Reassurnce is not enough !

Clinical scenario:

      A 35 year  healthy man presents with a complaint of chest pain, shortness of breath, and a feeling of impending doom. This is his fifth admission to the Emergency dept  for the same complaint. 

His cardiac evaluation was negative. ECG was unremarkable Fig 1  and Troponin-I was negative every time he presented to emergency dept . 

While you are waiting for his test results, he looks anxious and tells you that he is unemployed and recently divorced his wife.

Fig  Normal ECG 

Would you feel comfortable prescribing a benzodiazepine and arranging outpatient follow-up?

Teaching points:

• Rule out cardiac disease by appropriate tests and take a detailed history 
• The patient presents with significant symptoms of an anxiety disorder (most likely: Panic disorder).
• His somatic symptoms are due to anxiety and he does not have a cardiovascular disorder. 
• The correct treatment would be an anxiolytic medication. 
• In such a case there is no contraindication to prescribing short term use of a benzodiazepine.  
• The longer he remains untreated, the higher his risk of relapse.
• The correct treatment for this patient would include short term use of a benzodiazepine

           Ex: Lorazepam (Ativan) 1mg PO q8hrs to 12hrs prn for anxiety. 

          Dispense #15 tabs with no     refill.

• The patient should be referred for Mental Health follow-up or see his PCP for referral within one week.
•            

For further Reading click the Link: Panic disorder

This case was contributed by

Dr Yasir Al-Twarqi.

Consultant Psychiatrist 

Assistant  Professor 

College of Medicine 

Taif university KSA