59F with nocturnal episodes of altered sensorium

http://classworkdecjan.blogspot.com/2017/01/severe-obesity-and-hypoglycemia-even.html

 59 year old woman with obesity, snoring since 10 years, diabetes since 5 years and recent nocturnal episodes of altered sensorium:

CLASSWORKDECJAN.BLOGSPOT.COM

severe Obesity and Hypoglycemia even after food

Disclaimer:- This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here dec...

13You, Shreyas Chawathey, Pallab Roy and 10 others

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• Rakesh Biswas

  Admin

  Dr 

  Preeti

   a similar patient of OSA was offered a prosthesis by one of your students a few years back. Is it still be offered at PCDS? 

  Amy

  , 

  Vasumathi

   would it be possible to share literature around efficacy of prosthesis toward patient outcomes in obstructive sleep apnoea?

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  •  · 4 y
• Boudhayan Dm

  Sir has the Polysomnography report come ??

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  •  · 4 y
• Rakesh Biswas

  Admin

  Polysomnography is scheduled for tomorrow

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  •  · 4 y
• Boudhayan Dm

  Sarfaraz Jalil Baig

   welcome Sir. Sir is one of the exponents of Bariatric Surgery in Bengal . Request for his inputs. Will request Dr. 

  Jagat J Mukherjee

   

  Soumik Goswami

   Sir for their inputs on further work up on the Obesity aspect. 

  Avinash Kumar

   can u pls upload all the investigations and reports so far regarding Obesity work up we have done

  

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  •  · 4 y
• Boudhayan Dm

  Request Drs 

  Shantanu Panja

   

  Dipankar Datta

  Arjun Dasgupta

   

  Prasanna Datta

   regarding the ENT aspects of Morbid Obesity which should be addressed and explanations for the mechanism behind the oral manifestations

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  •  · 4 y
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• Rakesh Biswas

  Admin

  " In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared." http://pittsburghdentalsleepmedicine.com/wp.../docs/02.pdf

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  •  · 4 y
• Rakesh Biswas

  Admin

  A study to "identify independent prognostic predictors of the efficacy of oral appliance (OA) therapy for obstructive sleep apnea syndrome (OSAS) revealed "that it is is more effective in patients with large anteroposterior diameter of the maxilla and large lower facial height." http://file.scirp.org/Html/9-1460141_22666.htm

  

  FILE.SCIRP.ORG

  Prognostic predictors on the efficacy of oral appliance therapy for obstructive sleep apnea syndrome

  Prognostic predictors on the efficacy of oral appliance therapy for obstructive sleep apnea syndrome

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  •  · 4 y
• Rakesh Biswas

  Admin

  Treatment of obstructive sleep apnea with mandibular advancement appliance over prostheses: A case report: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608885/

  

  NCBI.NLM.NIH.GOV

  Treatment of obstructive sleep apnea with mandibular advancement appliance over prostheses: A case report

  Treatment of obstructive sleep apnea with mandibular advancement appliance over prostheses: A case report

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  •  · 4 y
• Rakesh Biswas

  Admin

  "A likely explanation for similarity in key health outcomes is that oral appliances are more consistently used for a greater proportion of the total sleep period, compared to CPAP." http://www.jdsm.org/ViewArticle.aspx?pid=30229

  AADSM.ORG

  Object moved

  Object moved

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  •  · 4 y
• Preeti Nair

  Rakesh, will letvu know

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  •  · 4 y
• Rakesh Biswas

  Admin

  Her altered sensorium/psychosis persists in spite of her documented normal Spo2. Our psychiatrist, Dr 

  Imon Paul

   has evaluated her and begun her on Arpiprazole. Over to Dr 

  Imon

   for her inputs and thoughts on this patient.

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  •  · 4 y
  • Imon Paul

    I think we need to analyse the sleep study result and also keep in mind the fact that she was consuming some unknown medication.....currently she has disorientation, agitation n irrelevant speech.....keeping in mind her metabolic profile aripiprazole has been started

    

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    •  · 4 y
  • Boudhayan Dm

    We have ordered for 24 hr Urinary cortisol? Patient was consuming Sorbitrate tablets and Ayurveda Meds( possibly containing steroids) at her own will for several years without the knowledge of the others at home? 

    Namrata Dass

     Maam what else can we evaluate for this morbid obesity? If all reports are negative do we have any option other than Bariatric Surgery ??....... What we need presently is a good cardiac evaluation....... Echo screening was not much useful...... Will request our Cardiologist Consultants to do it personally.

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    •  · 4 y
  • Rakesh Biswas

    Admin

    Thanks Dr 

    Imon

    . Interestingly there are counter views on Aripiprazole as some studies have shown that " the incidence of Metabolic syndrome was 37% for

    patients on aripiprazole and was higher than olanzapine. Other studies have shown higher rates of drug discontinuation associated with an insufficient advantage in terms of metabolic side-effects) http://onlinelibrary.wiley.com/doi/10.1111/acps.12468/pdf

    ONLINELIBRARY.WILEY.COM

    Metabolic syndrome and drug discontinuation in schizophrenia: a randomized trial comparing aripiprazole olanzapine and haloperidol - Parabiaghi - 2015 - Acta Psychiatrica Scandinavica - Wiley Online Library

    Metabolic syndrome and drug discontinuation in schizophrenia: a randomized trial comparing aripiprazole olanzapine and haloperidol - Parabiaghi - 2015 - Acta Psychiatrica Scandinavica - Wiley Online Library

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    •  · 4 y
  • Rakesh Biswas

    Admin

    Would be good to have Dr 

    Karthik

    's inputs on the above

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    •  · 4 y
  • Namrata Dass

    Boudhayan Dm

     1. I believe you are thinking of hypercortisolism which is definitely a differential diagnosis in this patient. Also, she possibly has a history of exogenous use of steroids (we don’t know which one) so she likely has iatreogenic hypercort… 

    See more

    

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    •  · 4 y
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  • Rakesh Biswas

    Admin

    Thanks 

    Namrata

     for this very well elaborated and useful inputs. Yes we have abandoned getting the 24 hour urine for cortisol and her psychosis is much better now and we hope to release her soon.

    

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    •  · 4 y
  • Boudhayan Dm

    Yes 

    Namrata Dass

     Maam. We also thought on similar lines and am not getting the levels done. With her lifestyle may not be the solution but then other than Kolkata I don't think Bariatric Surgery is performed anywhere else

    

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    •  · 4 y
  • Namrata Dass

    Rakesh Biswas

    Boudhayan Dm

    Okay, I just hope that we have confirmed the medication that she is taking since that may change the management completely.

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    •  · 4 y
  • Boudhayan Dm

    Chemical analysis of the medications not available in most centres..... Thank you 

    Namrata Dass

    Ma'am for your inputs.......

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    •  · 4 y

  Write a reply…

  
  
• Ambarish Bhattacharya

  pCO2 level?

  

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  •  · 4 y
• Rakesh Biswas

  Admin

  Hope to soon share the detailed sleep study results done yesterday

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  •  · 4 y
• Rakesh Biswas

  Admin

  Interestingly there are reports of OSA associations with psychosis and one postulate is that it could be due to sleep deprivation stress: https://www.actaspsiquiatria.es/.../14-75-ENG-43-45...

  

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  •  · 4 y
• Rakesh Biswas

  Admin

  Thanks 

  Namrata

   for this very well elaborated and useful inputs. Yes we have abandoned getting the 24 hour urine for cortisol and her psychosis is much better now and we hope to release her soon.

  

  1

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  •  · 4 y
• Rakesh Biswas

  Admin

  Avinash

   can you also share her polysomnography report in her online record?