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
