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Answer 2
  1. Thyroid function tests. A simple screen consisting of a physical examination, complete blood count, fasting glucose, electrolytes (including calcium, phosphorus, and protein/albumin), an electrocardiogram, and thyroid function tests rules out the common medical causes of panic in the typical population of women between ages 20 and 40 years. Onset of panic disorder after age 40 years is atypical and requires more extensive screening.1 A 24-hour urine screen for catecholamine metabolites characteristic of pheochromocytoma is unproductive in a normotensive patient with panic disorder, because patients with known pheochromocytomas do not typically fulfill the full criteria for panic disorder despite their paroxysmal symptoms. Glucose tolerance testing for reactive hypoglycemia is also likely to be misleading. Reactive hypoglycemia is not uncommon in young women, but panic attacks have not been correlated with hypoglycemia, even in patients with abnormal glucose tolerance tests. If suspicion of pulmonary emboli is warranted (eg, the patient takes oral contraceptives and smokes), pulse oximetry is the appropriate screening test, not a ventilation perfusion scan. Stress testing and Holter monitoring may be indicated if the patient has other major risk factors for or classic symptoms of cardiovascular disease, but these tests are not indicated on the basis of panic disorder symptoms alone.

    1. Nesse RM, Zamorski MA: Anxiety disorders in primary care. In Primary Care Psychiatry. Knesper DJ, Riba MB, Schwenk TL, eds. Philadelphia: WB Saunders, l997:32-163.

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