Transcript Medical Grand Rounds Clinical Vingette 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.
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.
Additional History
Past Medical History:
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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:
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Telmisartan 40 mg daily
Metoprolol XL 100mg daily
Metformin 1000mg twice daily
Ezetimibe/Simvastatin 10mg/40 mg every evening
Mometasone nasal spray as needed
Review of Systems: negative
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
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
Working Diagnosis
Obstructive sleep apnea
Outpatient Course
The patient was referred for an outpatient
sleep study, the results of which are
shown:
Nocturnal Polysomnography (NPSG)
Severe OSA with frank apneas and oxygen
desaturations down to 65% during REM sleep
Nocturnal Polysomnogram with Nasal CPAP
CPAP titration of 13 relieving OSA even during REM sleep.
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
Final Diagnosis
Severe Obstructive Sleep Apnea
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 apneic episodes