OBSTRUCTIVE SLEEP APNEA

History of Present Illness

“Mark is a 49-year-old Caucasian male who presents to his primary care provider (PCP) for a routine cholesterol check. Mark has a BMI of 35.4 and was recently diagnosed with high cholesterol. His doctor had previously advised him to eat better and exercise to lose weight to improve his cholesterol levels. Although Mark has been making better nutritional choices in avoiding foods high in cholesterol, he still hasn’t lost any meaningful weight. His wife, Sherry, accompanies him to his appointment. She has been increasingly concerned with Mark’s actions while resting. She decides to discuss her concerns with the physician during the routine exam.

OBSTRUCTIVE SLEEP APNEA

History of Present Illness

Sherry tells the doctor that Mark wakes up throughout the night, sometimes very abruptly, with choking sounds. She says that sometimes it also appears as if he is holding his breath for short amounts of time or even not breathing. When she wakes him, he is usually startled. The doctor asks if Mark snores, to which Sherry laughs that Mark has snored very loudly for as long as she can remember. The doctor questions Mark as to how he feels in the morning when he wakes up. Mark responds that he usually still feels tired and catches up on sleep by taking naps. The doctor refers Mark to a sleep specialist to determine the cause of his symptoms.”

OBSTRUCTIVE SLEEP APNEA

History of Present Illness

“Mark arrives with his wife at the specialist’s office the following week. Before he sees the physician, the nurse has Mark and Sherry complete an Epworth questionnaire to subjectively assess Mark’s degree of sleepiness. The doctor then performs a physical examination and takes Mark’s medical history, including sleep and daily functioning habits for him and his family. The doctor also checks Mark’s tonsils, uvula, and soft palate for enlarged tissues. Following the examination, the doctor suspects sleep apnea and orders a polysomnogram (PSG) at the sleep center in a nearby hospital.

OBSTRUCTIVE SLEEP APNEA

History of Present Illness

The next evening, Mark appears at the hospital for his PSG. His doctor has scheduled him to stay overnight for the test. While he sleeps, the PSG is recording his brain activity, eye movement, muscle activity, breathing and heart rate, airflow through his lungs, and oxygen percentage in his blood. He is monitored by staff at the sleep center while he sleeps. The next morning, Mark leaves the hospital and is told by staff that his sleep specialist will call him with the results of the PSG.”

OBSTRUCTIVE SLEEP APNEA

Past Medical History

• Athlete’s foot 3 months ago
• GERD since age 40
• Hemorrhoids since age 38

Family History

• Father survived a myocardial infarction at 68 years old; currently has a pacemaker
• Mother is treated for hypertension and high cholesterol
• Has three daughters, 20 year old is treated for depression

Social History

• Smoked 1 pack of cigarettes a day between age 16 and 40 (24 pack years)

Meds

• Cimetidine (Tagamet HB) 200 mg BID, H2-blockers work by decreasing the amount of acid produced by the stomach.
• Zolpidem (Ambien CR) 10 mg at bedtime (treatment of insomnia)

OBSTRUCTIVE SLEEP APNEA

Physical Examination

• Overweight with large neck
• Speech is paced and content us normal
• Appears tired but no apparent distress

Vital Signs

BP (sitting)                 152/88                                 Norm (≤ 120/80)	RR                      18 and unlabored	HT                 6’2”
P                                 86 and regular	T                          98.7	WT                276 lbs
		BMI                35.4

OBSTRUCTIVE SLEEP APNEA

BMI Chart:

• Underweight                    under 18.5
• Normal                             18.5 - 24.9
• Overweight                      25.0 - 29.9
• Obese Class I                  30.0 - 34.9
• Obese Class II                 35.0 - 39.9
• Obese Class III                ≥ 40.0

Skin

• Normal skin turgor and color
• Warm, moist, and soft
• (-) rashes, bruises or other lesions

