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.



  • 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.


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

Monday 14 November 2016

Guarding the Specialty of EM in India ~ A call to Action by Qualified Real Emergency Physicians !

By Vimal Krishnan Pillai, MD, FACEE                                                                                Principal Secretary, The Emergency Medicine Association 

India is at Cross roads of conflict when it comes to Emergency HealthCare.

The Health Care Industry in India is booming with Corporate for Profit hospitals mushrooming across India …thanks to Investments in India’s HealthCare.

The culture in India is that every MBBS Physician in India aspires to be a specialist. There are around 65,000 MBBS seats in India and only around 20,000 PG seats

 Due to the staggering difference was a constant struggle to achieve some sort of an accredited qualification after MBBS.

This also gave birth to a corrupt pathway where non-accredited courses were designed and marketed for monetary gains. These could be anything from paid Fellowships to any type of non-accredited courses.

Even though there are clear guidelines on what should be quoted as a qualification, there are numerous non- accredited courses thriving here due to regional heterogeneity in medical education and the challenge to govern, regulate and track healthcare providers enforcing the rule was tough.

With the rise of International Investments in HealthCare, like the west the expectations from these investment driven hospitals to prove Quality Emergency Care 24/7 grew.

The campaign to get EM Recognized by the regulatory bodies like Medical Council of India (MCI) and the National Board of Examinations (NBE) as a specialty was only was realized after 2009.

Running a Competent for profit Emergency Department needed committed and qualified Emergency Physicians.

That was the elbow gap when vested forces started manufacturing non-accredited Training Courses which are illegal in India.

If unconfirmed estimates have to be believed there are over 1000+ Medical students who have been lured into such courses.

The unregulated manner in which these malignant and corrupt courses have mushroomed has left the academic community in India stunned.

There has been massive anxiety as regards the factors under which such Unrecognized Training Programs are conducted at hospitals without permissions.

Physicians not recognized or qualified to be Teachers are impersonating the role of being trainers and are conducting training programs using the most vulnerable patients presenting to the Emergency Departments as training subjects without governmental permissions.

Physicians/ Institutions/ Associations not permitted to train are handing out qualifications.

These factors raise a lot of ethical and patient safety concerns.

There are all sorts of Certifications in India without prior permission of the Government of India. These Certifications are also causing a lot of confusion and disharmony for the regulatory agencies.

In this era where Government is moving towards One Nation-One Admission-Uniform Training- One Examination- Standardized Model there will be a dire need to immediately regulate and discipline these irregularities.

It is sad that Emergency Medicine has emerged as a front runner in this misconduct as this is a new specialty and the violators are misusing the brand value of Emergency Medicine to fulfill their selfish motives.

The violators try to justify their actions saying that they are doing “Capacity Building”. They forget that when it comes to be being certified as a SPECIALIST …there has been a system in place for India since independence. The Medical Council of India and The National Board of Examinations have that role well mandated.

CAPACITY BUILDING to improve Emergency Care by training physicians to better care is one thing but to assume and impersonate training programs and award non- accredited masters or degree is grossly illegal.

It is a known fact that India needs Specialist not only in EM but in every field. The worst fear is that If EM Violators continue to foster then other specialties will try to do the same and India will be flooded with Surgeons, Physicians, Pulmonologists, and Intensivists with all sorts of certificates.

It’s a Pandora’s Box which will spring open if this misconduct is not stopped.

At One hand Indian Hospitals are boasting of being a Medical Tourism Destination and one the other hand they are involved in irregularities.

I am a firm supporter of Governmental control of HealthCare and Medical Education.

Violations like these grossly undermine the authority of the Medical Council of India and the National Board of Examinations.

The Government is working hard to improve HealthCare at large and standardize the Medical Education system…..

The Emergency Medicine Irregularities have emerged to be its biggest hurdle.

Violators are fooling the medical fraternity and community while the government accredited degree holders MD/DNB face the uncertainty of being in a job market where non-accredited training and certifications are being doctored as the standards for qualification and quality care.

The future of hardworking post graduate qualified MD/DNB Emergency Physicians are in danger if steps are not taken to one and for all discipline the violators.

No Country would allow this indiscipline or forgive the violators.  India is no different!

