Psychatry: Diagnosis?
meduploader - 06-01-09 13:31

A 26-year-old established patient has an appointment for follow-up of an emergency department (ED) visit. Over the past three weeks, she has been seen on three occasions in an out-of-state ED for episodes of severe chest pains and other symptoms. Her evaluation there consisted of routine lab tests, an electrocardiogram (ECG), a chest radiograph, and two ventilation/perfusion (V/Q) scans, all of which were negative. She has come to you for the first time to discuss her symptoms.She acknowledges that the past weeks have been stressful. Her mother died suddenly a month ago of a ruptured cerebral aneurysm, and she has been in her home state attending to the funeral arrangements, financial matters, and other family obligations. The first episode of pain occurred while she was driving alone. She recalls having severe, stabbing pain in the precordial region that increased over a few minutes and was accompanied by palpitations, "trembling all over," sweating, and a feeling that something terrible was going to happen to her. The symptoms gradually passed over an hour or so. Two other severe episodes occurred subsequently, also without any obvious precipitants. During these last two attacks, she felt as though she had to escape from the places in which the attacks occurred (a grocery store and a church). She has been very worried about havin more attacks, and she has started to avoid certain places (especially supermarkets and shopping malls) where she feels it might not be easy to leave if she were to have an attack. She has avoided driving alone since the first attack unless she is close to home.Her past medical history is unremarkable, with no history of mental illness. She takes oral contraceptives, has no allergies, and does not smoke, drink alcohol, or use illicit drugs. She is married, has no children, and works as a secretary. She feels as though she is coping with her mother's death as well as can be expected. She has trouble sleeping because she is aware of her heart pounding as she is trying to fall asleep, but she denies typical symptoms of depression. She has comprehensive medical benefits through her HMO. Her physical exam is unremarkable, but she does appear anxious.
Of the following, which is the most accurate diagnosis for this patient?