A man in his early 40s presented to his primary care physician with intermittent anxiety attacks and progressive fatigue. An active duty service member, the patient had a history of panic disorder since deployment to Iraq 6 years earlier. Between his anxiety attacks, he had also developed severe fatigue characterized by persistent feelings of tiredness and a generalized sense of weakness.
Three months prior to presentation, the patient changed duty stations to a more remote post in Eastern Asia. Almost immediately after arrival at his new post, he noted worsening of his panic disorder symptoms. He had been using lorazepam as needed, which provided little relief. He had also recently been prescribed venlafaxine, which he had to stop taking owing to feelings of light-headedness.
Howells JW, Short PA. The Importance of Clinical Context When Interpreting Serum Ammonia LevelsA Teachable Moment. JAMA Intern Med. 2015;175(12):1902-1903. doi:10.1001/jamainternmed.2015.5772