Sunday, 11 December 2016

Sorting out Gabrahat ~ The Common Complaint in the ED


From The Desk Of Sagar Galwankar, MD

Gabrahat is often a common complaint with many implications.

 While working in Emergency Departments in India I have been surprised with what the ultimate diagnosis was when I investigated Gabrahat.

For me Gabrahat is as vague as the Horizon and I take this complaint very seriously. It is very easy for any Nurse or Emergency Physician to get framed and just label Gabrahat as Anxiety or Hysteria.

This can be the Epic Blunder of Large Proportions.

Many times relatives who accompany the patient will Frame the Emergency Physician by saying words like “There is Tension”.

What they mean to imply is Gabarahat is Stress Related.

I often relate Gabrahat to a “SENSE OF IMPENDING DOOM”

When you grade GABRAHAT in that perspective, it guides the Emergency Physician to be very Proactive and diligent.

Let me share a few blasts from the past which I have modified for the sake of Education.

Case One:

Middle Age Female comes to the ED saying that she is feeling SOB. She is hyperventilating and Diaphoretic. She says that she has been having pain all over the body and fells GABRAHAT as if something is going to happen to her.

Her vitals are stable but she continues to breathe hard and breath fast.

The relatives were doing a Fine job of Framing her as hysteria.

Rapid Fire Questionnaire Labs EKG Trop and a X-ray Beta HCG UA and a BNP are ordered.

On examining the patient the only Finding is the breathing.

Lorazepam given IV and Oxygen started and ABG Ordered which is showing alkalosis.

Aspirin given and a bedside Glucose is Normal.

She settles down but continues to breathe hard. A CTA Chest is ordered.

There are massive shower Pulmonary Emboli.

Pt gets thrombolyzed and goes to ICU.

 

Case Two:

A 55-year-old women comes with GABRAHAT. She says that she is afraid something is going to happen.

She has no other symptom. She has no Past Psyc Issues.

Labs EKG Trop and an X-ray UA ordered. She has had a prior hysterectomy.

She had an ST Elevation MI. Went to the Cath Lab.

No Symptoms at all. No Past History at all.

 

Case Three:

30-Year-old man came saying He had Gabrahat and felt that there was Irritation in the Chest. NO PAIN BUT ONLY IRRITATION.

Exam Past History negative.

Cardiac labs CBC RFT LFT was negative so was his EKG and Xray.

Against the will of the Internal Medicine Colleagues Pt admitted.

4 hour repeat EKG and Trop was placed from the ED

His EKG was normal but his Trop had become positive.

Cardiology who scheduled the patient for a cath after admitting him to CCU found a Tight Lcx Lesion which needed a Stent.

 

Case Four:

48 Female with Gabrahat.

Second visit after discharge from the hospital.

Come back saying she is afraid.

No Pain, No Focus of Infection.

CBC RFT LFT Cardiac Labs X-ray Beta HCG and UA Negative.

Says her Mind tell her Something is wrong. She has GABRAHAT.

Was admitted in a nursing home. CBC Electrolytes creatinine and SGPT was done and after overnight IV Fluids patients sent home.

A CT Head done and the patient had SAH. No Neck stiffness no Eye signs. Admitted to Neurosciences ICU

The only thing that prompted a CT Head was “My Mind is telling Me.

This was perceived as Hallucinations hence CT Head Ordered.

Case Five:

18 Year Old Male comes with Gabrahat with Hallucinations.

He was at friends party and says “ I have gabrahat as I see a ghost”.

Tox Work up was done and it was positive for multiple substances.

Routine CBC RFT LFT EKG Trop UA and Xray with a CT Head and Tox Screen were done.

Case Six:

40 year old male comes saying that he has Gabrahat and he feels like a huge Log of wood just fell on his head and nailed his whole body vertically into the ground.

Clinical Exam and Vitals were normal.

CBC LFT RFT Trop EKG Xray negative

No Neck stiffness Neuro exam normal.

He kept saying I am afraid I am sinking into the ground.

CTA Aortagram ordered: He had a dissection from Thorax to iliac bifurcation.

Admitted to CVTS Sx.

 

Summary:

  • Basic Approach should be T/P/R/BP/Pulse Ox
  • I always order a CBC LFT RFT EKG Trop CXR. Looking for Rhythm abnormalities is also important. Fever can also cause Gabrahat.
  • In Females in the Pregnancy Age group a HCG-UA is ordered
  • If Patient has SOB I will R/O Thoracic Causes like Dissection/Pneumothorax and PE.
  • If Patient has a presentation of Altered Mental Status I always order a CT Head.
  • If Toxicology screen is available, I will order one.
  • Co-Symptoms should guide further investigations.
  • Discussing with the Relatives in key to educate them- that this is not Hysteria / Tension / Stress. Those are the diagnosis to be considered once Major Life threatening causes are ruled out.
  • I have often Seen Marital Discord / Intimate Partner Abuse to be causes of GABRAHAT. So Going deeper into the history. Sitting with the patient with Privacy is the key.
  • Anxiety / Panic attack also can be on the differential once Major causes are ruled out.
  • Being a Compassionate Emergency Physician is the key. Communication is the answer and Competency to Care is crucial.
  • GABRAHAT CAN KILL !

 

I want to Share a Web Review of what Non EM Experts say about GABRAHAT.

I feel a Well Trained Emergency Physician leaves no stone unturned to do the best for his/her patient

 

Web Review:




 

Image Courtesy: Anxiety Cartoons on Bing Images

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