DATE OF SERVICE: MM/DD/YYYY
REASON FOR VISIT: The patient is a pleasant (XX)-year-old gentleman seen in office followup of obstructive sleep apnea syndrome.
HISTORY OF PRESENT ILLNESS: The patient has history of severe obstructive sleep apnea syndrome. He underwent a split-night sleep study that showed severe obstructive sleep apnea with apnea-hypopnea index of 52 per hour associated with oxygen desaturation with nadir oxygen desaturation of 84%. A CPAP of 13 cm water pressure resulted in improvement in sleep-disordered breathing.
The patient was subsequently seen in followup. He was prescribed CPAP at 13 cm water pressure with a full face mask. The patient started using CPAP. Initially, he was able to use it for 2-4 hours at a time and noted improvement in his daytime fatigue and sleepiness. However, after first week of starting treatment, he developed significant trouble tolerating nasal CPAP and was not able to initiate sleep.
Part of the problem was nasal mask air leak due to improper nasal mask fitting and also was waking up with complaints of high CPAP pressure. He was also seen in our CPAP clinic and ResMed Activa Mirage nasal mask was recommended with Adams circuit chin strap. He has not received his new mask or chin strap. The patient is here to discuss other options of treatment.
PAST MEDICAL HISTORY: Diabetes mellitus, hypothyroidism, history of seizure disorder, history of hypertension, stroke, and myocardial infarction.
MEDICATIONS: Insulin, levothyroxine, and Dilantin.
SOCIAL HISTORY: The patient is an ex-smoker. He does not drink alcohol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As noted in history of present illness. He still has significant daytime fatigue and sleepiness. He does not have complaints of sleepiness while driving. He has not had driving accidents. He has no symptoms of narcolepsy. No complaints of restless legs. No significant difficulty initiating or maintaining sleep off nasal CPAP. Weight has been stable. Of note, he has had tonsillectomy in the past. No nasal symptoms.
PHYSICAL EXAMINATION: The patient is an alert gentleman, in no distress. Vitals are stable. Blood pressure is 128/72, pulse 72, weight is 148 pounds. Oxygen saturation is 100%. Pupils are equal and reactive. Nasal mucosa is noncongested. Adequate flow, both nares. Oropharynx, slightly elongated uvula, Mallampati class II airway. Absent tonsils. No micrognathia or retrognathia. Neck without adenopathy. Trachea is midline. No thyromegaly. Lungs are clear. Heart reveals S1, S2, regular. Abdomen is unremarkable. Extremities have no edema, clubbing or calf tenderness. Neurologically alert, no deficits noted.
IMPRESSION:
1. Severe obstructive sleep apnea/hypopnea syndrome associated with significant daytime hypersomnia.
2. Intolerance of nasal CPAP, which is multifactorial, i.e. high CPAP pressure, mask leak and improper mask fitting.
3. Diabetes mellitus.
4. Hypothyroidism.
5. Remote history of seizure disorder.
PLAN AND RECOMMENDATIONS: We discussed pathophysiology of sleep apnea, especially in light of severe obstructive sleep apnea and associated nocturnal hyposomnia. We did discuss cardiovascular complications and discussed options of treatment, including surgical intervention such as UPPP and oral appliance therapy. Given the fact that he has severe sleep apnea, the best option is nasal CPAP therapy. We discussed surgery, which we do not recommend, possibility of oral appliance therapy, a combination of oral appliance therapy and nasal CPAP therapy.
After discussing pros and cons, our recommendations are:
1. Trial of decreasing nasal CPAP to 11 cm of water pressure.
2. Order a new ResMed Mirage Activa nasal mask with a chin strap.
3. Re-evaluate in about six to eight weeks.
4. If symptoms persist, consider CPAP therapy versus BiPAP therapy and consideration of oral appliance therapy. He has intact dentition.
