REASON FOR REFERRAL: Evaluation of patient from a sleep apnea standpoint who has already been evaluated with nocturnal polysomnography and a followup CPAP titration by an outside physician. The gentleman has requested a second opinion, and for those reasons, he is here. He has other issues related to his lungs, which we will address separately.

HISTORY OF PRESENT ILLNESS: This pleasant (XX)-year-old gentleman underwent nocturnal polysomnography, initial night on MM/DD/YYYY, and was documented to have a total respiratory disturbance index of 5.4, which we believe may be a misrepresentation as we believe his respiratory disturbance index may be lower, as it was recorded that his REM RDI was 5.4.

He was set up for a CPAP titration, was apparently titrated up to pressures of 12, and then recommended that he be set up on pressures of 10. He followed up with Dr. John Doe. He was instructed that he did not require a CPAP and that was it.

During his evaluations with Dr. John Doe, he also underwent a brief workup for possible interstitial lung disease, which did not demonstrate any significant interstitial lung disease on a high-resolution CT scan of the thorax; it was performed earlier this year.

He also had pulmonary function tests, which revealed a total lung capacity of 60% of predicted. We did not perform this test; reliability of this study is questionable. Diffusing capacity adjusted for alveolar volume was normal.

We do not see any significant parenchymal abnormalities other than some very mild bronchiectasis. The study was without contrast, and it was not of adequate technique to evaluate mediastinum, but no obvious lymphadenopathy was noted, masses or nodules to any significant degree.

This gentleman states that his bedtime is usually around 11 p.m. He tries to sleep for about 7 hours. Sleep onset is described as 10 to 15 minutes. He wakes up at 7:30 in the morning, gets out of bed. No early morning headaches, no snoring, and this was correlated with his bed partner. Mostly tries to sleep on his side, but we believe he sometimes falls on his back. He has brief periods of witnessed apneas. He does not have any pathological excessive daytime somnolence based on my examination. He may have some degree of periodic limb movements but not enough for us to treat at this time. He occasionally has dreams. No parasomnias in childhood.

REVIEW OF SYSTEMS: Very rare wheezing, mostly noted at night. He has some dyspnea with high levels of exertion, but actually, today, he was 20 minutes on his treadmill at medium speed and did quite well. He apparently has some intolerance to cold but states he has had his thyroid function tests, and they were normal. He sometimes has some mild orthopnea. He has some gastroesophageal reflux disease but not very bad.

PAST MEDICAL HISTORY: Positive for cardiac disease, diabetes, some DJD, pneumonia 9 years ago, and may have some neuropathy of his feet. He has had nasal polyps in the past and left shoulder repair 3 years ago.

SOCIAL HISTORY: No industrial exposures. May have some caffeinated drinks; last one 9 a.m., smoked for 25 years, quit (XX) years ago.

FAMILY HISTORY: Noncontributory at this point.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed gentleman in no distress.
VITAL SIGNS: WT: 210 pounds H: 5 feet 10 inches. P: 66 per minute RR: 20 per minute. BP: 120/60.
HEAD AND NECK EXAM: No JVD, good jaw/face ratio. I did not see any oral exudates, and the oropharyngeal area is not very crowded.
CARDIAC: Regular.
LUNGS: Actually quite clear. There are no crackles on my exam.
EXTREMITIES: The patient has some varicose veins but apparently negative ultrasound of the lower extremities done in the recent past.

DIAGNOSTICS: We reviewed his high-resolution CT scan on the monitor, agree with the reading.

IMPRESSION:
1. Very mild obstructive sleep apnea, which at this point in time only requires positional therapy and weight loss.
2. Nocturnal hypoxemia, unclear etiology. He is on 2 liters nasal cannula right now, and what we would like to do is check an overnight oximetry on the 2 liters to confirm that we are obtaining adequate saturations throughout the night. If indeed it is adequate, he will continue with his oxygen, and in 6 months, we will once again recheck his overnight oximetry on room air to see if he needs continued oxygen support.

PLAN: We would recommend pulmonary function test in one year. If this patient develops any other pulmonary symptoms, he should contact our office. We are anticipating that you have checked his thyroid function, and if not, please check it. We will call him with the results of the overnight oximetry.

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Sleep Study Transcribed Sample Report #1

DATE OF TEST / DATE OF STUDY: MM/DD/YYYY

REASON FOR THE TEST: Extreme daytime fatigue, somnolence and obstructive sleep apnea.

