SAMPLE TYPE: Sleep Medicine/Sleep Apnea.
REASON FOR REFERRAL: Evaluation of patient from a sleep apnea standpoint who has already been evaluated with nocturnal polysomnography and a followup CPAP titration by an outside physician. The gentleman has requested a second opinion, and for those reasons, he is here. He has other issues related to his lungs, which we will address separately.
HISTORY OF PRESENT ILLNESS: This pleasant (XX)-year-old gentleman underwent nocturnal polysomnography, initial night on MM/DD/YYYY, and was documented to have a total respiratory disturbance index of 5.4, which we believe may be a misrepresentation as we believe his respiratory disturbance index may be lower, as it was recorded that his REM RDI was 5.4.
He was set up for a CPAP titration, was apparently titrated up to pressures of 12, and then recommended that he be set up on pressures of 10. He followed up with Dr. John Doe. He was instructed that he did not require a CPAP and that was it.
During his evaluations with Dr. John Doe, he also underwent a brief workup for possible interstitial lung disease, which did not demonstrate any significant interstitial lung disease on a high-resolution CT scan of the thorax; it was performed earlier this year.
He also had pulmonary function tests, which revealed a total lung capacity of 60% of predicted. We did not perform this test; reliability of this study is questionable. Diffusing capacity adjusted for alveolar volume was normal.
We do not see any significant parenchymal abnormalities other than some very mild bronchiectasis. The study was without contrast, and it was not of adequate technique to evaluate mediastinum, but no obvious lymphadenopathy was noted, masses or nodules to any significant degree.
This gentleman states that his bedtime is usually around 11 p.m. He tries to sleep for about 7 hours. Sleep onset is described as 10 to 15 minutes. He wakes up at 7:30 in the morning, gets out of bed. No early morning headaches, no snoring, and this was correlated with his bed partner. Mostly tries to sleep on his side, but we believe he sometimes falls on his back. He has brief periods of witnessed apneas. He does not have any pathological excessive daytime somnolence based on my examination. He may have some degree of periodic limb movements but not enough for us to treat at this time. He occasionally has dreams. No parasomnias in childhood.
REVIEW OF SYSTEMS: Very rare wheezing, mostly noted at night. He has some dyspnea with high levels of exertion, but actually, today, he was 20 minutes on his treadmill at medium speed and did quite well. He apparently has some intolerance to cold but states he has had his thyroid function tests, and they were normal. He sometimes has some mild orthopnea. He has some gastroesophageal reflux disease but not very bad.
PAST MEDICAL HISTORY: Positive for cardiac disease, diabetes, some DJD, pneumonia 9 years ago, and may have some neuropathy of his feet. He has had nasal polyps in the past and left shoulder repair 3 years ago.
SOCIAL HISTORY: No industrial exposures. May have some caffeinated drinks; last one 9 a.m., smoked for 25 years, quit (XX) years ago.
FAMILY HISTORY: Noncontributory at this point.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed gentleman in no distress.
VITAL SIGNS: WT: 210 pounds H: 5 feet 10 inches. P: 66 per minute RR: 20 per minute. BP: 120/60.
HEAD AND NECK EXAM: No JVD, good jaw/face ratio. I did not see any oral exudates, and the oropharyngeal area is not very crowded.
CARDIAC: Regular.
LUNGS: Actually quite clear. There are no crackles on my exam.
EXTREMITIES: The patient has some varicose veins but apparently negative ultrasound of the lower extremities done in the recent past.
DIAGNOSTICS: We reviewed his high-resolution CT scan on the monitor, agree with the reading.
IMPRESSION:
1. Very mild obstructive sleep apnea, which at this point in time only requires positional therapy and weight loss.
2. Nocturnal hypoxemia, unclear etiology. He is on 2 liters nasal cannula right now, and what we would like to do is check an overnight oximetry on the 2 liters to confirm that we are obtaining adequate saturations throughout the night. If indeed it is adequate, he will continue with his oxygen, and in 6 months, we will once again recheck his overnight oximetry on room air to see if he needs continued oxygen support.
PLAN: We would recommend pulmonary function test in one year. If this patient develops any other pulmonary symptoms, he should contact our office. We are anticipating that you have checked his thyroid function, and if not, please check it. We will call him with the results of the overnight oximetry.
