A 28-year-old woman presents to the emergency department reporting a sudden onset of inten… — USMLE Step 2 CK

A 28-year-old woman presents to the emergency department reporting a sudden onset of intense chest pain, palpitations, shortness of breath, and a feeling of impending doom that began 20 minutes ago while she was resting at home. She states, "I thought I was having a heart attack and going to die." This is her fourth similar episode this month. She is now terrified of having another attack and has stopped driving to work out of fear of losing control. Her medical history is notable for a severe depressive episode two years ago. At that time, she was started on citalopram, but within days she developed racing thoughts, a decreased need for sleep, and impulsive spending, which led to her hospitalization. She currently takes no medications. Her temperature is 37.0°C (98.6°F), blood pressure is 128/82 mm Hg, pulse is 110/min, and respirations are 22/min. Physical examination, ECG, and serial cardiac troponins are unremarkable. The patient's acute symptoms resolve completely after reassurance in the emergency department. Which of the following is the most appropriate long-term management strategy for this patient's current psychiatric condition?

Cognitive-behavioral therapyCevap
B
Sertraline monotherapy
C
Admit to the cardiac step-down unit for continuous monitoring
D
Reassure and observe, as formal diagnosis requires a minimum 6-month symptom duration
E
Prescribe paroxetine and phenelzine concurrently

Cevap

Cognitive-behavioral therapy

The patient's presentation of recurrent, unexpected panic attacks followed by persistent concern about future attacks and maladaptive avoidance behavior confirms a diagnosis of Panic Disorder. The first-line treatments for panic disorder are selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT). However, this patient's history of a manic episode immediately following citalopram administration indicates she has underlying Bipolar Disorder. In patients with a history of bipolar disorder, antidepressant monotherapy (such as an SSRI alone) is strongly contraindicated due to the high risk of precipitating a manic switch. Therefore, Cognitive-behavioral therapy is the safest and most appropriate initial long-term management strategy.

Adım Adım Çözüm

Evaluate the patient's acute physical presentation and diagnostic tests.

The acute onset of chest pain and sympathetic hyperactivity, resolving completely with normal cardiac enzymes and ECG, rules out acute coronary syndrome and points to a panic attack.

Medical emergencies must always be ruled out first before attributing cardiopulmonary symptoms to a psychiatric etiology.

Analyze the pattern of the psychiatric symptoms.

The patient has had four unexpected panic attacks in a month and exhibits maladaptive behavioral changes (avoiding driving) due to anticipatory anxiety, fulfilling the DSM-5 criteria for Panic Disorder.

Identifying the specific anxiety disorder is necessary to select the correct evidence-based treatment.

Review the patient's psychiatric history for crucial contraindications.

The patient experienced a classic manic episode (racing thoughts, decreased need for sleep, impulsivity) shortly after taking an SSRI (citalopram) in the past, establishing an underlying diagnosis of Bipolar I Disorder.

Psychiatric comorbidities profoundly influence psychopharmacological choices, particularly regarding antidepressant use.

Select the safest long-term management strategy.

Cognitive-behavioral therapy (CBT) is chosen because it is highly effective for Panic Disorder and carries zero risk of precipitating mania, unlike typical first-line pharmacotherapy (SSRI monotherapy).

First-line treatments for panic disorder include CBT and SSRIs; however, SSRIs must be avoided as monotherapy in patients with bipolar disorder.

Anahtar Kavram

First-line management of panic disorder in patients with a history of bipolar disorder

Tahmini Süre:1m 30s

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru