SUBJECTIVE: The patient was seen in followup in the office today. The patient has been on an auto-titrating bilevel since the end of September. He states that he has been using a medium ResMed Quattro for facemask. He is presently going to bed at midnight and waking up at 5:30 a.m. two times a week and 9 to 10 a.m. the rest of the mornings of the week. The patient states that he was using his bilevel PAP regularly up until a week ago at which time he developed an upper respiratory tract infection. He does notice a difference the next day if he had used his BiPAP the previous night, of feeling more awake and alert. The patient’s medications are Nasonex, Dymista, Z-Pak, and Robitussin.
OBJECTIVE:
VITAL SIGNS: Weight 192 pounds, blood pressure 112/82 mmHg, pulse 78 beats per minute, and respirations 16 breaths per minute.
HEENT: Tympanic membranes are intact bilaterally. Nose revealed normal mucosa. Mouth and throat showed a Mallampati 2 to 3.
NECK: No lymphadenopathy.
HEART: Regular.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft.
EXTREMITIES: Negative for edema.
We reviewed the patient’s compliance data from MM/DD/YYYY through MM/DD/YYYY. It showed that the patient was only using his bilevel device 48% of the night. His average usage too at night was 2 hours and 35 minutes. His IPAP pressure 90% of the time or less is 17 cm of water, and his EPAP pressure 90% of the time or less is 15 cm of water. His residual apnea-hypopnea index is 23.
ASSESSMENT AND PLAN: Severe obstructive sleep apnea, presently on auto-titrating bilevel PAP. We told the patient that he needs to improve his compliance. He understands. We told him to be more compliant and that we will recheck the smart card data in two months. He should also work on weight reduction.
Sample #2
SUBJECTIVE: The patient was seen in the office today. The patient was last seen here in June. She had an apnea-hypopnea index of 44 events per hour on her home sleep test. She did get a mask fitting done with a ResMed Liberty small size mask. She reports that the mask does not lead to a large amount of leak; however, she is waking up four to five times a night and hits the ramp button because she feels the pressure is too high and there is too much noise coming from the CPAP unit. She will then fall back asleep after hitting the ramp button. The patient states she is presently going to bed at 12 midnight and waking up at 6 to 7 a.m. She reports some sleepiness during the day at 4 to 5 p.m. She is not taking any naps. The patient’s medications are metoprolol, diltiazem, Crestor, aspirin, CoQ10, multivitamin, calcium, and Klonopin.
OBJECTIVE:
VITAL SIGNS: Blood pressure 142/80 mmHg, pulse 74 beats per minute, respirations 14 breaths per minute, and pulse oximetry 99% on room air.
HEENT: Tympanic membranes are intact bilaterally. Nose revealed normal mucosa. Mouth and throat revealed a Mallampati 2-3.
NECK: No lymphadenopathy.
HEART: Regular.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft.
EXTREMITIES: Negative for edema.
MUSCULOSKELETAL: Kyphoscoliosis.
On review of her smart card data, it shows a residual apnea-hypopnea index of 19 events per hour without a significant large leak noted.
ASSESSMENT: Severe obstructive sleep apnea, now with no significant leak using her ResMed Liberty mask but with a residual apnea-hypopnea index of 19 events per hour. We are concerned that she might have what we refer to as ramp abuse where she wakes up repeatedly during the night feeling the pressure is too high and hitting the ramp button to lower the pressure.
PLAN: Recommended that we do an in-lab titration and then change her to a fixed pressure based on the study results. She is agreeable, and we will talk to her after the study is completed.
Sample #3
SUBJECTIVE: The patient was seen in followup in the office today. The patient states that he did get a new CPAP unit this past summer. It is an auto-titrating CPAP with a pressure setting range of 5-20 cm of water. He is presently going to bed at 11:30 p.m. At 10:30 p.m., he takes valerian, melatonin 1 mg, and an herbal pill. He will sleep until 1 a.m. and then go to the bathroom. He will then read for 30 minutes and then fall back asleep until 2 to 3 a.m. He finally gets up out of bed at 7:30 a.m. He feels awake and alert during the day. He may nap for 30 minutes in the afternoon. The patient’s medications are valerian, melatonin, herbal medication, Diovan, Norvasc, Lipitor, multivitamin, Synthroid, vitamin D, vitamin B6 and B12.
OBJECTIVE:
VITAL SIGNS: Weight 210 pounds. Blood pressure 148/88 mmHg, pulse 76 beats per minute, respirations 16 breaths per minute, and pulse oximetry 96% on room air.
HEENT: Cerumen bilaterally. Nose revealed normal mucosa. Mouth and throat were negative for erythema or exudate.
NECK: No lymphadenopathy.
HEART: Regular with occasional premature beats noted.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, symmetrically enlarged.
EXTREMITIES: Negative for edema.
ASSESSMENT:
1. Severe obstructive sleep apnea with an apnea-hypopnea index of 36 events per hour. We told, however, that we would like to check on his smart card data to see what his pressure requirements are and to evaluate his compliance.
2. Insomnia. We told the patient that it is fine to continue with his present medication regimen that he is taking prior to bedtime.
PLAN: We will contact the patient after we review his smart card data.
Sample #4
SUBJECTIVE: The patient was seen in the office today. The patient is a (XX)-year-old Hispanic male with a history of obstructive sleep apnea with an apnea-hypopnea index of 44 events per hour back 10 years ago. He was treated with CPAP with 7 cm of water but did not use it at that time. He had a repeat polysomnogram this September for continued symptoms of snoring, witnessed apnea, and daytime sleepiness. He falls asleep if he is not active during the day. He reports that this weight had been up and down over the last year. He states that following his more recent polysomnograms, he did not receive any new equipment. His medications are QVAR, ProAir, Lovaza, Tricor, Lantus, NovoLog, Mellaril, baby aspirin, and Hyzaar.
OBJECTIVE:
VITAL SIGNS: Weight 260 pounds, blood pressure 126/72 mmHg, pulse 86 beats per minute, respirations 16 breaths per minute, and pulse oximetry 98% on room air.
HEENT: Tympanic membranes are intact bilaterally. Nose revealed normal mucosa. Mouth and throat showed a Mallampati 3 with a crowded oropharynx.
NECK: Short.
HEART: Regular.
LUNGS: Some upper airway wheeze noted.
ABDOMEN: Symmetrically enlarged.
EXTREMITIES: Negative for edema.
We reviewed a split-night polysomnogram study done on MM/DD/YYYY. The initial component was done off CPAP and showed severe obstructive sleep apnea with an apnea-hypopnea index of 97 events per hour. He was then treated with CPAP, which was changed to BiPAP, and it showed a decrease in his index to 8 events per hour with BiPAP at 20/16 cm of water. It was recommended that he be treated with BiPAP at 20/16 cm of water using a ResMed Quattro FX full face mask. He had significant sleep consolidation on BiPAP with REM rebound noted.
ASSESSMENT: Severe obstructive sleep apnea, adequately treated with bilevel PAP at 20/16 cm of water.
PLAN: We told him that he needs to start on bilevel PAP immediately and that we would like to check his smart card compliance data in two months. He is agreeable, and we will arrange for equipment.
