DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR REFERRAL: The patient is a pleasant (XX)-year-old female referred for evaluation of possible sleep-disordered breathing.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old female who has a history of going to bed between 11:30 and 12. She sleeps for 8-9 hours. Sleep onset is described as 5-10 minutes. She gets up to go to the bathroom and wakes up between 8 and 9. No apparent early morning headaches. She does not wake up refreshed. She does have dry mouth occasionally. She has a history of snoring. She has mostly slept on her back over the last few months. She does take naps 1-1/2 to 2 hours. Sometimes, they are refreshing. They are on a daily basis. Occasionally, she awakes confused, occasional bad dreams, occasionally talks, and may have some degree of periodic limb movements.
PAST MEDICAL HISTORY: She has a history of pulmonary embolism, status post IVC filter. She has a history of coronary artery disease, diabetes, uterine cancer treated, had a total abdominal hysterectomy in the remote past, multiple back surgeries, and chronic pain syndrome.
SOCIAL HISTORY: The patient is presently disabled. No caffeinated drinks. Quit smoking 10 years ago. Prior to that, the patient smoked 12 pack years.
FAMILY HISTORY: At this point in time, noncontributory.
REVIEW OF SYSTEMS: Epworth score of 18, which is abnormal. Sometimes cold intolerance. We are sure somewhere along the line her thyroid has been checked, as she is actually on Synthroid.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a well-developed female in no distress.
VITAL SIGNS: Weight 196 pounds, height 5 feet 8 inches, blood pressure 102/56, pulse 72 per minute, respiratory rate 18 per minute, and saturations on room air at rest 95%.
HEENT: Oropharyngeal area is slightly crowded with no exudates.
NECK: No JVD or adenopathy noted. Evidence of neck surgery, both anterior and posterior, is noted.
HEART: Regular.
LUNGS: Clear for the most part.
EXTREMITIES: The patient has no peripheral edema, cyanosis or clubbing.
DIAGNOSTIC DATA: No chest x-rays are available for review.
IMPRESSION: Obstructive sleep apnea more than likely represented in this female.
PLAN: The patient’s symptoms have manifested possibly more based on the body position for sleeping. Based on a history of having underlying heart disease and review of systems as detailed by her significant other, we believe nocturnal polysomnography is indicated, and one will be ordered. If need be, a second night for a CPAP titration will be ordered. We did demonstrate to her the CPAP mask and explained the sleep study to her. The patient is in agreement to proceed with the study.
