Name: Anxiety / panic attack — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Panic disorder is common — and "just a panic attack" is a diagnosis of exclusion that has buried more than one MI and PE. The defensible chart documents that the dangerous organic mimics were screened, that panic is a positive clinical pattern rather than a shrug, and that suicidality was assessed.

01What's at stake

Palpitations, chest tightness, dyspnea, tremor, and a sense of doom are the symptoms of a panic attack — and of acute coronary syndrome, pulmonary embolism, hypoglycemia, thyrotoxicosis, arrhythmia, and stimulant toxicity. Anchoring on a psychiatric label, especially in a young patient, is how the organic emergency gets missed. A first-ever "panic attack," an older patient, or risk factors should raise the bar for the medical workup.

02Can't-miss mimics

Acute coronary syndrome — chest pain/pressure, dyspnea, diaphoresis; ECG and risk-based workup. → ECG
Pulmonary embolism — dyspnea, tachycardia, pleuritic pain, VTE risk; pretest probability.
Metabolic — hypoglycemia (check the glucose) and electrolyte disturbance.
Thyrotoxicosis / toxidrome — heat intolerance, weight loss, tremor; stimulant/sympathomimetic use, withdrawal.
Arrhythmia — SVT and other dysrhythmias presenting as "palpitations/anxiety."

03Assessment

Mimic screen — vital signs, ECG, glucose, and a targeted history/exam for cardiac, PE, thyroid, and toxicologic causes; test based on risk, not reflex. → mimic screen
Red flags against a purely psychiatric label: first episode, older age, exertional symptoms, hypoxia, sustained tachycardia/abnormal vitals, focal findings.
Suicide-risk screen — anxiety and panic carry psychiatric comorbidity; assess SI. → SI screen
Document the positive features of panic (recurrent, peaks within minutes, prior identical episodes, resolves) rather than diagnosing by exclusion alone.

Skip the typing

Work the case in the Anxiety / Panic Workup — it records the organic mimic screen (ECG, glucose, PE/thyroid consideration) and the suicide-risk screen, and assembles an MDM that documents the dangerous causes were excluded.

04Management

Exclude the mimic first, then treat the panic — reassurance, a calm environment, and breathing techniques.
Short-term symptom relief if needed; arrange outpatient mental-health follow-up and SSRI/therapy referral for panic disorder (not an ED initiation in isolation).
Address comorbidity — substance use, depression, and suicidality; involve psychiatry/crisis services when SI is present.
Clear return precautions for chest pain, syncope, dyspnea, or escalating symptoms.

05What to document

▼ weak

"Young patient, palpitations and SOB, anxious. Panic attack. Discharged."

▲ defensible

"Recurrent episodes of palpitations, chest tightness, paresthesias peaking within minutes, identical to prior panic attacks, now resolved. Vital signs normal, ECG normal (no ischemia/arrhythmia), glucose normal. No exertional component, no pleuritic pain or VTE risk (PE low probability), no thyroid/stimulant features. Pattern consistent with panic disorder, not a medical mimic. Suicide-risk screen negative. Reassurance and breathing techniques; outpatient mental-health follow-up arranged. Return precautions for chest pain, fainting, shortness of breath, or worsening/atypical symptoms."

06Where charts fail

Diagnosing "panic attack" by exclusion without an ECG, glucose, or vital-sign review.
Anchoring on a psychiatric label and missing ACS, PE, arrhythmia, or thyroid storm.
Not recognizing a first-ever episode or an older/at-risk patient as needing more workup.
No suicide-risk screen.
No documented positive features of panic or return precautions.

07Sources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) — panic disorder. 2022.
Huffman JC, Pollack MH, Stern TA. Panic disorder and chest pain: mechanisms, morbidity, and management. Prim Care Companion J Clin Psychiatry. 2002;4(2):54-62.
Katon WJ. Panic disorder. N Engl J Med. 2006;354(22):2360-2367.
Wulsin LR, Yingling K. Psychiatric aspects of chest pain in the emergency department. Med Clin North Am. 1991;75(5):1175-1188.

Anxiety & panic: documentation that holds up