
Anything else?
DH
Any regular medications?
Allergies
New meds?
FH
Any problems with anxiety in your family?
Any mental health problems in your family?
Anything else?
SH
Smoking, alcohol.
Job
Support network
SN and FU
If symptoms get worse come back to the GP
Severe central crushing chest pain - go to A&E or dial 999
FU in a month (or sooner if starting medications)
Investigations and examination
BP, HR, RR, assess for tremor and examine thyroid
Symptom diary - may help to identify any triggers
ECG, FBC, TFT (if suspect other pathology)
Patient filled questionnaires:
- GAD-7 for GAD
- Trauma-screening questionnaire (TSQ)
- Yale-Brown OCD scale
Explaining panic attacks
Very common
Symptoms are related to fight or flight response - body thinks you are in danger
Treatment of Panic attack
- NHS website for information on panic attacks/leaflet
- Online support groups
- Relaxation techniques - e.g. mindfulness or yoga
- Regular outdoor exercise
- Sleep hygiene
- Avoid caffeine
- During an attack, breathe slowly, remind yourself it will pass
- OTC can buy rescue spray to help with anxiety
- Can self-refer for online or community CBT
- In the future if these measures don’t work we can prescribe an SSRI or a beta blocker - if recurrent panic attacks
Treatment of GAD, Phobic disorders, PTSD, OCD,
Similar but may need sooner CBT, SSRI, (Propranolol for GAD),
PTSD over 4 weeks refer to specialist mental health service- for trauma focused CBT, and/or eye movement desensitization and reprocessing. May start mirtazapine (NaSSA)
Treatment of cardiogenic causes
ACS -
- Examine BP, Pulse, heart sounds , ECG if it doesn’t delay immediate transfer to hospital
Stable angina:
- ECG and bloods (lipids, FBC, glucose)
- Lifestyle modification
- GTN spray
- Aspirin
- Safety net
AF:
- ECG
- CHADSVASC assessment to assess risk of stroke
- Consider bloods (FBC, U+E, TFT) and CXR to investigate cause
- Anticoagulation treatment
- Rate control for most e.g. BB or rate limiting calcium channel blocker (e.g. verapamil)
- Refer for rhythm control (electrical or pharmacological cardioversion) if < 48hrs from onset, haemodynamic compromise, symptomatic, HF or who has a reversible cause (eg chest infection)
Treatment of Hyperthyroidism
Bloods - TSH (would be low), T4 (high)
Refer to endocrinology
In the meantime, consider a BB (eg propranolol) to counter adrenergic Sx.
