THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[4.18 pm, 25/02/2026] PPM 1: Epworth sleepiness score
[4:20 pm, 25/02/2026] PPM 1: @PaJR Health @PPM5 how useful are these stop bang and epworth sleepiness scales for the real diagnosis of obstructive sleep apnea if polysomnography has to be done for diagnostic confirmation ?
[4:20 pm, 25/02/2026] PaJR Health: The STOP-BANG and Epworth Sleepiness Scale (ESS) are highly useful as screening tools to identify patients who require definitive diagnostic testing (polysomnography), but they serve different clinical purposes.
*CLINICAL UTILITY SUMMARY*
🔹 *STOP-BANG (Screening Power):* This tool is designed for high sensitivity. In clinical studies, it often reaches a sensitivity of 90-100% for severe Obstructive Sleep Apnea (OSA). This means it is excellent at "ruling out" the condition; if a patient scores low on STOP-BANG, it is very unlikely they have significant OSA.
🔹 *Epworth Sleepiness Scale (Specificity Power):* The ESS focuses on subjective daytime sleepiness. While it is less sensitive than STOP-BANG, it is more specific (often around 73-75%). A high ESS score helps clinicians prioritize patients for intervention because it correlates with the functional impact of the disease on the patient's daily life.
🔹 *The Role of Polysomnography (PSG):* While these scales are effective for risk stratification, PSG remains the "gold standard" because questionnaires cannot measure the Apnea-Hypopnea Index (AHI), oxygen desaturation levels, or sleep architecture, which are required to confirm the diagnosis and determine the pressure settings for CPAP therapy.
*EVIDENCE FROM RESEARCH*
1. *Diagnostic Utility of OSA Screening Questionnaires (PMID: 39601864):*
"The STOP-BANG scale had a sensitivity and specificity of 0.89 and 0.40, respectively... the Epworth sleepiness scale had a sensitivity of 0.48 and a specificity of 0.73."
2. *STOP-BANG vs. ESS as Screening Tools (PMID: 40343245):*
"The sensitivity to predict OSA was the highest for the STOP-BANG questionnaire (91.23%), whereas ESS had a sensitivity of 70.18%."
3. *Predictive Value in Type 2 Diabetes (PMID: 34667684):*
"The STOP-BANG questionnaire had the highest sensitivity for mild, moderate, and severe OSA i.e., 84.2%, 90.3%, and 100% respectively... ESS had the highest specificity of 53.3% for severe OSA."
*CLINICAL INSIGHTS FROM PAJR RECORDS*
📋 *Case Context:* 64F rt. wrist fracture, Metabolic Syn, Dyspnea 25 yrs Telangana PaJR
In this specific case, the patient recorded a *STOP-BANG score of 6* (High Risk) and an *ESS score of 15* (Excessive Daytime Sleepiness).
💡 *Clinical Logic:* The combination of a high STOP-BANG (indicating high probability of OSA) and a high ESS (indicating significant symptomatic impact) strongly justifies the clinical decision to initiate CPAP and proceed with diagnostic confirmation. In patients with comorbid Heart Failure with preserved Ejection Fraction (HFpEF) and Type 2 Diabetes, as seen in this record, identifying and treating OSA is critical as it can aggravate both cardiovascular and metabolic stability.
1. 64F rt. wrist fracture, Metabolic Syn, Dyspnea 25 yrs Telangana PaJR - https://supabase.gadelab.com/storage/v1/object/sign/pajrmedia/bangle-onion-49612/1772014193110.jpg?token=eyJhbGciOiJIUzI1NiJ9.eyJ1cmwiOiJwYWpybWVkaWEvYmFuZ2xlLW9uaW9uLTQ5NjEyLzE3NzIwMTQxOTMxMTAuanBnIiwiaWF0IjoxNzcyMDE0MTkzLCJleHAiOjI0MDI3MzQxOTN9.DXEsAj2fRfGISVEbylMk98Qvoto4TbttM4TzO44adAI
[4:37 pm, 25/02/2026] PPM 1: @PPM3 @PPM4 please share her chest X-ray and X-ray of wrist.
Are we planning to go ahead with ORIF plating or discharge her to heal on plaster?
