DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR REFERRAL: Sleep disturbance.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old female who we first met in April of last year, at which time she had pulmonary embolism with chronic anticoagulation. Now, she is status post IVC filter x2. At the time of her discharge, we were very concerned that she had a sleep disturbance with excessive daytime somnolence and fatigue, and unfortunately, she never followed up. She had an overnight oximetry that showed that her saturations were 78% or less, at times, on room air. She was placed on supplemental oxygen. She does feel better with that, but she is still quite fatigued and tired during the day. In the hospital, she did have witnessed apneas. She has been sleeping in a recliner for about a year and a half. She recently had pulmonary function test that showed that she has a positive bronchodilator response at the level of small airways and was recently started on Advair, which she does seem to think has helped. She does snore. She takes a nap every day for about an hour, and other than that, she has had no other major sleep problems, except she is frequently tired and snores and had an abnormal overnight oximetry.
PAST MEDICAL HISTORY: Hypertension, DJD, asthma, hypothyroidism, arrhythmia and PE.
PAST SURGICAL HISTORY: Hysterectomy, cholecystectomy, and left cataract.
MEDICATIONS: Advair 100/50 mcg b.i.d., Prevacid 30 mg daily, Darvocet, Coumadin, trazodone 100 mg t.i.d., Xanax 0.5 mg as needed, hydrochlorothiazide, Univasc 15 mg b.i.d., Synthroid, and Ritalin in the morning.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father is deceased, 98, with old age. Mother is deceased, 74, with a stroke.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative.
HEENT: The patient has an Epworth score of 4.
GASTROINTESTINAL: GERD.
GENITOURINARY: Negative.
CARDIOPULMONARY: As in the HPI. She has dyspnea on exertion and occasional wheezing.
HEMATOLOGIC: Negative.
ENDOCRINE: Negative.
PSYCHIATRIC: Negative.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is an obese female in no distress.
VITAL SIGNS: Weight 268, respiratory rate 18, pulse 90, blood pressure 122/74, and saturations on room air 93%.
HEENT: The patient has normal contour to her oropharynx. She has a stage IV oropharynx. She is edentulous. PERRL. Conjunctivae are pink. Nares are difficult to visualize.
NECK: Thick but supple without increased JVP, adenopathy or bruits.
HEART: PMI is not appreciated. S1, S2 without any murmurs or gallops.
ABDOMEN: Obese, soft and nontender.
EXTREMITIES: No C/C/E.
IMPRESSION: The patient has excessive daytime somnolence and fatigue, witnessed apneas and snoring and likely has some type of sleep apnea syndrome. She also has abnormal overnight oximetry. She has reactive airways disease, mild hypoxemia and shortness of breath. She has a history of pulmonary embolism, on chronic anticoagulation therapy, status post two IVC filters.
PLAN: We reviewed the pathophysiology of OSA and CSA with her. We discussed PSG testing with her, and she has agreed to do that. The patient also understands the concept of CPAP. We will send her for PSG, and we will see her back after that.