I call upon my Fellow MD/NBE PG Students and Qualified Emergency Physicians to unite in this struggle against this fraud where the Authority of our Accreditors (MCI/NBE) is undermined and a mockery of Academic Emergency Medicine is being made.

The Time is now before it’s too late !
 Jai Hind !


Wednesday 2 November 2016

Mergers, Acquisitions, and Physicians

From The Desk Of ~ Sagar Galwankar, MD

As I read the media there is never a time that I don't get aware that some group is buying some group or merging with some group.

Merging and Acquiring hold the same meaning : It means Reorganization of Resources and Finances for Better Performance and Stronger Position in the Competitive Landscape.

Each of the above words narrows down to only one thing - SROI - Strategic Returns on Integration- Which is a nicer acronym for Financial Growth.

Financial Growth for the harvesters and the investors who steer these initiatives.

The real question is : Where does it leave US (the emergency physicians) and what is our future in US (the United States)

In this aggressively reorganizing industry called EMERGENCY HEALTHCARE , I see ourselves being repositioned to be skilled laborers. We the laborers have a highly competitive growing segment  called the  Mid Level Workforce.

EM is going through a phenomenon called LEAP FROG.

The IT industry evolved from large computers to a stage of internet in phones. It evolved and expanded.

We in EM are now straight away a part of this technology driven Industrialization without going through phases of evolution. We have become a small part of the the capitalistic revolution.

We have leaped the cycle of Evolution in this capitalistic revolution, I just hope like the cycle of life evolution , we don't face extinction.

 Care and Cost Balancing is driving the industry productivity. 

Customer- client satisfaction is a metric for stability.

We as a speciality have to evolve with this leap and be aggressive to change, we should think and act to stabilize our present and sustain our future.

The specialty we love needs to live on and live in itself.

The time is now and Optimism is the first phase of evolution.

Fear to not sustain is the key to effectively sustenance.

Creating and Encouraging Thinkers and Innovators to come up with solutions coupled with implementation of strategies nationally are steps which can change things for a better future.

Rethinking Leadership and transforming Education And Innovation for a progressive tomorrow which is in sync with  the changing landscape is the need of the hour.

Change is inevitable & we are all able, let's work to make it stable !

Just thought , hence shared !

Saturday 8 October 2016

Good Karma is a Great Investment !

Yesterday I ended working the Hurricane Shifts. 

Patients came to  the ED With clean cut non emergent complaints.

I was a little taken aback until one of them after giving a long list of complaints 
softly said - " I am afraid of the dark"

That left me thinking - the ED is definitely not a happy place to be, the ED is 
not where I would wish for anyone to be , 
it's only when someone feels that they have no one or they 
will find someone who will care for them that they turn to ED.

Patients genuinely believe they have a problem and they come to us, 
and they confidently know that we will care for them and
WILL SEE THEM whatever their complaints are.

Regulations, Legal Threats and Metrics may be ruling us but over and above all these 
challenges ..... it's is the faith of these patients which keeps our specialty going.

I also get worried when I see patients seek pain medications and they come 
for non emergent complaints .... but thinking further ... 
who created that sense of security for them ..... 
the system did and we as a physician specialty did it ! 

It is challenging that we have to face so much 
pressures in terms of patients per hour etc and still balance satisfaction scores .....
 I will say that perform and be calm in stress is not easy.

There is no one solution for what we are going through , 
but definitely there is one solution .....
 let's start thinking that we are the only ones who 
can help those who need our help and we have 
only a certain number of Of hours in which we can make a difference.

To be on the other side of the bed is not easy ..... 
when you make it easy for someone .... it does make a difference.

Good Karma is a great investment.

On another note .... 
our soldiers defend our nation and freedom no matter what it takes ...
 they are at the front lines of defense .....
we are the front lines of Health Security for our citizens 24x7 .

Our patients take it for granted that we will care for them and the EM system is solid ...
 that's a good thing !

Just Thought .... should share !

Stay Blessed ! 

Monday 8 August 2016

It’s all about the Encounter……, but what about Metrics?

There have been waves of changes which are happening across the world of emergency care. Different nations approach emergency medical services differently.

The one thing that continues to remain common is the patients their pathologies and the metrics which govern the operations of emergency departments.

