Initial Sleep Consult Template

Patient Name: Date of Consultation: Medical Record Number: Referring Physician:

History of Present Illness: To be dictated. REVIEW OF SYSTEMS: 10-point review of systems was performed and is negative except that mentioned above in the history of present illness. Specifically, the patient denies any significant fever, chills, visual changes, headaches, hair loss, polydipsia, difficulties swallowing, shortness of breath, chest/ abdominal pain, PND, nausea/ vomiting, diarrhea, constipation, or melena/ hematochezia.

PAST MEDICAL HISTORY: 1. Hypertension 2. Dyslipidemia 3. Coronary Artery Disease 4. GERD 5. Atrial Fibrillation 6. (Type 1/ Type 2) Diabetes Mellitus 7. Allergic Rhinitis 8. Migraine Headaches 9. Asthma 10. COPD 11. Congestive Heart Failure 12. h/o Cerebrovascular Accident (CVA) 13. Mood Disorder 14. To be dictated PAST SURGICAL HISTORY: To be dictated. MEDICATIONS: ALLERGIES: SOCIAL HISTORY: Work: ________________. He/she is currently (married/divorced/single/widowed) with ______ children. Pt (smokes _____ pack/s a day with a cumulative ____pack-yr history/ is a nonsmoker). Alcohol intake: ____. Caffeine intake: ____. Energy drinks: ____.

FAMILY HISTORY: 1) Mother with a history of (OSA, narcolepsy, insomnia, parasomnias, RLS, snoring.) 2) Father with a history of (OSA, narcolepsy, insomnia, parasomnias, RLS, snoring.) 3) Sister(s) with a history of (OSA, narcolepsy, insomnia, parasomnias, RLS, snoring.) 4) Brother(s) with history of (OSA, narcolepsy, insomnia, parasomnias, RLS, snoring.) 5) No family history of sleep disorder.

PHYSICAL EXAM: Comfortable appearing (male/female) in no distress. Blood pressure ____________ Pulse ____________ Weight ____________ Height ____________ BMI_____ HEENT: PERRLA. Sinuses nontender. Nasal passages were (clear/obstructed/narrow). Turbinates (normal/enlarged). Oropharynx showed (good dentition, poor dentition, overbite, underbite, normal teeth alignment). Pt has a (normal, enlarged, elongated, swollen) uvula, with a (normal/crowded) posterior pharyngeal airspace. Mallampati class (1,2,3,4). Soft palate has a (normal, shallow, steep) slope. Tongue was (normal, enlarged, broad based). Neck was (short, normal) and supple without masses, thyromegaly, or JVD. There was (no/mild/moderate/severe) retrognathia. LUNGS: Clear to auscultation. There were no wheezes, rales, or rhonchi. CARDIAC EXAM: (Regular/Irregular) rhythm without murmur, gallop, or rub. ABDOMEN: Soft, nontender, without masses or organomegaly. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC EXAM: Pt. was alert and oriented. Cranial nerves 2-12 intact. Gait was normal. Motor function was normal. Deep tendon reflexes 2+ bilaterally. IMPRESSION: (Please number one after the other if there is more than one) Template 1: Probable sleep apnea-hypopnea-syndrome (ICSD 327.23): The patient was educated about the pathophysiology, diagnosis, and clinical manifestations of sleep apnea-hypopnea syndrome (SAHS). The potential medical comorbidities associated with SAHS were reviewed. Treatment options based on severity were discussed to include positive airway pressure (PAP), oral appliance therapy, surgery, and weight loss. In addition, the patient was cautioned about

potential impairment driving and performing other complex tasks until further treatment is initiated. Template 2: Primary snoring (ICSD 327.20): The pathophysiology of primary snoring (PS) was reviewed. It is recognized that in over 75% of patients with PS the principal cause is relative vibration and resonation of the soft palate/uvula. Additionally it is recognized that PS can cause disruption of sleep architecture with resultant daytime sleepiness and may be a risk factor for hypertension. Treatment options were reviewed to include surgery (palatal pillar implants, somnoplasty, uvulopalatopharyngoplasty), oral appliance therapy, positional therapy, and weight loss. It is acknowledged that obstructive sleep apnea (OSA) is seen in approximately 25% of individuals who snore and that approximately 30% of people with clinically significant OSA deny subjective sleepiness. Therefore before proceeding with directed therapy for primary snoring, it is my recommendation that some form of diagnostic testing be performed to rule out superimposed OSA. Template 3: Restless Legs Syndrome ( ICSD 333.99): As described above the patient relates a history consistent with Restless Legs Syndrome (RS). This disorder can result in difficulties with sleep initiation and maintenance, the latter of which is secondary to periodic limb movements disrupting sleep architecture (seen in 80-90% of individuals with RLS). The pathophysiology, diagnosis, and treatment of RLS was discussed with the patient. In most cases diagnosis is made by clinical history and typically does not require formal sleep testing. Template 4: ?Periodic Limb Movement Disorder (ICSD 327.51): The patient relates a history suspicious for Periodic Limb Movement Disorder (PLMD). By definition PLMD occurs while asleep and is not associated with RLS symptoms while awake. PLMD most often affects the lower extremities and can cause difficulties with sleep initiation and maintenance. Periodic limb movements (PLMs) most often occur during stage N2 (formerly stage 2) sleep and cause disruption of sleep architecture. Diagnosis is made by nocturnal polysomnography. Template 5: Insufficient sleep syndrome (ICSD 307.44): As mentioned, the patient reports a history of getting insufficient sleep on a chronic basis. Most individuals require a minimum of 7 hours of sleep to capture the last and longest REM cycle. This can contribute to symptoms of daytime fatigue and relative cognitive impairment. Template 6: Excessive Daytime Sleepiness (NOS): As stated above the patient reports a history excessive daytime sleepiness/fatigue despite adequate sleep duration and description of subjectively sound sleep. There is no history to suggest a specific nocturnal sleep disorder such as obstructive sleep apnea or periodic limb movement disorder. The patient denies history consistent with cataplexy. Therefore the primary differential diagnosis is between Idiopathic Hypersomnia with/without long sleep time and Narcolepsy without cataplexy. The pathophysiology, diagnosis, and treatment of these disorders were discussed in detail. In addition, the patient was cautioned about