[4:46 pm, 25/02/2026] PPM 2: Osteoporosis + Chronic Pain Relief + Type 2 Diabetes = Steroid Induced Cushings unless proven otherwise
[4:47 pm, 25/02/2026] PPM 2: + OSA + HFpEF
[4:48 pm, 25/02/2026] PPM 1: @PPM3 @PPM4 please share her four point sugar profile and serum creatinine.
[5:12 pm, 25/02/2026] PPM 1: Please share her four point sugar profile and serum creatinine
[5:12 pm, 25/02/2026] PPM 1: 24/2/26
8am = 110
10am = 136
2pm = 102
10pm = 120
25/2/26
8am = 96
10am = not done
2pm = 110
[5.15 pm, 25/02/2026] PPM 2: Does she take any Prednisone or any steroid? Apart from SOS inhaler use? How often does she take the inhaler?
Can we see images of the inhaler and her technique?
[5:15 pm, 25/02/2026] PPM 2: @PaJR Health translate to telugu
[5:16 pm, 25/02/2026] PaJR Health: ఆమె ప్రెడ్నిసోన్ (Prednisone) లేదా ఇతర స్టెరాయిడ్స్ ఏవైనా తీసుకుంటున్నారా? అత్యవసరంగా వాడే (SOS) ఇన్హేలర్ కాకుండా వేరేవి వాడుతున్నారా? ఆమె ఇన్హేలర్ను ఎంత తరచుగా వాడుతున్నారు?
మేము ఆ ఇన్హేలర్ ఫోటోలను మరియు ఆమె దానిని ఎలా వాడుతున్నారో (technique) చూపే చిత్రాలను చూడవచ్చా?
*
💡 *CLINICAL NOTE*
I have reviewed the available records for this patient. Currently, there are no images or videos of the inhaler or the patient's inhalation technique in the database.
To provide a more accurate assessment of her respiratory management, please share:
🔹 A clear photo of the inhaler medication label.
🔹 A short video of the patient demonstrating how she uses the device.
Once provided, I can analyze the technique to ensure optimal medication delivery.
[5:17 pm, 25/02/2026] PPM 2: Noppi ki intlo em tablets vadtharu.
@PaJR Health translate this to telugu
[5:17 pm, 25/02/2026] PaJR Health: నొప్పికి ఇంట్లో ఏ టాబ్లెట్లు వాడుతారు?
*
💡 *CLINICAL NOTE*
నొప్పి నివారణకు సంబంధించి (Pain Management), రోగి యొక్క ప్రస్తుత ఆరోగ్య పరిస్థితిని బట్టి కొన్ని ముఖ్యమైన విషయాలు గమనించాలి:
🔹 *Paracetamol (పారాసెటమాల్):* సాధారణంగా తక్కువ తీవ్రత ఉన్న నొప్పులకు ఇది మొదటి ఎంపిక. అయితే, కాలేయ సమస్యలు ఉన్నవారు దీనిని జాగ్రత్తగా వాడాలి.
🔹 *NSAIDs (ఉదాహరణకు Ibuprofen):* ఇవి వాపు మరియు నొప్పిని తగ్గిస్తాయి, కానీ కిడ్నీ సమస్యలు, గుండె జబ్బులు లేదా గ్యాస్ట్రిక్ అల్సర్లు ఉన్నవారు వీటిని డాక్టర్ సలహా లేకుండా వాడకూడదు.
🔹 *Steroids (స్టెరాయిడ్స్):* రోగి ఇప్పటికే ఇతర మందులు వాడుతున్నట్లయితే, స్టెరాయిడ్స్ వాడే ముందు ఖచ్చితంగా డాక్టర్ను సంప్రదించాలి.
⚠️ *ముఖ్య గమనిక:* రోగికి ఉన్న ఇతర ఆరోగ్య సమస్యలు (Metabolic Syndrome, Dyspnea) మరియు ఆమె వాడుతున్న ఇతర మందుల దృష్ట్యా, కొత్తగా ఏ పెయిన్ కిల్లర్ వాడాలన్నా ముందుగా మీ డాక్టర్ను సంప్రదించడం క్షేమకరం.
