Panic Attack
The most appropriate diagnosis for this patient is Panic Attack, given the sudden onset of multiple somatic symptoms (chest pain, palpitations, shortness of breath, nausea, difficulty concentrating) with comprehensive medical workup excluding organic pathology and no history of recurrent episodes to establish Panic Disorder. 1, 2
Diagnostic Reasoning
Why Panic Attack is the Correct Diagnosis
A panic attack represents a discrete episode of intense fear or discomfort with abrupt onset of somatic symptoms peaking within minutes. 1 This patient's presentation demonstrates:
- Sudden onset of multiple concurrent symptoms (chest pain, palpitations, shortness of breath, nausea, difficulty concentrating, headache) 1, 2
- Comprehensive exclusion of organic causes through normal CBC, CMP, urinalysis, TSH, ECG, and vital signs 3
- No previous history of these symptoms, indicating this is a first episode rather than a pattern 1
- Medical clearance confirming no cardiac, pulmonary, metabolic, or thyroid pathology 3
The American College of Cardiology notes that more than half of ED chest pain presentations are ultimately found to have noncardiac causes, and psychiatric causes account for 8-11% of chest pain presentations. 3, 1
Why NOT Panic Disorder
Panic Disorder requires recurrent unexpected panic attacks followed by at least one month of persistent concern about additional attacks or maladaptive behavioral changes. This patient explicitly denies any previous history of these symptoms, making Panic Disorder diagnostically premature. A single episode constitutes a panic attack, not panic disorder. 1
Why NOT Generalized Anxiety Disorder (GAD)
GAD is characterized by excessive anxiety and worry occurring more days than not for at least 6 months across multiple domains. 1 This patient presents with:
- Acute, sudden onset symptoms rather than chronic worry
- No documented history of persistent anxiety symptoms
- Discrete episode rather than pervasive, ongoing anxiety pattern
The sudden, episodic nature with multiple somatic symptoms is inconsistent with GAD's chronic, persistent worry pattern.
Why NOT Post-Traumatic Stress Disorder (PTSD)
PTSD requires exposure to actual or threatened death, serious injury, or sexual violence, followed by intrusive symptoms, avoidance, negative alterations in cognition/mood, and hyperarousal lasting more than one month. 1 This patient:
- Denies recent trauma explicitly
- Presents with acute somatic symptoms without trauma exposure
- Shows no evidence of re-experiencing, avoidance, or hyperarousal symptoms related to a traumatic event
Critical Clinical Considerations
Organic Causes Appropriately Excluded
The medical team correctly ruled out life-threatening conditions before psychiatric consultation: 3, 2
- Acute coronary syndrome excluded by normal ECG, vital signs, and presumably cardiac biomarkers 3
- Pulmonary embolism unlikely with normal vital signs and oxygen saturation 2, 4
- Thyroid storm/hyperthyroidism excluded by normal TSH 3
- Metabolic derangements excluded by normal CMP 3
The American Heart Association emphasizes that women may present with accompanying symptoms such as nausea and shortness of breath with cardiac pathology, making thorough cardiac evaluation essential before psychiatric diagnosis. 3
Common Pitfall Avoided
The emergency team appropriately did not dismiss these symptoms as "just anxiety" without comprehensive medical evaluation. The 2021 AHA/ACC guidelines emphasize that evaluation of all patients with chest pain should focus on early identification or exclusion of life-threatening causes, even when psychiatric etiology is suspected. 3
Documentation for Future Episodes
If this patient experiences recurrent episodes, the diagnosis would evolve to Panic Disorder. Close psychiatric follow-up is essential to monitor for pattern development and provide appropriate treatment, which may include cognitive-behavioral therapy and/or pharmacotherapy for panic attacks. 1