In accountable cultures the patient experience is a key feature of the emergency department visit. Physician salaries and insurance payment for clinical care are tightly tied to the satisfaction level of the patient once the care provided has been availed. It is more like an evaluation you give after you avail a Telephone customer service. There is also a lot discussion which suggests that Good Patient Experience in the Emergency Department leads to lesser complaints and lesser legal problems.

On the other hand we have the massive pressure of metrics. There are different metrics in different cultures and different nations. It’s all about the financial logistics which drive sustainability.
So the demands on the Emergency Physician are tremendous.

Let’s look at the parameters of this perspective:

Emergency Departments are getting overcrowded:
That is good for the specialty but also a reflection of the strength of primary care available. Hence when patients seek Emergency Care for primary Care pathologies….there is a strain on the system. Seeing patients fast, screening the life threatening pathologies out from the waiting room and maintaining pleasant patient experiences becomes challenged.

Emergency Department Metrics:
Metrics and Measures drive the working of a Modern Emergency Department. How many patients are seen per hour per physician, how many CT Scans are ordered, How many tests are ordered, how soon were antibiotics, aspirin and life saving measures instituted etc. These are benchmarks and may like these to which an Emergency Physician has to strictly adhere too or there may be no employment…

 Patient Experiences:
With the existence of above pressures which include seeing patients fast, evaluating them and treating them safely, and maintaining the numbers for meeting core measures and metrics the Emergency Physician is responsible for making the patient experience a satisfying encounter.
There is a lot of thrust on the above Marker. I am well aware that hospitals and health system are hiring 5 Star Hotel Hospitality Gurus to create Hospitality Training Models for health care workers.

How does one welcome the patient, how does one behave with the patient as soon as the patient car hits the gate of the hospital, till the time the patient goes home.

It’s all about Communication Skills….. That’s what it comes down too.

But what about Emergency Life threatening Conditions, Critical Life Saving decisions Scenarios, a critical environment where things change within seconds…..

Emergency Departments and Emergency Patients are different from Primary Care Patients and Clinic practices.

I firmly support that compassion is key to patient care and it’s all about communication skills BUT different things are done differently in different situations.

It’s good to be inspired from the airline industry to design a Safety checklist for healthcare and it is good to be inspired by the hospitality industry to introduce customer satisfying protocols….but in Emergency Health Care…. We have real patients…. Not Air Travelers and definitely not the crowd which visits resorts and beach hotels.

The psychological mindset is totally different on either sides… patients and providers.

We have to work on Safety norms which consider the culture of Acute Decision Sciences at the same time the Communication algorithms have to be modified into a systems approach.

Physicians have to be kind to their patients and communicate with them and also meet the metrics.

Greeting patients, updating them about the plan and also appraising them of the test results and the future course of action is key. Closing the encounter by telling the patient what you are going to do …discharge or admission and details of the process are key.

If you haven’t been able to appraise them then apologizing and then appraising them is of help…. But again this if put into a process will definitely change the way we deal with our patients.

The process needs to play a role because metrics and overcrowding are key factors and just assuming that Patient Experience is directly equal to Physician Communication Skills is not completely correct.
The whole culture of communication has to start from the time patient arrives in the ED. If the patient expresses the slightest concerns then the team member has to activate the physician of the concern and that should be addressed and documented.

Documentation is key and Communication is also visible via the documentation in the chart.
There will be patients who are tough to deal with … but again it’s all about the skills and not getting emotionally hijacked is the key.

All this needed intense training and an ongoing commitment to improve oneself. Taking the feedback on patient complaints positively and the advice of your colleagues and nurses positively is very important for personal growth as a human being.

Treat you patients like you would like to be treated……. My Teacher taught me that and I continue to practice the same !

  From the Desk of                                                                                                                                                                                         Sagar Galwankar, MBBS, DNB, FACEE (India), MPH, Dip. ABEM (USA), FRCP (UK)

Friday 15 July 2016

PokeMon Emergencies : A Call for Public Health Safety

From the Desk Of:
Sagar Galwankar, MBBBS, DNB, FACEE (INDIA), MPH, Dip. ABEM (USA), FRCP (UK)

As I went to work I saw few of my colleagues discussing about this new app called PokeMon GO.

