Psychobehavioral Disorders - Free CME Quick Quiz

Educational Objective:

Differentiate between symptoms of anxiety and potential indicators of a pulmonary embolism.

Key Point:

A patient with a history of psychiatric disorders, such as panic attacks, may have symptoms that overlap with serious medical conditions, such as a pulmonary embolism (PE).

Clinicians must be careful not to attribute the symptoms solely to the psychiatric disorder and should further evaluate patients, especially when risk factors or abnormal findings are present.

Explanation:

This case presentation and electrocardiographic results are concerning for pulmonary embolism (PE), which mimics the symptoms of anxiety. Chest pain, shortness of breath, and feelings of impending doom are all shared symptoms between PE and anxiety. It is important to remember that individuals with a primary anxiety disorder may have concomitant medical conditions.

Every clinician knows that a thorough history and physical examination are important in all patients, but in those with pre-existing disorders, especially psychiatric disorders, it is easy to miss a new onset medical condition that mimics the underlying psychiatric illness.  

In general, the presence of abnormal vital signs in the evaluation of anxiety should prompt the consideration of a medical condition. Obviously, the history of a plane flight (prolonged immobility), calf pain, oral contraceptive use, and smoking put this patient at risk for PE. The electrocardiography results depicted show an S1Q3T3, which is not normal and therefore further strengthens the suspicion that SOME TYPE of underlying medical problem is present.

The ECG pattern of an S1Q3T3 nearly doubles the patient’s already significant pre-test probability (flight, smoking, calf pain, oral contraceptives, shortness of breath) for PE; obtaining a D–dimer to evaluate for PE is therefore appropriate in this case. Urinary toxicology to screen for drugs of abuse is not indicated.

Lorazepam may ameliorate the physical manifestations of this current episode, but the potential PE diagnosis will be missed without further investigation. A period of observation similarly is not needed, given the history, presentation, and ECG findings.

Pearl:

The S1Q3T3 ECG pattern is a sign of pulmonary hypertension and by itself is not sufficiently sensitive and specific to diagnose PE. However, the S1Q3T3 ECG pattern, as well as symmetric T-wave inversion or incomplete/complete bundle branch blocks all double the risk of PE in the context of a PE Gestalt (with symmetric T-wave inversion being a stronger sign than the S1Q3T3 ECG pattern).