Sleep parameters showed total recording time of 414.5 minutes and total sleep time of 333 minutes with sleep efficiency of 82%. Latency to sleep onset was 10.5 minutes and latency to REM sleep was 116.5 minutes. Number of awakenings were 6 and awake after sleep onset was 55.5 minutes. Sleep parameters showed awake time of 66 minutes or 15.9% of total. Stage I was 172 minutes or 51.7% of total. Stage II was 144 minutes or 43.2% of total. Stage III and IV was 3.5 minutes or 1.1% of total. REM stage was 13 minutes or 3.9% of total. Cardiopulmonary parameters showed heart rate was 90 during awake and 91 during sleep time. Respiratory rate was 16 during awake time and 14 during sleep time. Periodic leg movements were 103 with no arousals and the index was 18.6 per hour. Respiratory data showed total number of apneas and hypopneas was 47 with 4 apneas and 43 hypopneas. Apnea index was 0.7 per hour and apnea/hypopnea index was 8.5 per hour. Arousal index was 1.8 per hour. The total number of REM events was 7. Desaturation profile showed 3 events with O2 saturation between 60-65%, 7 events with O2 saturation between 65-70%, 10 events with O2 saturation between 70-75%, 11 events with O2 saturation between 75-80%, 17 events with O2 saturation between 80-85%, 17 other events with O2 saturation between 85-90%, and 54 events with O2 saturation between 90-95%. The longest respiratory event was 38 seconds and the lowest desaturation was 60%. Snoring was recorded to be 3-4/10. Epworth sleepiness scale was 19/24.

IMPRESSION: This test shows:
1. Poor sleep efficiency, probably secondary to first-night effect.
2. Disturbed sleep architecture.
3. Mild obstructive sleep apnea.
4. Severe desaturation during the night.
5. Severe daytime somnolence as reported by the patient.

Sleep Study Transcribed Sample Report #2

DATE OF TEST:

REASON FOR TEST: Daytime somnolence, excessive sleepiness during the daytime and fatigue.

The total recording time was 479.3 minutes and total sleep time was 426 minutes. Sleep efficiency was 91%. Latency to sleep onset was 1.5 minutes. Latency to REM sleep was 104 minutes. Number of awakenings were 14. Awake after sleep onset was 41. Sleep percentages showed awake time was 42.5 minutes or 8.9% of total. Stage I was 97.5 minutes of total or 22.9% of total. Stage II was 206 minutes or 48.4% of total. Stage III and IV were 61 minutes or 14.3% of total. Cardiopulmonary parameters showed a heart rate of 55 during awake and 50 during sleep and a respiratory rate of 16 during awake and 12 during sleep. Periodic leg movements were 23 with no arousals and the PLMS index was 3.2 per hour. Arousal index was 0 per hour. Respiratory data showed total number of apneas and hypopneas of 9, number of apneas 3 and number of hypopneas 6. Apnea index was 0.4 per hour and apnea-hypopnea index was 7.3 per hour. Arousal index was 0.7 per hour. There were no REM events. Desaturation profile showed 3 events with O2 saturation between 50-55%, 3 events with O2 saturation between 55-60%, 2 events with O2 saturation between 60-65%, 3 events with O2 saturation between 65-70%, 3 events with O2 saturation between 70-75%, 1 event with O2 saturation between 75-80%, 5 events with O2 saturation between 80-85%, 15 events with O2 saturation between 85-90%, 41 events with O2 saturation between 90-95%, and 1 event with O2 saturation above 95%. The longest respiratory event was 21.3 seconds and the lowest desaturation was 24%. There was one event with O2 saturation between 30-35% and one event with O2 saturation less than 30%. There was no snoring during the night. The patient’s Epworth sleeping scale is reported to be 4/24.

IMPRESSION: This test shows:
1. Normal sleep architecture.
2. No obstructive or central sleep apnea.
3. Severe desaturation during the night, which explains the patient’s fatigue during the morning.

Sleep Study Transcribed Sample Report #3

DATE OF TEST:

REASON FOR TEST: Excessive daytime fatigue and sleepiness.

Total recording time was 450.8 minutes. Total sleep time was 256 minutes. Sleep efficiency was 58%. Latency to sleep onset was 90.5 minutes and latency to REM sleep was 252.5 minutes. Number of awakenings were 7 and awake after sleep onset was 94.5. Sleep percentages showed awake time 184.5 minutes or 40.9% of total. Stage I was 70 minutes or 27.3% of total. Stage II was 64 minutes or 25% of total. Stage III and IV were 95 minutes or 37.1% of total. REM stage was 26.5 minutes or 10.4% of total. Cardiorespiratory parameters showed heart rate of 73 during awake and 74 during sleep time. Respiratory rate was 60 during awake time and 20 during sleep time. Periodic leg movements showed total number of 74 with no arousals and PLMS index 17.3 per hour and number of periodic leg movement arousal index was 0. Respiratory data showed total number of apneas and hypopneas of 9 with no apneas and 9 hypopneas. Apnea index was 0 per hour and apnea-hypopnea index was 2.1 per hour. Arousal index was 0.5 per hour. Total number of REM events was 8. O2 saturation showed 1 event with O2 saturation between 80-85%, 18 events with O2 saturation between 85-90%, 29 events with O2 saturation between 90-95%. The longest respiratory event was 13.2 seconds and the lowest desaturation was 82%. Snoring was reported to be 1-2/10.

IMPRESSION: This test shows:
1. Poor sleep efficiency.
2. Disturbed sleep architecture.
3. Mild periodic leg movement, that was clear would not interfere with the patient’s sleep because there was no awakening.
4. No obstructive or central sleep apnea.
5. Few events with desaturation during the night.

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