Examkin

Question

Difficulty: HardAnxiety, OCD, and Trauma-Related Disorders

Paramedics bring a 30-year-old primigravid woman at 32 weeks gestation to the emergency department. She called 911 reporting sudden, overwhelming chest tightness, diaphoresis, and a sensation of smothering. Upon arrival in the ED, the patient is tremulous and states, "I thought I was having a heart attack and going to die." She reports the symptoms began while she was watching television and peaked within five minutes. She admits to having three similar episodes over the past four weeks. Consequently, she has stopped driving and refuses to go to the supermarket out of fear that a similar event might occur in public.

Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, heart rate is 118/min, and respiratory rate is 26/min. Pulse oximetry is 99% on room air. Lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rhythm with a grade 2/6 early systolic murmur at the left upper sternal border. No lower extremity edema is present. An electrocardiogram demonstrates sinus tachycardia. Arterial blood gas on room air shows a pH of 7.50, pCO2pCO_2 of 27 mm Hg, and pO2pO_2 of 104 mm Hg. A plasma D-dimer level is 0.7 mg/L (normal non-pregnant ≤\leq 0.5 mg/L).

Which of the following is the most appropriate next step in management?

  1. Reassurance and referral for cognitive-behavioral therapyAnswer
  2. B
    Computed tomography pulmonary angiography
  3. C
    Intravenous furosemide administration
  4. D
    Intravenous sodium bicarbonate administration
  5. E
    Involuntary psychiatric admission for fetal protection

Answer

Reassurance and referral for cognitive-behavioral therapy
This patient's recurrent, unexpected episodes of intense fear, cardiopulmonary symptoms (palpitations, shortness of breath, chest tightness) peaking within minutes, and subsequent behavioral changes (avoidance of driving and public places) are highly characteristic of Panic Disorder with Agoraphobia. Her physical examination and laboratory findings help confidently rule out acute medical emergencies. The soft systolic murmur and slightly elevated D-dimer are normal physiologic changes of late pregnancy due to increased blood volume and a hypercoagulable state. Furthermore, the arterial blood gas shows an acute respiratory alkalosis secondary to hyperventilation, which is typical during a panic attack. Once life-threatening conditions are ruled out, the most appropriate next step is reassurance and initiation of treatment. Cognitive-behavioral therapy (CBT) is a first-line, evidence-based treatment for panic disorder. In a pregnant patient, non-pharmacological interventions like CBT are particularly preferred to effectively manage the disorder while avoiding potential adverse fetal effects associated with psychotropic medications.

Step-by-Step Solution

1
Analyze the clinical presentation and temporal pattern.
The patient has abrupt, recurrent episodes of intense fear and cardiopulmonary symptoms peaking in minutes, coupled with consequent avoidance behavior.
To differentiate between acute medical emergencies and primary psychiatric conditions.
2
Evaluate physical exam and laboratory findings in the context of the third trimester of pregnancy.
The grade 2/6 systolic murmur and mild D-dimer elevation are noted as normal physiologic changes of pregnancy. Oxygenation is excellent, and lungs are clear.
To rule out organic causes of dyspnea and tachycardia (e.g., pulmonary embolism, heart failure) without overreacting to normal gestational physiology.
3
Interpret the arterial blood gas.
Elevated pH with a low pCO2pCO_2 indicates acute respiratory alkalosis secondary to hyperventilation.
To confirm the physiologic consequence of a panic attack and rule out underlying metabolic derangements.
4
Establish the diagnosis and select the safest, most effective treatment.
The diagnosis is Panic Disorder with Agoraphobia. Cognitive-behavioral therapy (CBT) is selected as the next step.
CBT is a first-line treatment for panic disorder and avoids the potential teratogenic risks of pharmacotherapy during pregnancy.

Key Concept

Diagnosis and management of Panic Disorder and Agoraphobia in pregnancy, emphasizing the differentiation of anxiety symptoms from normal physiologic changes of pregnancy.
Rate this question

Topics

Anxiety, OCD, and Trauma-Related Disorders

More questions from this topic