OBSTRUCTIVE SLEEP APNEA

Head, Eyes, Ears, Nose, and Throat

• PERRLA
• EOMs intact
• Eyes anicteric
• Normal conjunctiva
• Vision satisfactory with no eye pain
• Fundi without AV nicking, hemorrhages, exudates, and papilledema
• Nares clear
• (-) tinnitus and ear pain
• Tongue normal size
• Breaths through his mouth
• No throat pain or difficulty swallowing
• Excessive vibration of the uvula and soft palate
• Enlarged tissue in his throat

OBSTRUCTIVE SLEEP APNEA

Neck/Lymph Nodes

• Neck supple
• Trachea mid-line
• No palpable nodes or JVD notes

Chest and Lungs

• Chest clear to auscultation
• Normal breath sounds
• (-) axillary and supraclavicular lymphadenopathy

OBSTRUCTIVE SLEEP APNEA

Heart

• Regular rate and rhythm
• Normal S₁ and S₂
• No rubs or murmurs

Abdomen

• (-) hepatosplenomegaly, fluid wave, tenderness, and distension
• (-) masses, bruits, and superficial abdominal veins
• Normal BS

Genitalia and Rectum

• Hemorrhoids

OBSTRUCTIVE SLEEP APNEA

Musculoskeletal and Extremities

• (-) spine and coatovertebral angle tenderness
• Denies muscle aches, joint pain, and bone pain
• Normal range of motion throughout

Neurological

• Alert and oriented to person, place, and time
• Irritability associated with poor sleep
• Cranial nerves intact
• Motor 5/5 upper and lower extremities bilaterally
• Strength, sensation, and deep tendon reflexes intact and symmetric
• Gait steady

OBSTRUCTIVE SLEEP APNEA

Laboratory Blood Test Results

Na                 141 meq/L	Ca                      9.8 mg/dL	Plt                  270 x103/mm3
K                   3.9 meq/L	TSH                    5.1 μU/mL	LDL                158 mg/dL                 Norm (< 130 mg/dL)
Cl                  109 meq/L	FT4                     2.3 ng/dL	HDL                41 mg/dL
HCO2            30 meq/L	PTH                    282 pg/mL	Triglycerides   200 mg/dL               Norm (< 165 mg/dL)
BUN              15 mg/dL	Hb                       13.4 g/dL
Cr                  0.8 mg/dL	Hct                       39.1%
Glu, fasting   105 mg/dL	WBC                    8.7 x103/mm3

OBSTRUCTIVE SLEEP APNEA

Sleep Laboratory Results

• 24 awakenings during 6.63 hours (1.1 hours awake and 5.5 hours asleep)
• Sleep onset latency of 5.5 minutes (i.e., quickly falls asleep)
• Sleep efficiency is 84% (e.g.,≥ 85% normal)
• Stage 1 sleep for 116.5 minutes
• Stage 2 sleep for 203 minutes
• REM (rapid eye movement)for 10.5 minutes
• HR of 90 bpm, with his highest HR at 197 bpm and lowest 41 bpm
• Hear rate sleep 80-110 bpm during 82.11% of sleep
• Obstructive apneas 226 times; longest event lasted 41.7 seconds

OBSTRUCTIVE SLEEP APNEA

Sleep Laboratory Results

• Hypopneas 446 times; longest event lasted 37.9 seconds
• Respiratory disturbance index (RDI) was 122.2 (RDI is the number of apneas plus hypopneas per hour of sleep)
• Mark slept on his back
• Oxygen saturation score (reductions in blood oxygen levels or desaturation) was >4% of baseline at 629 (total number of drops)
• 148 respiratory arousals; 26.9/hour
• Index of 8.36 for limb movements

OBSTRUCTIVE SLEEP APNEA

Clinical Course

Mark was diagnosed with obstructive sleep apnea, which is the most common form. It occurs when throat muscles relax. He was started on a positive airway pressure machine during the time he was sleeping. After a couple weeks both Mark and Sherry were booth sleeping better. Mark was no longer sleep during the day. So when he had to go out of town for a conference he brought his machine with him. Mark was also stated on an antihypertensive medication for his elevated blood pressure. OSA is known to be a secondary cause of hypertension.

OBSTRUCTIVE SLEEP APNEA

Clinical Values for Case Study Problem-Solving

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations