Panic Disorder  notes taken from Tintinalli ,  Rosen
In service notes                        J.Ferrara M.D.
http://members.tripod.com/~uncljoedoc/index.html

        diagnosis by exclusion - this is a special term referring
                to a diagnosis which can not be made until other
                more serious diagnoses are certainly ruled out.

        index of suspicion - a measure of ones vigilance for a  
                particular condition which is serious but often
                difficult to find. For example in Groton we 
                have a high index of suspicion for Lyme Disease
                if we see a child with joint swelling and rash;
                and in a middle aged or older hypertensive with
                back or flank pain one should maintain a high
                index of suspicion of abdominal aortic aneurysm.

        examples of diagnosis by exclusion
                globus hystericus-hysterical pain and dysphagia can
                occur but first must firmly rule out a ruptured
                esophagus or obstruction of esophagus by foreign
                body, stricture or tumor.

                back sprain- lower back pain is common and often 
                benign however it is a diagnosis by exclusion in the
                middle aged or elderly patient who may actually have
                a renal colic or enlarging abdominal aortic aneurysm.
                
                anxiety or panic attacks may present as chest pain and
                diaphoresis. However these diagnoses must await exclusion 
                of other more serious conditions such as acute myocardial
                infarction or pneumonia.

        anxiety disorders -        
                - a mental disorder with physical signs and symptoms
                - marked apprehension fear and excessive worry
                - somatization : the formation of signs and symptoms
                  experienced by a patient due soley to a mental disorder
                - anxiety may also be associated with pre-existing medical
                  conditions, depressions, neurologic syndromes, psychoses
                  and so must be thought of as a diagnosis by exlusion. 
                  
        panic disorder
                - one of the anxiety disorders
                - patient has epidodes of severe anxiety with no underlying
                  medical or more serious psychiatric disorder      
                - panic disorder interferes with work and activities of  
                  daily living and may be associated with a phobia such as      
                  a fear of heights, enclosed spaces, or wide open spaces.
                - one must assess the presence of domestic violence or
                  sexual abuse in this case
                - may occasion          palpitations
                                        dyspnea 
                                        chest pain
                                        diaphoresis
                                        dread or other psychological states

                - there are firm criteria for the diagnosis in addition
                  to it being a diagnosis of exclusion. These criteria
                  involve the number and quality of the attacks.




                panic disorder as other forms of anxiety may present 
                with chest pain, diaphoresis, feeling of dread, difficulty
                breathing, difficulty swallowing. As such panic disorder
                must be thought of as a diagnosis by exclusion. In the
                emergency setting it is necessary to protect the patient
                from the effects of agitation and at the same time work
                rapidly to rule out other immediately life threatening 
                conditions such as:

        1 cardiovascular - angina, mi, syncope...
        2 dietary - vitamin deficiency states, caffeinism...
        3 drug related - cocaine, dig and anticholinergic toxicity...
        4 hematologic - anemia
        5 immunologic - anaphylaxis 
        6 metabolic - hypoglycemia, hyperthyroid...  
        7 neurologic - seizure, encephalitis...
        8 respiratory - asthma, pneumothorax
        9 secreting tumors - pheochromocytoma produces epinephrine...

        Treatment of Panic Disorder
                In the emergency setting maintain a high index of
        suspicion. As mentioned above, carefully rule out 
        other more life threatening diagnoses by means of history 
        taking, cbc and chemistries, urine and serum toxicologies, chest
        xray and ekg.
                Maintain a high index of suspicion for other more serious
        conditions.
                Reassure the patient and prevent hyperventilation
        syndrome by instructing the patient to breath slowly and nasally
        using th abdominal muscles if possible.
                Drugs such as Valium(diazepam) and Ativan (lorazepam)
        and Xanax (alprazolam), the benzodiazepines, are anxiolytic; that
        is they are useful medications in the treatment of anxiety.
                Psychotherapy also plays a role.


        In an ICU setting a post operative patient was to be extubated.
        The physician noted a tachycardia. He was told to extubate the 
        patient since the patient was simply anxious. Instead a chest xray  
        was obtained revealing a tension pneumothorax. A chest tube was 
        inserted and the patient was then extubated.

        This interesting and actual case description demonstrates the 
        clinical usefulness of thinking of anxiety disorders as a
        diagnosis by exclusion.