Sunday 1 January 2017

severe Obesity, SOB and talking in sleep

Disclaimer:-


This is a de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

5 years ago I was diagnosed with diabetes type 2.  I am 59 year old and I was married at the age of 23 after one year I had flight to weight gain and i delivered my 1st child. After 8 year again gain weight and delivered 2nd child. Though i gained weight my child was under weight, and he was not premature.


After that i gained lots of weight but never sudden increase or decrease, it just continously kept on increasing. Now my BMI is 40+ . recently after starting diabetes medication i again gained weight of around 8-9 kg in 20 days. I was 88-89 and in 20 days i became 97.


5 year ago, i had cataract surgery in both eyes at 1 month interval and i was then at same time diagnosed as diabetic. My vision is very good now.


I decreased sweet and sugar intake in last 20 days, but other food habbits are same, and also i eat very less. My urination is normal. Since 10-15 days i am finding difficulty in breathing. My life style is not very active. Since 10-15 years i have habbit of snoring in sleep and occasionally talking in sleep in very low voice. But now since 10-15 days i am also snoring loudly and talking a lot in sleep in very high voice (volume) as my family say.


Recently in 10-15 days i also got lots of mouth ulcers also and feeling that right side of face is swelled up.

Now along with respiratory problem, very loud snoring and talking in sleep, mouth ulcer, obesity and every time i take medicine, required insulin and food still having hypoglycemia even after food.

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Her HbA1C was within normal.
ENT evaluation - mallampatti grade 2 (soft palate not visible at all)

Grade 2 fatty liver changes










Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. 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? AmyVasumathi would it be possible to share literature around efficacy of prosthesis toward patient outcomes in obstructive sleep apnoea?
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Boudhayan Dm Sir has the Polysomnography report come ??
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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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Boudhayan Dm Request Drs Shantanu Panja Dipankar DattaArjun 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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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. " 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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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. 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
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. "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
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AADSM.ORG

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Preeti Nair Rakesh, will letvu know
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. 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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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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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 evalSee more
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. 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
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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 hypercortSee more

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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. 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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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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Namrata Dass Rakesh BiswasBoudhayan DmOkay, I just hope that we have confirmed the medication that she is taking since that may change the management completely.
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Boudhayan Dm Chemical analysis of the medications not available in most centres..... Thank you Namrata DassMa'am for your inputs.......
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. 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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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. 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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