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Social History
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The patient denies any alcohol use or
abuse, caffeine use, stimulants, or street drug abuse or history of it.
Patient only takes thiazide diuretic for control of hypertension and
denies nocturia. Patient denies palpitations, diaphoresis, tremor, or any
other signs of thyroid disease. When asked if the patient sleeps alone, pt
states "I never sleep alone and my partner never has any complaints." Past
medical history is significant only for obesity and hypertension. Family
history for sleep disorders is noncontributory. Patient denies psychiatry
history. ROS: Pt. denies arthritis, burning sensation when eating foods,
and abdominal pain associated with meals, or angina. Pt. denies leg
weakness and pain when performing activities or at rest.
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Physical Examination
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Findings
from physical exam significant for: Vital
signs : Temp 38.1; blood pressure 150/80 ; pulse 80; respiration 16;
weight 250 lb; height 5' 3" Obese
male, generally awake/alert/oriented.
Speech understandable and comprehensible, without slurring or hesitation. No infection identified; uvula, palate are midline,
noninflamed, and normal in size. There
are no masses palpable in the thyroid.
Chest wall absent for deformities, breathing is deep with regular
rate, good air exchange without wheezes or egophony.
Heart exam within normal limits.
Abdominal exam within normal limits. Neurological exam is grossly
intact.
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Test Results
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Labs come back with elevated hemoglobin & hemocrit, normal WBCs, normal
renal function, normal thyroid panel.
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The
patient returns two weeks later with his daughter for her appointment. In
passing you ask the patient how he was sleeping and he states that he is
not having much success. He says that he has followed your recommendations
and show you his sleep log record.
(the same the next week) |
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The
patient returns two weeks later with his wife for his follow-up
appointment. The patient’s
daughter is doing well and her rash from poison ivy has resolved. You ask
the patient how he is sleeping now? The patient says better, but the lights
(the phototherapy) are bothersome hassle and his wife hates it. He states
that he is sleeping more now and gets 6 hours of sleep but still is
unrefreshed on awakening and sometimes finds himself napping through the
day. He showed you his sleep log record.
(the same the next week) |
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The wife states. “You need to do something about his sleeping. He snores so
loud it is ridiculous. He keeps me up all night with that noise. When I
finally get to sleep, he sometimes kicks me and wakes me up as he gasps for
air.”
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