This is a Freely available Video Game played via a downloadable app. 

This allows players to capture digital creatures at real locations synchronized with GPS. The GPS Activated locations are called POKESPOTS and the players can capture and gain points called XP. 

There are various awards and rewards by playing this game. 

This has a lot of implications. 

There is massive Public Frenzy and craze and as I had guessed People are trespassing and many accidents and injuries are anticipated when driving walking as people continue to play  and not pay attention.

A New Era of Public Safety Threat has emerged and reached a whole new level !

I recently read this article:

Were we not glued on enough to the Smart Phone on Social Media and video games ?

Were we not disconnected enough that Messaging became the New means of Communication ?

Were we not lonely enough that animated characters are the new friends ?

Technology can with advances but also came with Public Health Threats.

Smarts Phone created a new platform and era of STAT COMMUNICATIONS and UPTODATE INFORMATION.

That brought the Public Health Threat of Civil Safety as Social Media played an Open Access Platform with information about who is doing what and when.

It also brought to light the Road Safety issues where crashes happened while Texting.

It brought to light the violation of privacy of people in the world.

I believe that Mass Frenzy is a phenomenon which has often been the single most important factor to heightened ignorance and accidents.

Travel on Roads as a Driver/ Rider or Pedestrian, Walking at Home or at work and not focusing on what you do will cause a fall/crash and injuries are more severe than ever.

I have seen patients who have got insomnia as a result of sounds and rings of social media and their addiction to see the phone a Pavlov Rat.

This Digital Plantation of Revolutions have brought a new age of humans who have isolated themselves to find solace in their single trusted friend.....their smart phone.

Video Games are the new friends introduced by this trusted friend.

There have been many news which have already started reporting injuries and accidents and I soon think we will have to ask for every car crash / and fall .....Were you playing on the SmartPhone ?

The answer may just be YES.

I think its time that Public Health Social Marketing Strategies highlight the urgency to design initiatives to break this addictive unsafe habits of SmartPhone Public Health can be safer than before !

When people's mind is fixated on one thing then that is what drives their lives. 

Texting, trespassing and all the crashes falls and accidents with the above apps proves that these are sane people who are conditioned to commit themselves to this public safety risk and hazards..... this is much bigger than just a Habit.... this is addiction and the single biggest Mental Health Challenge to Public Health.

Thursday 7 April 2016

"For The Patients" ~ Lets talk about Headache in Adults !

From the Desk of Sagar Galwankar, MBBS, DNB, FACEE, MPH, Diplomat. ABEM, FRCP

The Patients who come seeking Emergency Care...."My Emergency Patients in My ED" is all that has mattered since years as it is because of them that I am a EM Doc and this specialty called EM exists.

I see lots of Social media Posts trying to be to become Education Materials. I see EKGs being discussed on social media. Nowadays they are the new classrooms.

So lets talk about symptoms which need lots of thinking and are High Risk.

This series will be called "For the Patients"

Today I will discuss HEADACHE.

Headache is one of the common symptoms when patients come to the ED.

Headache can be a Presenting Complaint when the patient arrives. "I got a Headache" and sometimes when patients are being evaluated at bedside for some other symptoms they can add the complaint "..and I also have an Headache"

History takes paramount importance when a patient complains of Headache as a Primary Symptoms or a Co-Symptom as a part of a Series of Complaints.

Always evaluate Headache keeping a 360 Degree approach.

Always address Headache. via your Thought process, History taking and Clinical Exam.

Vital Signs take a Lot of Importance and ask for them as you immediately prescribe pain medications to treat the PAIN.

Temperature, Pulse, Blood Pressure, Respiration, Pulse Ox, and Bedside Glucose are key stat Bedside Parameters which guide you to a story. Order an EKG Stat and read it.

Remember:  Gender does matter ! Pregnant Females & Females who do not know they are pregnant can come to the ED. Being Pregnant Changes the way you will evaluate these patients. Having abdominal pain, Hyperemesis gravidarum vaginal bleed can come with an headache and evaluating for abdominal emergencies and Ruling out Ectopic Pregnancy at the same time deciding about CT Head and Headache work up is a complex issue. They can also have HELP Syndrome or Eclampsia also can start with Headache.

