DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Sleep apnea.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old woman with past history significant for hypertension, GERD, dyslipidemia, anxiety, and depression. She has history of snoring and excessive daytime fatigue and sleepiness. A sleep study was ordered that showed mild degree of sleep apnea with apnea-hypopnea index of 8 per hour. She also was noted to have respiratory effort-related arousals at 10 per hour leading to total respiratory distress index of 18 per hour. Sleep efficiency was mildly reduced at 76%, decreased N3, increased N2 and N1, and absent REM sleep. Moderate snoring was noted.
Transient oxygen desaturation with lowest oxygen saturation of 85%. Periodic leg movements at 43 per hour with 9 per hour causing arousals. The patient was subsequently seen by Dr. Jane Doe, and treatment options were reviewed. The patient was not considered a candidate for surgical intervention for sleep apnea. The patient is referred here for further evaluation.
The patient has history of snoring, as stated above, with snore arousals. No choking arousals or witnessed apnea. Her usual bedtime is 11 p.m. and she gets up at 8 a.m. She does not feel rested. She has several nocturnal awakenings for unclear reasons. No symptoms of restless legs. She was told that she does have twitching of her legs during sleep. She does talk in sleep but no somnambulism. No other parasomnia, no dream-enacting behavior.
The patient has one to two episodes of nocturia. She denies morning headache. She has moderate degree of daytime fatigue and sleepiness. Epworth sleepiness score is 12/24. She has high chance of dozing off during passive activities. Only one episode of transient dozing off during driving when she was very tired, but otherwise, she has no problem driving or near accidents related to sleepiness.
The patient has gained about 20 plus pounds over the past year or so. She has had tonsillectomy. She denies any nasal symptoms. She apparently has had episodes of difficult intubation and was told it was due to narrowing of her airway.
PAST MEDICAL HISTORY: Hypertension, GERD, dyslipidemia, and anxiety and depression. She has no history of heart disease, no history of stroke, and no history of lung disease.
MEDICATIONS: Corgard 40 mg twice daily, hydralazine 25 mg t.i.d., aspirin 81 mg daily, omeprazole 20 mg daily, Lipitor 10 mg daily, Xanax 0.5 mg daily, MetroGel skin cream, Cymbalta, timolol, Wellbutrin 150 mg daily, felodipine 2.5 mg daily, multivitamins, calcium, and vitamin D.
ALLERGIES: Multiple, listed in the chart.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient does not smoke or does not drink alcohol. Does not drink coffee. Does not exercise. She is married. The patient’s husband has sleep apnea, on CPAP.
REVIEW OF SYSTEMS: No nasal sinus congestion. No history of nasal trauma. No history of hypothyroidism. She is a prediabetic. She has no history of lung disease. She never smoked. No history of coronary artery disease, congestive heart failure or cardiac dysrhythmia. Gastrointestinal review of systems is negative. She is status post cholecystectomy. History of pancreatitis in relationship to ACE inhibitor. She has weight gain as noted above. Chronic fatigue and sleepiness and history of depression as noted above; otherwise, review of systems is negative.
PHYSICAL EXAMINATION: The patient is a pleasant female, in no distress. Vitals are stable. Blood pressure is 142/74, pulse 66, weight is 214 pounds. Neck circumference is 18.24 inches. Oxygen saturation is 98%. Pain score is zero. Pupils are equal and reactive. Sclerae are clear. Nasal mucosa noncongested. Adequate flow, both nares. Oropharynx: Mallampati class IV airway. There is no micrognathia or retrognathia. Large neck. Trachea is midline. No thyromegaly. No lymphadenopathy. JVP is normal. Lungs have good aeration bilaterally. No wheezing, rhonchi or crackles. Heart has S1, S2, regular. There is no murmur, rub or gallop. Abdomen is mildly obese. Extremities have no edema, clubbing or calf tenderness. Neurologically, the patient is alert, no deficits noted.
LABORATORY DATA: The patient’s sleep results were discussed with her.
IMPRESSION AND PLAN:
1. Obstructive sleep apnea syndrome: The patient has mild to moderate degree of obstructive sleep apnea associated with hypersomnia and mild nocturnal hypoxemia. She has multiple comorbidities, including hypertension. We discussed pathophysiology of sleep apnea. Cardiovascular consequences of sleep apnea were discussed. Various treatment options were reviewed. She is not a candidate for surgical intervention for sleep apnea. She is not interested at this point in oral appliance therapy. We discussed CPAP therapy, and she is familiar with CPAP as her husband is on CPAP. She wished to proceed with nasal CPAP titration study followed by nasal CPAP therapy. We will schedule a nasal CPAP titration study as soon as possible and a telephone followup and starting nasal CPAP therapy. We discussed association of sleep apnea with hypertension, cardiovascular illnesses, hypersomnia, and diabetes.
2. Moderate obesity: Exercise and weight loss encouraged.
3. Driving and safety precautions were given.
4. Sleep hygiene measures were discussed.
5. Avoidance of sedatives and alcohol recommended.
6. Follow up after CPAP titration study.
