It's Just a Panic Attack
A 34-year-old woman is brought out of a mall bathroom, breathing fast, clutching her chest, and crying. She says it came on suddenly 20 minutes ago while she was walking. HR 124, RR 30, BP 118/76, SpO2 97% on room air, temp 37.2 °C, lungs clear, no wheeze. She says, 'I've had panic attacks before, this feels like one.' She takes a combined oral contraceptive and returned three days ago from a 12-hour flight from Europe. On exam, her right calf is 2 cm larger than the left and tender to touch.
1. Which findings push you away from 'panic attack', and what is your leading concern?
Read the worked answer
Anxiety is a symptom, and it is also the most common mask worn by a pulmonary embolism. What stops me closing the loop:
- Onset with no trigger - she was walking through a mall, not in a stressful situation.
- Pleuritic, localised pain, which is not typical of panic.
- Tachycardia out of proportion to the visible distress (124) with a normal temperature.
- Two strong risk factors: combined OCP plus a 12-hour flight three days ago. That is a textbook venous thromboembolism setup.
- Unilateral calf swelling and tenderness. This is the finding that changes the case, and panic does not cause it.
Also on my list: pneumothorax (sudden, pleuritic), acute coronary syndrome, hypoglycemia, anemia.
The trap here is anchoring on the patient's own label. She has had panic attacks before, so she and everyone around her has already assigned a diagnosis. My job is to test it, not inherit it. Nothing in her presentation excludes a PE, and one finding argues strongly for it.
2. You are 25 minutes from a hospital without CT. What do you do en route, and what changes if her SpO2 falls to 88%?
Read the worked answer
En route:
- Oxygen titrated to 94–98%. She is 97%, so no oxygen yet; start it if she drops.
- Continuous SpO2 and ECG, repeat vitals, and re-examine the calf and the pain.
- Position of comfort, minimal exertion, calm environment, quiet voice.
- IV access in case she deteriorates.
- Pre-alert with the words 'suspected PE'. The receiving team needs the hypothesis, not 'anxious young woman'.
If SpO2 falls to 88%:
- High-flow oxygen and prepare for assisted ventilation if she tires.
- Reconsider destination. With hypoxia, the closest facility is usually right, with the receiving physician arranging transfer. That is a patch call, not a solo call.
- Watch for hypotension and distended neck veins - a large PE obstructs right ventricular outflow and she can crash quickly, occasionally with pre-syncope first.
What I would not do: give nitroglycerin for 'chest pain', or tell her to calm down. Both are ways of pretending I have a diagnosis I do not have.
3. How do you talk to a patient who is convinced this is a panic attack?
Read the worked answer
She has an explanation for her symptoms and it is partly right - she may well be panicking now. Arguing with her costs trust and buys nothing.
- Validate without agreeing: 'This is frightening, and your body is doing exactly what you're describing. I'm also seeing a couple of things that don't quite fit a panic attack, and I want to check them.'
- Give her the concrete reasons - the flight, the pill, the leg. Patients cooperate when the logic is visible.
- Give her control where I can: position, a blanket, whether she wants someone called.
- Never say 'it's probably nothing.' If it is a PE, that sentence is the one she will remember, and it is the one that will be in the report.
- Explain each step before doing it and get consent for the IV and oxygen.
If she deteriorates, I want a patient who trusts me in the back of the truck - not one who thinks I dismissed her in the mall.