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A 37-year-old woman presents to the emergency department with chest pain. The pain started 20 minutes ago. It is severe and is located in her right chest; it does not radiate. Onset was not associated with physical activity. The patient also complains of shortness of breath, shakiness, palpitations, diaphoresis, and nausea. The patient has visited the hospital three times over the past 4 months with similar symptoms. She used to run 3 miles a day 3 days a week, but she has stopped running because of concerns of dying of a heart attack. Lately, she has been spending more time at home because she is concerned she would be helpless if she suffered a heart attack outside her house. One month ago, she underwent a stress test, the results of which were normal. The patient does not smoke; she drinks one glass of wine a night. Her father died of a heart attack when he was 60 years of age. On physical examination, the patient's heart rate is 130 beats/min; her respiratory rate is 28 breaths/min; diaphoresis and distal tremors are noted. The rest of the examination is unremarkable. An electrocardiogram shows sinus tachycardia. Which of the following is the most likely diagnosis, and which therapeutic intervention constitutes
first-line therapy for this disorder?
A. Panic disorder with agoraphobia; start a benzodiazepine
B. Panic disorder without agoraphobia; start a selective serotonin reuptake inhibitor (SSRI)
C. Panic disorder with agoraphobia; start cognitive-behavioral psychotherapy
D. Panic disorder without agoraphobia; refer to psychiatry
A 68-year-old man comes to your clinic for a follow-up visit. He was discharged from a local hospital 3 months ago after a long stay in the intensive care unit for multiple medical problems, including pneumonia that required mechanical ventilation for 3 weeks, acute renal failure, sepsis, and amputation of his right foot as a result of a vascular event. He requires home oxygen therapy, but he says his breathing is slowly improving. He has no active complaints. His wife says he has had insomnia since he was discharged from the hospital. She also says the patient has been waking up in the middle of the night sweating and very anxious. The patient has been having recurrent dreams in which he is hospitalized in the ICU.
Which of the following is the most likely diagnosis, and what therapy should be started for this patient?
A. Panic disorder; start an SSRI
B. Posttraumatic stress disorder (PTSD); start an SSRI
C. Generalized anxiety; start cognitive-behavioral psychotherapy
D. Hospital phobia; start a benzodiazepine
A 34-year-old man comes to your clinic complaining of a recurrent headache. The headache is locatedposteriorly and is constant, dull, and nonthrobbing. The patient says that it lasts for several hours and that the use of acetaminophen provides some relief. He has been experiencing these symptoms for the
past 8 months. On review of systems, the patient reports that he has been having difficulty falling asleep at night and that he has been experiencing fatigue. He says he is concerned about the headaches. He describes himself as a stressed person but denies feeling depressed. The patient smokes cigarettes and drinks alcohol socially. His physical examination is unremarkable. Basic laboratory studies, including acomplete blood count, a metabolic profile, and thyroid function tests, are normal.
What therapeutic intervention would you recommend for this patient?
A. Start a beta blocker for headache prophylaxis
B. Start venlafaxine
C. Start a benzodiazepine
D. Reassurance
A 34-year-old man comes to your clinic complaining of a recurrent headache. The headache is locatedposteriorly and is constant, dull, and nonthrobbing. The patient says that it lasts for several hours and that the use of acetaminophen provides some relief. He has been experiencing these symptoms for the
past 8 months. On review of systems, the patient reports that he has been having difficulty falling asleep at night and that he has been experiencing fatigue. He says he is concerned about the headaches. He describes himself as a stressed person but denies feeling depressed. The patient smokes cigarettes and drinks alcohol socially. His physical examination is unremarkable. Basic laboratory studies, including acomplete blood count, a metabolic profile, and thyroid function tests, are normal.
What therapeutic intervention would you recommend for this patient?
A. Start a beta blocker for headache prophylaxis
B. Start venlafaxine
C. Start a benzodiazepine
D. Reassurance
A 29-year-old medical resident is often late for daily rounds. When asked for an explanation, he blames the traffic and his need for taking care of different issues at home before coming to the hospital. It has been noticed that he disappears during rounds, and he has been found several times washing his hands for several minutes before coming back to rounds.
What is the most likely diagnosis for this resident, and what would be the best therapeutic intervention to try first?
A. Obsessive-compulsive disorder (OCD); start clomipramine
B. Substance abuse; refer for psychotherapy
C. Schizophrenia; start an atypical antipsychotic
D. Social phobia; start an SSRI
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