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Good morning. I have a case that I would appreciate any commentary on. For those of you in academics, I wouldn't mind you drawing this to the attention of relevant faculty.
I have a patient I saw Thursday. She has a peculiar history of insomnia and lack of appetite since a surgical procedure in 2011. But first some background. This is her story...
Ms. A is a 42-year-old right-handed African-American female with a past medical history of migraine headaches, hypertension, hyperlipidemia, obesity (BMI of 33.1 kg/m2), chronic insomnia, and moderate obstructive sleep apnea. This latter was diagnosed by full-night sleep study completed May 12, 2013, with an overall apnea-hypopnea index of 15.0, REM apnea-hypopnea index 29.0, supine apnea-hypopnea index 6.9, oxygen saturation nadir 79%, and 22.9 minutes spent with oxygen saturation less than 88%. She had a titration polysomnogram completed May 26, 2013, which found that BiPAP at 10/6 cm H2O normalized the apnea-hypopnea index to 0.6 with an oxygen saturation nadir of 93%. She was ordered a BiPAP machine and returned to me Thursday for follow-up after having last been seen in clinic on May 1, 2013, with an Epworth Sleepiness Score of 2 (and being ordered her first sleep study). Epworth Sleepiness Score in the office is 2 (normal is less than 10). She loves the BiPAP. She denies trouble with it. Her energy levels and quality of sleep are improved for using BiPAP when she actually sleeps.
But that's not what bothers me here.
She has a history of very short sleep times since a second hysterectomy (for fibroids and bleeding) in 2011. Before this, she would sleep around 6 hours per night. The six hours were totally refreshing for her. After having the second hysterectomy surgery, she immediately noted postoperatively that she slept much less because she was "wired" and she also noticed that her hunger drive diminished. She now sleeps between 0 and 4 hours per night. It is not unusual for her to average 1.5 hours per 24 hour cycle. She feels fine when she awakens, if not exactly completely refreshed. This has been unresponsive to medications, including trazodone or over-the-counter sleep aids. She has no diminished energy levels or side effects of the lack of sleep. She actually isn't complaining about this per se. Just a bit annoyed and perhaps slightly fatigued.
I don't have copies of her operative report, hospital stay, or any history of an MRI brain. She tells me she'll bring in her records from the hospital.
Her neurologic exam is non-focal.
I had previously thought she simply had short sleep times. I didn't get her post-op history and the clue of lack of appetite until this last office visit.
For the non-sleep disorders people, the lateral hypothalamus contains the orexin-producing neurons that stimulate wakefulness and appetite. Loss of these cells gives you that picutre of narcolepsy (and increased appetite). If my patient's symptoms were actually secondary to a stroke, or some manner of injury from the anesthesia or surgery, where would it localize to? What actually could I do about it save watchful waiting? Again, she has no true complaints beyond what I've listed, and I plan on getting the MRI (though this happened two years ago). Probably be denied by insurance.
I'm just curious if you guys believe I'm overthinking this. Where should the lesion actually localize to (providing there is one)? What would you do with her (I know there are some new sleeping medications on the horizon that block orexin receptors)? I cannot find any articles with a similar clinical constellation, are any of you aware of some? Any help from those here, or specific faculty at your home institutions would be appreciated. I am available by PM if you don't wish to post.
Kind regards.
I have a patient I saw Thursday. She has a peculiar history of insomnia and lack of appetite since a surgical procedure in 2011. But first some background. This is her story...
Ms. A is a 42-year-old right-handed African-American female with a past medical history of migraine headaches, hypertension, hyperlipidemia, obesity (BMI of 33.1 kg/m2), chronic insomnia, and moderate obstructive sleep apnea. This latter was diagnosed by full-night sleep study completed May 12, 2013, with an overall apnea-hypopnea index of 15.0, REM apnea-hypopnea index 29.0, supine apnea-hypopnea index 6.9, oxygen saturation nadir 79%, and 22.9 minutes spent with oxygen saturation less than 88%. She had a titration polysomnogram completed May 26, 2013, which found that BiPAP at 10/6 cm H2O normalized the apnea-hypopnea index to 0.6 with an oxygen saturation nadir of 93%. She was ordered a BiPAP machine and returned to me Thursday for follow-up after having last been seen in clinic on May 1, 2013, with an Epworth Sleepiness Score of 2 (and being ordered her first sleep study). Epworth Sleepiness Score in the office is 2 (normal is less than 10). She loves the BiPAP. She denies trouble with it. Her energy levels and quality of sleep are improved for using BiPAP when she actually sleeps.
But that's not what bothers me here.
She has a history of very short sleep times since a second hysterectomy (for fibroids and bleeding) in 2011. Before this, she would sleep around 6 hours per night. The six hours were totally refreshing for her. After having the second hysterectomy surgery, she immediately noted postoperatively that she slept much less because she was "wired" and she also noticed that her hunger drive diminished. She now sleeps between 0 and 4 hours per night. It is not unusual for her to average 1.5 hours per 24 hour cycle. She feels fine when she awakens, if not exactly completely refreshed. This has been unresponsive to medications, including trazodone or over-the-counter sleep aids. She has no diminished energy levels or side effects of the lack of sleep. She actually isn't complaining about this per se. Just a bit annoyed and perhaps slightly fatigued.
I don't have copies of her operative report, hospital stay, or any history of an MRI brain. She tells me she'll bring in her records from the hospital.
Her neurologic exam is non-focal.
I had previously thought she simply had short sleep times. I didn't get her post-op history and the clue of lack of appetite until this last office visit.
For the non-sleep disorders people, the lateral hypothalamus contains the orexin-producing neurons that stimulate wakefulness and appetite. Loss of these cells gives you that picutre of narcolepsy (and increased appetite). If my patient's symptoms were actually secondary to a stroke, or some manner of injury from the anesthesia or surgery, where would it localize to? What actually could I do about it save watchful waiting? Again, she has no true complaints beyond what I've listed, and I plan on getting the MRI (though this happened two years ago). Probably be denied by insurance.
I'm just curious if you guys believe I'm overthinking this. Where should the lesion actually localize to (providing there is one)? What would you do with her (I know there are some new sleeping medications on the horizon that block orexin receptors)? I cannot find any articles with a similar clinical constellation, are any of you aware of some? Any help from those here, or specific faculty at your home institutions would be appreciated. I am available by PM if you don't wish to post.
Kind regards.
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