WBR0556

Author	[[PageAuthor::Ayokunle Olubaniyi, M.B,B.S [1]]]
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Respiratory
Prompt	[[Prompt::A 17-year-old college student is brought to the ED because of shortness of breath and palpitation. The symptoms came on suddenly about one hour after she got back from the airport where she had arrived from a 6-hour flight visiting her parents. She tells you, "I can't get my breath and I'm having pains in my chest. My face is numb. I think I'm dying. Do something!" The past medical history is unremarkable, except for the oral contraceptive pills that she takes occasionally. Physical examination is normal except for tachypnea and tachycardia. Electrocardiogram shows sinus tachycardia but is otherwise normal. Arterial blood gas values while breathing room air show: PO2 – 90 mm Hg PCO2 – 42 mm Hg pH – 7.38 Which of the following is the best next step towards the management of this patient?]]
Answer A	AnswerA::Provide reassurance and explanation of the condition
Answer A Explanation	AnswerAExp::Incorrect. It is important to reassure and provide adequate information to patients with panic disorders, but this patients requires urgent attention to the arterial blood gas abnormalities.
Answer B	AnswerB::Urgent CT scan of the chest
Answer B Explanation	AnswerBExp::Incorrect. Urgent CT scan is required in cases of suspected pulmonary embolism. This is not done for patients with panic disorders.
Answer C	AnswerC::Correct. Oxygen administration by face mask and monitor with pulse oximeter
Answer C Explanation	AnswerCExp::Oxygen should be urgently administered to correct this patient’s arterial blood gas abnormalities.
Answer D	AnswerD::Intravenous beta-blockers
Answer D Explanation	AnswerDExp::Incorrect. This is not required in the management of this patient.
Answer E	AnswerE::Advice her to discontinue taking the OCP and refer to a psychiatrist
Answer E Explanation	AnswerEExp::Incorrect. Alternative birth control methods should be sought and the patient should be referred to a psychiatrist, but this should be after supportive therapies have been implemented
Right Answer	RightAnswer::C
Explanation	[[Explanation::The patient in this vignette is experiencing symptoms of panic disorder. Panic disorder is defined as the experience of spontaneous and unpredictable panic attacks. Panic attacks are periods of intense fear with the presence of 4 out of 13 defined symptoms appearing suddenly and reaching a peak within 10 minutes from the onset of the symptoms. The symptoms are: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sense of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint De-realization or depersonalization (feeling detached from oneself) Fear of losing control or going crazy Fear of dying Numbness or tingling sensations Chills or hot flashes There have been a few reported cases suggesting a casual association between panic attacks and intake of oral contraceptive pills. Initial management should be tapered around supportive measures – oxygen therapy, monitor oxygen saturation, lay in the supine position, analgesia , antiemetics. Acute attacks may require intravenous beta blockers or intravenous benzodiazepine consideration. The long term therapy of panic disorder involves referral to a psychiatrist, cognitive behavioral therapy (CBT) and with the use of SSRIs e.g., paroxetine. The next step in the management of this patient is administration of oxygen to correct the arterial blood gas abnormality. Educational Objective: Panic attacks occur suddenly or triggered by some factors. The first line therapy is SSRIs, but in a patient with arterial blood gas abnormalities, supportive therapy precedes administration of drugs e.g., administration of oxygen. Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Panic disorder, WBRKeyword::respiratory acidosis
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::