Medical Grand RoundsMedical Grand RoundsClinical VignetteClinical Vignette

March 11, 2009March 11, 2009

By Melissa Price, M.D.By Melissa Price, M.D.

Chief ComplaintChief Complaint

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

History of Present IllnessHistory of Present Illness

The patient notes that he has been The patient notes that he has been overweight his “entire life.”overweight his “entire life.”

However, over the past 2 years, he has However, over the past 2 years, he has gained an additional 20 lbs.gained an additional 20 lbs.

During this time, he reports increasing During this time, he reports increasing daytime sleepiness, despite increasing daytime sleepiness, despite increasing hours of sleep.hours of sleep.

He also notes that he has difficulty arising in He also notes that he has difficulty arising in the morning and rarely feels refreshed.the morning and rarely feels refreshed.

Additional HistoryAdditional HistoryPast Medical History: Past Medical History: – Hypertension Hypertension – Hypercholesterolemia Hypercholesterolemia – Diabetes Diabetes – Obesity Obesity – Seasonal allergies Seasonal allergies

Past Surgical History:Past Surgical History:– DeniesDenies

Social History: Social History: – no smoking, alcohol or drug use no smoking, alcohol or drug use – drinks 2- 3 cups of coffee each morning drinks 2- 3 cups of coffee each morning

Family History: Family History: – Mother with diabetes Mother with diabetes – Father with hypertensionFather with hypertension

Allergies: no known drug allergiesAllergies: no known drug allergiesMedications: Medications: – Telmisartan 40 mg daily Telmisartan 40 mg daily – Metoprolol XL 100mg daily Metoprolol XL 100mg daily – Metformin 1000mg twice daily Metformin 1000mg twice daily – Ezetimibe/Simvastatin 10mg/40 mg every evening Ezetimibe/Simvastatin 10mg/40 mg every evening – Mometasone nasal spray as needed Mometasone nasal spray as needed

Review of Systems: negativeReview of Systems: negative

Physical ExamPhysical ExamGeneral: obese male in no apparent General: obese male in no apparent distressdistressVital Signs: BP 158/88, HR 72, RR 18, Vital Signs: BP 158/88, HR 72, RR 18, T 98, 02 sat 97% on room air T 98, 02 sat 97% on room air – Weight 300 lbs, Height 5’11, BMI 41.8Weight 300 lbs, Height 5’11, BMI 41.8

The remainder of the physical exam The remainder of the physical exam was normalwas normal

Laboratory FindingsLaboratory Findings

Basic metabolic panel and complete blood Basic metabolic panel and complete blood count with differential were within normal count with differential were within normal limitslimits

HbA1C- 7.8 %HbA1C- 7.8 %

TSH- 3.7 mU/mlTSH- 3.7 mU/ml

Lipid Panel- Cholesterol 153, LDL 84Lipid Panel- Cholesterol 153, LDL 84

EKG- sinus at 72 bpm, borderline LVHEKG- sinus at 72 bpm, borderline LVH

CXR- no acute cardiopulmonary pathologyCXR- no acute cardiopulmonary pathology

Working DiagnosisWorking Diagnosis

Obstructive sleep apneaObstructive sleep apnea

Outpatient CourseOutpatient Course

The patient was referred for an outpatient The patient was referred for an outpatient sleep study, the results of which are sleep study, the results of which are shown:shown:

Nocturnal Polysomnography (NPSG)Nocturnal Polysomnography (NPSG)

Severe OSA with frank apneas and oxygen Severe OSA with frank apneas and oxygen desaturations down to 65% during REM sleepdesaturations down to 65% during REM sleep

Nocturnal Polysomnogram with Nasal CPAPNocturnal Polysomnogram with Nasal CPAP

CPAP titration of 13 relieving OSA even during REM sleep.CPAP titration of 13 relieving OSA even during REM sleep.

Nocturnal Polysomnogram ResultsNocturnal Polysomnogram Results

Axis A Diagnosis: Axis A Diagnosis: – Severe Obstructive Sleep ApneaSevere Obstructive Sleep Apnea

Breathing was regular and without Breathing was regular and without significant apnea once therapeutic levels significant apnea once therapeutic levels of CPAP were obtainedof CPAP were obtainedCPAP at 16 cm H20 delivered via large CPAP at 16 cm H20 delivered via large sized nasal mask with heated humidifier sized nasal mask with heated humidifier was recommended during all sleep was recommended during all sleep periodsperiods

Final DiagnosisFinal Diagnosis

Severe Obstructive Sleep ApneaSevere Obstructive Sleep Apnea

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