Differential Diagnosis

The symptoms described could be related to various conditions, and a thorough evaluation is necessary to determine the cause. Here's a categorized differential diagnosis:

• Single most likely diagnosis

  • Panic attack: The combination of symptoms such as feeling of choking, depersonalization, stiff shoulders, neck and chest, and the sensation of something pulling from the stomach, especially occurring 20-30 minutes after taking medication and lasting about 30 minutes, could suggest a panic attack. The temporal relationship with medication intake might indicate a reaction to the medication, but the symptom complex itself is highly suggestive of a panic attack.

• Other Likely diagnoses

  • Anxiety disorder: Given the symptoms of depersonalization, feeling of choking, and stiff muscles, an anxiety disorder could be a plausible explanation. The reaction could be exacerbated or triggered by the medication.
  • Medication side effect: The symptoms starting 20-30 minutes after taking medication suggest a possible adverse reaction to the medication. Many medications can cause a range of side effects, including anxiety, panic, or physical symptoms like those described.
  • Hyperventilation syndrome: The feeling of air not being able to get through the nose and the expanded diaphragm could indicate hyperventilation, which often accompanies panic attacks or anxiety but can also be a standalone condition.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Pulmonary embolism: Although less likely given the symptom complex, a pulmonary embolism can cause sudden onset of chest pain, shortness of breath, and can lead to a feeling of choking or panic. It's crucial to rule out this life-threatening condition.
  • Cardiac issues (e.g., myocardial infarction): Chest pain or discomfort, especially if accompanied by shortness of breath or a feeling of choking, could indicate a cardiac problem. Immediate medical evaluation is necessary to rule out such conditions.
  • Anaphylaxis: A severe, life-threatening allergic reaction that can cause respiratory distress, a feeling of choking, and rapid onset of symptoms. Given the temporal relationship with medication intake, this is a critical diagnosis not to miss.

• Rare diagnoses

  • Vasovagal syncope: Could potentially cause some of the symptoms like depersonalization and a feeling of choking, but typically would be associated with a loss of consciousness.
  • Esophageal spasm: Might cause a choking sensation or chest pain, but the other symptoms like depersonalization and stiff shoulders would be less commonly associated with this condition.
  • Gastroesophageal reflux disease (GERD): Could potentially cause chest discomfort and a feeling of choking, especially if the stomach acid refluxes up into the throat. However, the other symptoms like depersonalization and stiff muscles are less typical for GERD.