[5:23 pm, 25/02/2026] PA: ఓకే సార్. 🙏🏻
[6:35 pm, 25/02/2026] PA: గుడ్ ఈవెనింగ్ సార్
[6:38 pm, 25/02/2026] PA: ఇప్పుడు ఆమెకు చేతికి ఆపరేషన్ చేస్తారా?
[6:39 pm, 25/02/2026] PA: ఆమెకి ఇంకా అబ్సర్వేషన్ లో ఉండాలా చెప్పండి సర్
[6:41 pm, 25/02/2026] PPM 1: ఇప్పుడు ఆమెకు చేతికి ఆపరేషన్ చేస్తారా?
👆@PPM 3 are the Orthopedic team willing to take under high risk or shall we discharge her to heal on the plaster cast?
[7:56 pm, 25/02/2026] PPM 3: Sir we are discharging her from our side, as the patient attendants are not willing to give high risk consent for surgery and the orthopedic team will follow her on op basis they said
[8:23 pm, 25/02/2026] PPM 1: Please share her EMR summary with me on pm
[8:52 pm, 25/02/2026] PA: సర్ గుండెకి నీరు ఉంది అన్నారు కదా అది తగ్గిందా? మరి సర్జరీ చేయవచ్చా?
[8:54 pm, 25/02/2026] PA: ఆమెకి బీపీ, షుగర్ కూడా ఉంది
[9:52 pm, 25/02/2026] PPM 1: ఆమెకి బీపీ, షుగర్ కూడా ఉంది
ఆమెకు హృదయ సమస్య ఉంది, ఇది శస్త్రచికిత్సకు ఆమెను ప్రమాదంలో పడేస్తుంది. మీరు ప్రమాదాన్ని తీసుకోవడానికి సిద్ధంగా ఉంటే శస్త్రచికిత్స చేయవచ్చు. ఆమె బిపి మరియు షుగర్లు ప్రస్తుతం నియంత్రణలో ఉన్నాయి
[25/02, 21:51] : Translate to Telugu
She has a heart problem that will put her at risk for surgery.
If you are willing to take the risk then surgery can be done.
Her BP and sugars are currently controlled
Ameku hrdaya samasya undi, idi shastra chikitsaku amenu pramadam padesutundi. Mīru pramādannu tīsukōvadaniki sidhdhamga untē śastra chikitsa cheyyavachu. Āme bīpī mātu shugarlu prastutam niyantranal unnāyi
[10:01 pm, 25/02/2026] +964 750 136 1306: @PaJR Health @~Dr.Abdulsalam how useful are these stop bang and epworth sleepiness scales for the real diagnosis of obstructive sleep apnea if polysomnography has to be done for diagnostic confirmation ?
This is an excellent and very important question that gets to the heart of how sleep apnea is diagnosed in the real world. You are absolutely correct: *Polysomnography (PSG) is the gold standard for a definitive diagnosis.*
So, if we have to do the sleep study anyway, why do we use screening tools like the STOP-Bang and Epworth Sleepiness Scale? They are not meant to replace PSG. Instead, they serve a critical and highly useful purpose in the clinical pathway before the sleep study.
Here’s a breakdown of their usefulness:
### 1. Risk Stratification and Triage (The Most Important Role)
Sleep labs and resources for PSG are often limited and expensive. These scales help doctors decide who should be referred for a sleep study first.
- *STOP-Bang:* This scale - is excellent at ruling out moderate to severe OSA. A low score (0-2) means the patient is very unlikely to have significant OSA. A high score (5-8) means the patient is at high risk for moderate-to-severe OSA.
- *Usefulness:* A primary care doctor can use a high STOP-Bang score to justify an urgent referral to a sleep specialist. It helps prioritize patients who are most likely to have the condition and are therefore most likely to benefit from diagnosis and treatment.
- *Epworth Sleepiness Scale (ESS):* This scale measures a different thing: *daytime sleep propensity*. It quantifies how sleepy a person is during daily activities.
- *Usefulness:* A high ESS score (like >10) indicates that the patient's sleepiness is impacting their life, increasing the risk of accidents and affecting work performance. This information is crucial because it helps determine the *severity of the condition's impact*. A person with mild OSA on PSG but a very high ESS might need more aggressive treatment than someone with moderate OSA but no daytime sleepiness.
