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Medical Grand Rounds Clinical Vignette March 11, 2009

Medical Grand Rounds Clinical Vignette March 11, 2009. By Melissa Price, M.D. Chief Complaint. A 40 year-old man is brought to clinic by his wife for evaluation of heavy snoring and witnessed apneic events while sleeping for the past 2 years, worsening over the past 6 months.

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Medical Grand Rounds Clinical Vignette March 11, 2009

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  1. Medical Grand RoundsClinical VignetteMarch 11, 2009 By Melissa Price, M.D.

  2. Chief Complaint • A 40 year-old man is brought to clinic by his wife for evaluation of heavy snoring and witnessed apneicevents while sleeping for the past 2 years, worsening over the past 6 months.

  3. History of Present Illness • The patient notes that he has been overweight his “entire life.” • However, over the past 2 years, he has gained an additional 20 lbs. • During this time, he reports increasing daytime sleepiness, despite increasing hours of sleep. • He also notes that he has difficulty arising in the morning and rarely feels refreshed.

  4. Additional History • Past Medical History: • Hypertension • Hypercholesterolemia • Diabetes • Obesity • Seasonal allergies • Past Surgical History: • Denies • Social History: • no smoking, alcohol or drug use • drinks 2- 3 cups of coffee each morning • Family History: • Mother with diabetes • Father with hypertension • Allergies: no known drug allergies • Medications: • Telmisartan40 mg daily • MetoprololXL 100mg daily • Metformin1000mg twice daily • Ezetimibe/Simvastatin10mg/40 mg every evening • Mometasonenasal spray as needed • Review of Systems: negative

  5. Physical Exam • General: obese male in no apparent distress • Vital Signs: BP 158/88, HR 72, RR 18, T 98, 02 sat 97% on room air • Weight 300 lbs, Height 5’11, BMI 41.8 • The remainder of the physical exam was normal

  6. Laboratory Findings • Basic metabolic panel and complete blood count with differential were within normal limits • HbA1C- 7.8 % • TSH- 3.7 mU/ml • Lipid Panel- Cholesterol 153, LDL 84 • EKG- sinus at 72 bpm, borderline LVH • CXR- no acute cardiopulmonary pathology

  7. Working Diagnosis • Obstructive sleep apnea

  8. Outpatient Course • The patient was referred for an outpatient sleep study, the results of which are shown:

  9. Nocturnal Polysomnography (NPSG) • Severe OSA with frank apneas and oxygen desaturations down to 65% during REM sleep

  10. Nocturnal Polysomnogram with Nasal CPAP • CPAP titration of 13 relieving OSA even during REM sleep.

  11. Nocturnal Polysomnogram Results • Axis A Diagnosis: • Severe Obstructive Sleep Apnea • Breathing was regular and without significant apnea once therapeutic levels of CPAP were obtained • CPAP at 16 cm H20 delivered via large sized nasal mask with heated humidifier was recommended during all sleep periods

  12. Final Diagnosis • Severe Obstructive Sleep Apnea

  13. Follow-up • Recommendations for CPAP with titration, weight loss and avoidance of alcohol, sedatives, and other respiratory depressants was given. • Counseling on increased risk of motor vehicle accidents and avoidance of driving and other critical tasks requiring sustained vigilance until daytime somnolence is treated • After 3 months of nocturnal CPAP administration, the patient rated his sleep as “better than ever before” and refreshing • His daytime somnolence resolved • His wife reported no further apneicepisodes

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