Age is crucial before Young Female with Headache and Cold and Cough is different from a 50 Year old with Headache and Blurry Vision.

History taking should include: When did it start, how severe is it from a scale of 1-10, any other symptoms of Dizziness, Focal weakness, Gen weakness, Vision changes, neck pain, Syncope Seizures, Nausea, V omitting Diarrhea, Chest Pain, SOB, Neck Pain/Stiffness, Dizziness, Vertigo have to be ruled in or ruled out.

Past History of DM HTN CAD CVA Cancer HIV Hep B Hep C are important.
Is patient on anticoagulants also is key history point.

Some Cluster approaches are:
Fever, Tachycardia, Headache, Neck Pain: Here Headache can be as simple as a Viral Fever or as severe as early meningitis or even a URI if Cold Cough Sinus Tenderness are present.

Headache could be a early Bleed (Subarachanoid) or even a CVA when patients have vasculitis, Bleeding disorders, Hypertension , DM.

Headache can be due to Glaucoma or due to Otitis Media or even early Temporal arteritis.
Headache can be segmental along a nerve for a early developing Zoster.

Syncope, Fall, Seizure, Loss of Sensorium, Altered Mental Status with Headache all can be indicating a worse diagnosis  than how the Headache presented.

Post Ictal Phase can present as Headache.

Another con-founder: MI/ACS can also present as an Headache so can arrhythmia or PE. So EKG Trop are Important.

There have been cases who have presented as an Headache and when you do labs there has been Low Hemoglobin and patient has a GI Bleed and the Immediate anemia has caused an headache.

Be very particular and alert when Patients says "Headache is what brought me to the ED"
On the other hand there is tons of Literature of approach to Migraine in ED.

Its very important that you read the literature as there are various combinations of medications used to break the migraine.

When a patient says "I have a Migraine attack" you still have to approach it as an HEADACHE.

Sometimes patients present with Neck Pain and Stiffness and we disregard it as "Slept on wrong side or Neck sprain". Evaluating for Cord Compression and keeping Dissection and SAH as a differential is equally important as much as ACS/MI or even a Retro pharyngeal abscess in a URI patient.

What it comes down to is:

Vitals, Past History, Med List, Clinical Co-Symptoms, History of Complaint, Detail Clinical Exam to include total undressing of patient Neuro Vascular HFN HEENT Exam and Lab Results is crucial.

Overdose and Drug abuse are important historical points which can indicate Cocaine abuse or even overdose unintentionally on paracetamol ibuprofen trying to self medicate with Over Counter Medications.

CBC, LFT RFT Trop EKG UA Tox Screen and CT / MRI ESR are a part of the work up in ED.
In a patients with Hypoglycemia or Hyperglycemia Ketoacidosis versus Toxicity v/s sepsis or infection has to be kept at back of mind.

In HTN emergency headache can be because of raised BP and Raised BP can cause headache. Treating both is important but also is important ruling out cardiac pathologies a CT Head and look for Posterior Reversible Encephalopathy Syndrome.

I have also read reports where patients were on anticoagulants and had neck pain and when MRI was done it has Hemomyelia into the spinal cord.

There have been cases alcoholism where patients wake up with headache in ED but they dont know that Methanol or Toxic alcohols were also drunk and they have an Headache.

Being very aggressive to rule out meningitis and SAH and using Spinal Taps with Clinical Co relation is important in the ED.

Patients often return post spinal tap with headache and at this time Blood Patch becomes a choice after you have ruled out any other cause or pathology.

Patients also have headache after Nitro given for Chest Pain.

Fever can exacerbate Headache and Hunger can do that too.

A TIA can be presenting as Headache being one of the Co-Symptoms.


Always Document in detail the history the clinical exam and the plan for ordering tests and meds and chart your thought process and notes as you reevaluate the patient.

That helps and maintains the continuum of care at the same time maintaining standards of care.
Discharge is a crucial part. Here too Educating the patient and giving return instructions is key.

Do not Disregard or Less regard HEADACHE. Its a Part of the PAIN PATHOLOGIES which can cause PAIN if ignored.

Patients have Pain , treat it first but work it up and decipher the cause then treat the cause....  FOR THE PATIENTS !