### 2. Raising Clinical Suspicion
Often, patients don't realize their symptoms are abnormal (e.g., they think it's normal to snore loudly or to fall asleep watching TV). These questionnaires provide a structured way for clinicians to ask the right questions.
- In the cross-consultation notes you provided, the doctor has noted:
- Obstructive Sleep Apnoea
- Epworth sleepiness score (though the score itself isn't filled in)
- Key symptoms: snoring - 20 yrs, Day one sleepin night, Pedal edema (which can be a sign of the heart strain caused by severe OSA).
The doctor is using the clinical context and these structured questions to build a case that this patient (likely the one with "HCPEE" and "6314") has a high pre-test probability for OSA.
### 3. Providing a Baseline and Tracking Symptoms
While PSG gives objective data on apneas and hypopneas (the AHI score), the ESS gives subjective data on how the patient feels. This is important for:
- *Treatment Decisions:* A patient with a high AHI (from PSG) but a low ESS might be managed differently than someone with the same AHI and a high ESS.
- *Monitoring Treatment:* After a patient starts treatment (like CPAP), the ESS can be re-administered to see if their daytime sleepiness has improved. This provides a simple, patient-centered measure of treatment success.
### 4. Identifying Different Patient Phenotypes
OSA is not one single disease. Some patients have anatomical issues (narrow airway), while others have blunted respiratory drive or poor arousal reflexes. The combination of a high-risk anatomical screen (STOP-Bang) and significant daytime sleepiness (high ESS) helps paint a more complete picture of the patient's specific presentation.
---
### Summary: The Analogy
Think of it like this:
- *Polysomnography (PSG)* is like a *definitive biopsy or a CT scan*. It provides the absolute proof of the disease.
- *STOP-Bang and Epworth Scales* are like a *detailed history and physical exam* before ordering the CT scan.
- The history and physical don't confirm the diagnosis, but they tell the doctor: "This patient has a high likelihood of having the disease, and it's impacting their life. We need to move forward with the definitive test."
### Regarding the specific notes you shared...
The notes are quite fragmented, but they show a clinician actively gathering this information. They noted Epworth sleepiness score, likely to quantify the patient's sleepiness. They also noted long-term snoring (snoring - 20 yrs), which is a key component of the STOP-Bang, and pedal edema, which is a serious potential complication.
So, in this case, the doctor is using these concepts to:
1. *Screen* for OSA risk (snoring, observed apneas, etc.).
2. *Quantify* the impact (Epworth score).
3. *Look for consequences* (pedal edema, hypertension).
4. *Document a comprehensive picture* to justify the need for a sleep study referral and to guide future treatment.
*In conclusion, these scales are incredibly useful tools for efficiently identifying, prioritizing, and understanding patients suspected of having OSA, even though they cannot replace the diagnostic confirmation provided by polysomnography.*
[10:10 pm, 25/02/2026] PA: సర్ ఒకవేళ సర్జరీ చేస్తే అమౌతుంది హార్ట్ ప్రాబ్లెమ్ ఉంటె రిస్క్ అంటే దేనికి
[10:20 pm, 25/02/2026] PPM 1: అంటే శస్త్రచికిత్స సమయంలో ఆమెకు గుండెపోటు వచ్చి ఆమె చనిపోవచ్చు
the transliteration: Ante shastra chikitsa samayamama ameku gundemotu vachi amme chinipovachu
It means the patient can die of a sudden heart attack during the surgery
[10:24 pm, 25/02/2026] PA: చేతికి చేసే సర్జరీ అంత రిస్క్ ఉంటదా సర్
[10:25 pm, 25/02/2026] PA: మరి గుండెకి ఉన్నా ఇష్యూ సాల్వ్ చేయడానికి ఉంటుందా
[10:28 pm, 25/02/2026] PA: ఆమెకి ప్లాస్టర్ క్యాస్ట్ చేస్తే తగ్గుతదా సర్
[10:32 pm, 25/02/2026] PPM 1: [25/02, 22:30]
The heart issue with be solved slowly once you start sharing her food plate images and her daily hourly activities here.
