Archive Of Standardized Exam Questions: Panic Disorder

OVERVIEW

This page is dedicated to organizing various examples of standardized exam questions whose answer is panic disorder. While this may seem a odd practice, it is useful to see multiple examples of how panic disorder will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a tradition question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a disease is quite valuable.

KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)

When it comes to standardized exams, each topic has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for panic disorder. 

• Panic attacks (that have no clear trigger) and have the features below:
  • Palpitations 
  • Shortness of breath

QUESTION EXAMPLES

Question # 1

A 23 year old man with no significant past medical conditions comes to the clinic with concerns about recurrent episodes that are characterized by: sudden heart pounding, shortness of breath, chest pain, shaking, dizziness, and a tingling sensation in his extremities. These episodes will last about 10 minutes, and are associated with feelings of detachment from his body. The patient is very anxious about this health, and fear that he has a heart condition or some other life threatening illness. He has seen several physicians who each have performed an extensive workup, however he has not been diagnosed with any abnormalities. His concerns have progressed over time, and now he feels anxious all father time. The patient does not use any illicit substances or alcohol. Routine labs, an EKG, and a physical exam are all unremarkable. What is the most likely diagnosis?

Explanation # 1

Question # 2

A 21 year old man comes to the emergency department for chest pain. By the time he is seen, the pain has stopped, however he remains agitated and is certain that he is going to have a heart attack “just like his father”. The patient explains that he has had 5 similar episodes over the past 2 months, and each episode has lasted for about 20 minutes. During these episodes he has felt a sudden “vice-like” girl in his chest, had difficulty breathing, and felt his “heart pounding”. He has become more and more fearful of leaving his home, and tearfully explains that he is going to lose his job if this continues. The patient works as a secretary, and has called in sick 4 times in the past 2 weeks because he has been fearful of having an episode at work. he denies the usage of any illegal substances, and his past medical history is unremarkable. His father had a history of heart disease and a myocardial infarction at the age of 47. The patient’s temperature is 98.8°F, blood pressure is 140/93 mm/Hg, pulse is 120/min, and respiratory rate is 29/min. An EKG shows sinus tachycardia, but no other abnormalities. Cardiac enzymes are negative. Hemoglobin is 12.7 g/dL, leukocyte count is 9,0000/µl, and TSH level is 2.8 µU/m. His urine drug screen is negative. While waiting for his discharge, the patient explains that the pain is returning and his breath becomes shallow and rapid. He begins sweating heavily and says “I think I am dying! I feel like I am having a heart attack!”. What is the most likely diagnosis in this patient?

Explanation # 2

Question # 3

A 26 year old woman comes to the emergency department for chest pain, shortness of breath, heart palpitations, peri-oral numbness, and diaphoresis. She seems extremely anxious and explains that her symptoms came on suddenly without any apparent reason. The patent explains that this same thing has happened a few times every week for the past 3 months. Her blood pressure is 155/90 mm Hg, pulse is 105/min, and respirations are 28/min. Cardiac enzymes are within reference range, and an EKG shows normal sinus rhythm without any remarkable findings. What is the most likely diagnosis for this patient?

Explanation # 3

Question # 4

A 35 year old woman comes to the clinic because she is feeling overwhelming anxiety and stress. The patient explains that she has been under a lot of job related pressure and has been working very long days at the office. She says that “the worst part is that all of a sudden I will get very nervous and feel shaky, dizzy, nauseous, and then start to sweat a lot!”. She explains that this happened once while she was speaking to there boss and she had to excuse herself. She is very worried about these episodes, and is concerned that they may happen at a work meeting. In light of these concerns, she does admit that these “episodes” have also occurred when she is at home relaxin. She explains that she has been avoiding going out with her friends recently because she is unsure as to when the next episode will strike. The patient has no notable medical history, and denies any alcohol or illicit drug usage. Her blood pressure is 115/80 mm Hg, pulse is 75/min and respirations are 17/min. Her physical exam and laboratory evaluation are unremarkable. What is the most likely diagnosis for this patient?

Explanation # 4

Question # 5

Question # 6

A 45 year old woman comes to the clinic because of a 3 week history of daily episodes of dizziness and the sensation that she is going to “pass out”. The patient explains that the episodes last for less then 5 minutes, and are accompanied by a flushing sensation throughout her body. She explains that she is concerned to go to sleep because she is afraid that her heart will stop, and that she will not be able to wake up. She explains that her symptoms are likely caused by stress and that they may indicate that she has recurrent hart problems. During the past 3 months she has been to the emergency room 5 times for the treatment of her chest pain. Each time the evaluation revealed that there were no abnormalities. She has had a previous myocardial infraction 6 years ago, and had a stent placed. She currently does not smoke cigarettes, drink alcohol, or use any illicit substances. Her temperature si 99.0°F, pulse is 106/min, respirations are 17/min, and blood pressure is 150/90 mm Hg. On physical exam there is no venous distention, and cardiac exam reveals no remarkable findings. Mental status exam reveals an anxious patient who says “her mood has been very down”. She explains that any sensation in her chest makes her worry that she is going to die. An ECG only shows sinus tachycardia. What is the likely diagnosis for this patient?

Explanation # 6

Question # 7

A 16 year old boy is brought to the emergency department by his father because of a 15 minute episode of chest pain and wearing that started close to an hour ago. The patient was reading a book when he began feeling the chest pain, pounding of his heart, and difficulty breathing. The patient thought eh was having a heart attack and was about to die. A few weeks ago, the patient had a similar even that occurred about an hour after his high school wrestling practice ended. At the time, he visited the emergency department and a workup (including lab studies and an ECG) showed no abnormalities. After this initial episode he quit the wrestling team and started to limit how much he exerted himself physically (to try and avoid “bringing on” a similar episode). He explains that he does to have any insomnia or changes to his eating habits. His father explains that he was diagnosed with a benign heart murmur when he was 5 months old, and this has been noted on his routine physical exams since then. His maternal grandfather died of a myocardial infraction 2 years ago at the age of 69 years. The patient does not have any other pertinent past medical history, and is not taking any medications. He denies smoking cigarettes, drinking alcohol, or using any illicit substances. His vital signs are within normal limits. Cardinal exam reveals a normal S1 and S2 with a variation of S2 on respiration. The rest of the physical exam is unremarkable. What is the most likely diagnosis?

Explanation # 7

Question # 8

Over the past 7 months a 21 year old woman has had 15 episodes of sudden apprehension that occur with a feeling of “impending doom”, agitation, tingling in her extremities, shortness of breath, and a “pounding heart”. During these episodes she admits to feeling dizzy and having a dry mouth. She has been worked up in the emergency department several times, and ECGs has never shown any abnormalities. In between these episodes she does not report feeling any anxiety. She is curious as to what is going on, but is reluctant to taking medications. What most likely explains this patient’s presentation?

Explanation # 8

TESTABLE FACTS ABOUT THIS TOPIC (BEYOND ITS IDENTIFICATION)

Many questions on standardized exams go beyond simply recognizing the underlying topic. Often there are specific testable facts regarding some aspect of the topic’s pathophysiology/management/clinical implications that are commonly asked. Some of these are listed below:

• Treatment:
  • Cognitive behavioral therapy
  • SSRI medications (frist line pharm): 
  • SNRI medications: Venlafaxine is first-line).

Page Updated: 09.12.2016