DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient was seen in the office today. He is a (XX)-year-old Hispanic male with a history of obstructive sleep apnea. He had a study done initially for reported snoring and daytime sleepiness. He was subsequently placed on CPAP at 7 cm of water, which he is using every night. He reports that his wife notes that his snoring has resolved, but he is still complaining of daytime sleepiness.
The patient states that he is presently going to bed at 12 midnight to as late as 1 a.m. He wakes up one to two times at night but is able to fall back asleep without difficulty. He finally gets up out of bed at 6 to 6:30 a.m. He feels sleepy one hour after he initially gets up. He denies any morning headaches.
The patient states that he may nap after breakfast for 45 minutes. He states that in the mid afternoons, he feels sleepy again. Overall, he will nap two out of seven days of the week. He states that his afternoon naps would usually last 15 minutes, and he usually feels better after them. His weight is unchanged over the last year. He denies any history of thyroid disease or head or nasal injuries. Caffeine-wise, he drinks one coffee a day. He states that he has been treated with Nuvigil, but now, it is no longer helping him in regards to daytime sleepiness.
PAST MEDICAL HISTORY: Multiple sclerosis, renal cyst, and obstructive sleep apnea.
PAST SURGICAL HISTORY: Intrathecal pump, right knee surgery, and cataract surgery.
MEDICATIONS: Copaxone injections, Prozac, Nuvigil, finasteride, CellCept, Aciphex, Ampyra, clindamycin, furosemide, Toviaz, multivitamins, fish oil, and aspirin.
ALLERGIES: Penicillin.
SOCIAL HISTORY: The patient quit smoking 20 years ago. Prior to that, he smoked one pack a day for 10 to 15 years. He has one to two glasses of wine at dinner.
FAMILY HISTORY: Father died at age 88 of old age. Mother died at age 94 of old age.
REVIEW OF SYSTEMS:
HEENT: The patient reports floaters and decreased acuity in his vision and decreased hearing.
RESPIRATORY: He denies shortness of breath or cough.
CARDIAC: He denies chest pain.
GASTROINTESTINAL: He denies nausea, vomiting or diarrhea.
GENITOURINARY: The patient reports that he has a catheter in place.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 122/78 mmHg, pulse 60 beats per minute, respirations 16 breaths per minute, and pulse oximetry 98% on room air.
HEENT: Ears: Tympanic membranes are intact bilaterally. Nose: He has excoriations noted in his right naris. Mouth and Throat: Showed a Mallampati I.
NECK: Without lymphadenopathy.
HEART: Regular.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and symmetrically enlarged.
EXTREMITIES: +3 edema, right greater than left.
We reviewed a split-night polysomnogram study from prior, which showed an apnea-hypopnea index of 55.6 events per hour during the initial portion of the study, which then decreased with CPAP therapy to 0 events per hour with CPAP at 7 cm of water. Overall, sleep quality was poor with a total sleep time of 214 minutes and a sleep efficiency of 48%.
IMPRESSION: A (XX)-year-old Hispanic male with previously diagnosed severe obstructive sleep apnea, presently on CPAP at 7 cm of water. We are uncertain if this pressure is truly adequate in treating his severe sleep apnea. Apparently, he has no smart card in his present device.
RECOMMENDATIONS: We would like to change him to an auto-titrating CPAP with a pressure range of 5-20 cm of water and then check the smart card data in one month. We will talk to him after the above is completed.