potential impairment driving and performing other complex tasks until further treatment is initiated. Template 7: Probable Narcolepsy with Cataplexy (ICSD: 347.01): As reported above the patient relates a significant history of daytime fatigue/sleepiness that is not influenced by sleep duration as well as history suspicious for cataplexy. Cataplexy is a unique phenomenon seen in some patients with narcolepsy and is characterized by sudden loss of bilateral muscle tone provoked by emotional stimuli, most often laughter. The loss of muscle tone ranges from a mild sensation of weakness (head drop, slurred speech, knee buckling) to complete postural collapse (rare). The pathophysiology, diagnosis, and treatment of both Narcolepsy and Cataplexy was reviewed in detail. In addition, the patient was cautioned about potential impairment driving and performing other complex tasks until further treatment is initiated. Template 7: Inadequate Sleep Hygeine (ICSD V69.4). Template 8: Shift work sleep disturbance (ICSD 327.36): The clinical impact of Shift Work Sleep Disturbance (SWSD) on an individuals circadian rhythm was reviewed. Recommendations were made as to methods of optimizing sleep hygiene, and reading material on this topic were provided. Template 10: Psychophysiological Insomnia (ICSD: 307.42): As reported above, the patient reports a fairly long history of difficulties both initiating and maintaining sleep. The essential feature in Psychophysiological Insomnia (PI) is that of a state of heightened arousal during the sleep period and learned sleeppreventing associations. This condition is seen in 1-2% of the general population, most commonly in adults. Primary treatment includes methods directed towards improving sleep hygiene, stimulus control, learned relaxation techniques and cognitive/behavioral interventions. Some individuals additionally benefit from the short-term administration of hypnotic medications. Template 11: Idiopathic Insomnia (ICSD: 327.00): As reported above the patient reports a longstanding history of difficulties initiating and maintaining sleep dating back to childhood. The clinical presentation is most consistent with Primary or Idiopathic Insomnia. This disorder is seen in < 1% of the population and has been shown to run in families. Diagnostic criteria requires history of difficulties sleeping dating back to infancy or at least early childhood. In addition to behavioral methods directed towards improving sleep hygiene and stimulus control, most individuals require some form of long term hypnotic therapy to optimize sleep. Template 12: To be dictated. PLAN: Template 1: 1.) Full nocturnal polysomnography (ICD-9: 95810) Template 2: 1.) Split-night polysomnography (ICD-9: 95811). Template 3: 1.) Portable polysomnography (Type III, GO399) Template 4: 1.) Portable Resmed Apnealink study (Type IV) Template 5: 1.) Full nocturnal polysomnography (ICD-9: 95810) with conditional next-day Multiple Sleep Latency Testing (MSLT, ICD-9: 95805).

Plus possibly: Template 1: Given high clinical suspicion for obstructive sleep apnea, CPAP titration study will be tentatively scheduled for 7-10 days following diagnostic polysomnogram. Template 2: With history suggestive of RLS, will check serum ferritin, folate, and Vitamin B12 levels. Template 3: Will proceed with directed therapy for RLS with Mirapex at 0.25 mg po qhs. Template 4: Patient advised to get more sleep on a regular basis. Template 5: Patient given information regarding methods of improving sleep hygiene. This includes maintaining a regular sleep/wake schedule, avoidance of clock watching, and leaving bedroom after approximately 30 minutes of wakefulness. Template 6: Patient given prescription for intranasal corticosteroid to be used in treatment of their chronic rhinitis. Template 7: Patient given prescription for (Provigil 200mg/Nuvigil 125mg) po q AM. Template 8: Given the subjectivity severity of the patients daytime sleepiness and risk for motor vehicle accident/decrement in workplace performance, a prescription for Adderall 10 mg po q 6 hours prn sleepiness will be provided pending results of diagnostic testing. Template 9: To be dictated. Approximately ____ minutes was spent with the patient more than half of which was dedicated to counseling.

Scott T. Bonvallet, MD, FCCP Diplomat, American Board of Sleep Medicine Medical Director, Overlake Sleep Disorders Center