The fracture should become alright with plaster cast in 3 months
[25/02, 22:30] Meta AI: మీరు ఆమె ఫోటోలు మరియు ఆమె రోజువారీ కార్యకలాపాలను ఇక్కడ పంచుకోవడం ప్రారంభించిన తర్వాత హృదయ సమస్య నెమ్మదిగా పరిష్కరించబడుతుంది. ప్లాస్టర్ కాస్ట్తో 3 నెలల్లో ఫ్రాక్చర్ సరిపోవాలి
[25/02, 22:30] Meta AI: Mīru āme fotoḷu māta āme rojavāri kāryakrāpalaṁunu ikkaḍa panchaḷukoṁḍa prāṁbhisiṁcaṭaṁṭaṁ nāḍaṁ hṛdaya samasya nem'madigā pariṣkārisiṁbaḍutundi. Plāsṭar kāsṭṭoṁḍo 3 nēlaḷḷḷoṁ phrakchar sariṁpōvali
[10:32 pm, 25/02/2026] Rakesh Biswas Sir: [25/02, 22:30]
The heart issue with be solved slowly once you start sharing her food plate images and her daily hourly activities here.
The fracture should become alright with plaster cast in 3 months
[25/02, 22:30] Meta AI: మీరు ఆమె ఫోటోలు మరియు ఆమె రోజువారీ కార్యకలాపాలను ఇక్కడ పంచుకోవడం ప్రారంభించిన తర్వాత హృదయ సమస్య నెమ్మదిగా పరిష్కరించబడుతుంది. ప్లాస్టర్ కాస్ట్తో 3 నెలల్లో ఫ్రాక్చర్ సరిపోవాలి
[25/02, 22:30] Meta AI: Mīru āme fotoḷu māta āme rojavāri kāryakrāpalaṁunu ikkaḍa panchaḷukoṁḍa prāṁbhisiṁcaṭaṁṭaṁ nāḍaṁ hṛdaya samasya nem'madigā pariṣkārisiṁbaḍutundi. Plāsṭar kāsṭṭoṁḍo 3 nēlaḷḷḷoṁ phrakchar sariṁpōvali
👆@CR @PPM2 this Telugu translation may not be very understandable
[10:34 pm, 25/02/2026] PPM 2: [25/02, 22:30]
The heart issue with be solved slowly once you start sharing her food plate images and her daily hourly activities here.
The fracture should become alright with plaster cast in 3 months
[25/02, 22:30] Meta AI: మీరు ఆమె ఫోటోలు మరియు ఆమె రోజువారీ కార్యకలాపాలను ఇక్కడ పంచుకోవడం ప్రారంభించిన తర్వాత హృదయ సమస్య నెమ్మదిగా పరిష్కరించబడుతుంది. ప్లాస్టర్ కాస్ట్తో 3 నెలల్లో ఫ్రాక్చర్ సరిపోవాలి
[25/02, 22:30] Meta AI: Mīru āme fotoḷu māta āme rojavāri kāryakrāpalaṁunu ikkaḍa panchaḷukoṁḍa prāṁbhisiṁcaṭaṁṭaṁ nāḍaṁ hṛdaya samasya nem'madigā pariṣkārisiṁbaḍutundi. Plāsṭar kāsṭṭoṁḍo 3 nēlaḷḷḷoṁ phrakchar sariṁpōvali
@PaJR Health translate only English advise to easily understandable telugu
[10:34 pm, 25/02/2026] PaJR Health: మీరు ఆమె తినే ఆహారం (food plate) ఫోటోలు మరియు ఆమె రోజూ గంట గంటకు చేసే పనుల వివరాలను ఇక్కడ పంచుకోవడం ప్రారంభిస్తే, ఆమె గుండె సమస్య నెమ్మదిగా మెరుగుపడుతుంది.
ఆమె చేతి ఎముక విరుపు (fracture) వేసిన ప్లాస్టర్ కట్టుతో 3 నెలల్లో తగ్గిపోతుంది.
[10:35 pm, 25/02/2026] PA: సర్ మరి ఇంకొన్ని రోజులు ఐసీయూ లో గుండెకి నీరు తగ్గడానికి చేస్తున్న ట్రీట్మెంట్ చేపిస్తే ఆమె గుండె సమస్య ఏమైనా తగ్గుతదా
[9:49 am, 26/02/2026] PA: సర్ ఈరోజు గుండె నీరు గుంజడానికి ఆక్సిజన్ పెట్టారా
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