The psychiatry service was called to evaluate a patient in the outpatient procedure unit who could not remember who she was or why she was there. “Ms. R” was a 36-yearold Hispanic woman with a history of morbid obesity who underwent an upper endoscopy for evaluation of nausea and inability to tolerate oral intake 1 month after a Roux-en-Y gastric bypass for her obesity. The endoscopy demonstrated moderate stenosis at the gastrojejunal anastomosis, which did not account for the severity of her nausea. The stenosis was dilated without incident. For the procedure, Ms. R received a total of 420 mg i.v. of propofol, 100 mg i.v. of lidocaine, and 0.2 mg i.v. of glycopyrrolate. She also received a total of 200 μg i.v. of phenylephrine for a transient decrease in blood pressure to 81/45. In the recovery room, when Ms. R awoke from her conscious sedation, she had no recollection of why she was in the hospital, was disoriented to place, and, most significantly, was unable to recall her identity. She was agitated, prompting the psychiatric consultation. Ms. R was visibly frightened when any person tried to approach her, including her boyfriend of 5 years. She repeatedly asked why she was there but was unable to retain the information received. She was given 2 mg of midazolam for agitation, after which a minor improvement in behavior was observed. A repeat dose of midazolam was administered, without further improvement. Forty-five minutes after the procedure, Ms. R was still unable to recall her date of birth. Her vital signs and general physical and neurological examination were within normal limits. Her mental status examination was significant for agitation, disorientation to person and place, and extensive memory loss, which continued for the rest of the day. She repeatedly expressed the delusion that the baby she had just delivered was taken from her. She had no evidence of hallucinations. A preprocedure pregnancy test was negative. Ms. R was on a liquid diet and taking a multivitamin once daily, 1,000 μg of vitamin B12 three times a week sublingually, and calcium citrate daily. Ms. R’s past medical history included a history of gallstones as well as the Roux-en-Y gastric bypass surgery 1 month earlier, at which time her body mass index (BMI) was 47. Ms. R had received 200 mg of propofol as part of the anesthesia during the 3-hour bariatric surgery without incident. Ursodiol was begun 3 weeks before the endoscopy for nausea that developed while she was consuming a postoperative liquid diet. When her diet was advanced to soft foods, she began vomiting. She returned to a liquid diet, and the endoscopy was scheduled. Ms. R’s past psychiatric history was significant for a dissociative fugue, which occurred at the same time as her divorce 7 years earlier and for which she was psychiatrically hospitalized. She continued in individual and group treatment for 2 years after that hospitalization. She had no history of traumatic events. Because of Ms. R’s persistent amnesia and agitation, she was admitted to amedical unit for further evaluation. Results of all testing, routine laboratory tests, urine drug screen, head CT, head MRI, and EEG were normal except for ketones in the urine. Ms. R’s BMI had decreased to 40.5. She was started on a clear liquid diet and had no further nausea. The neurology consultant agreed with the psychiatrist’s diagnosis of dissociative amnesia. During her hospitalization, Ms. R slowly regained some of her memory. She vaguely remembered that she had an adult son living in another state. Ms. R could not remember how to use her cell phone. She was afraid to take a shower without supervision as she was not sure she would know what to do. She also could not recall important historical events, such as the September 2001 attacks on the World Trade Center. There was no evidence of anterograde amnesia after the first hospital day. After showing some improvement over her 6-day hospitalization, she was discharged home with her boyfriend. Two weeks after hospital discharge, Ms. R continued to recover some of her memories and to increase her activities. It was unclear, however, whether her retrograde amnesia was improving or whether she was only retaining newly learned information. She began to cook on her own and reported increased comfort around her boyfriend and her family. Ms. R was afraid to return to work because she was concerned that she would not remember how to do her job. Within 2 months of the episode, Ms. R was retrained by her employer and successfully resumed her work as a secretary. Six months after the procedure, Ms. R’s retrograde amnesia had significantly improved and she continued to form new memories without difficulty.
Search from 250 M+ research papersSearch from 250 M+ research papers
Open Access
Sep 18, 2014
Laura J Gaydos + 2
