Case Of EXCESSIVE SLEEPINESS in a 45 year old male

 Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Here, 

  A 45 year old gentleman, driver by occupation, presented with chief complaints of excessive sleepiness associated with snoring since 10 years. 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 10 years ago when he developed excessive sleepiness during the day. Associated with snoring and breathlessness episodes in sleep.

He is also complaining of headache on both sides on the back of his head and corresponding neck pain which could be attributed to the position of his neck during his sleep episodes.

The patient is a driver by occupation and his daily routine on a normal working day starts at 8 am and ends at 8 pm, when he comes back home from work.

On an average working day, he drives 50-100 kms each day, sometimes upto 200kms.

His major concern was with respect to his profession as he could not afford to fall asleep during his working hours.

Whenever he felt sleepy, he used to stop the car and consume pan/gutka to avoid drowsiness.

Each time he fell sleep during the day, it used to be for around 15 minutes, and then he used to wake up on his own.

PAST HISTORY

• He is a known case of hypertension since 10 years for which he is on medication - Olmesartan 20 mg + Amplodipine 5 mg since 10 years.
• Not a known case of DM, TB, Bronchial Asthma, CAD.
• There is a history of trauma to his nose which occured in his 9th class while playing sports, which resulted in right sides caudal dislocation.
• No history of any previous surgeries.

PERSONAL HISTORY

 

• His appetite is normal, consumes mixed diet consisting mainly of no veg 4-5 days a week and his bowel and bladder movements are regular.
• He consumes alcohol twice a week for the last 8 years.
• He's also been a smoker for the past 10-12 years, wherein everyday he smokes 1/2 cigarettes.
• He consumes gutka/pan during driving to stay awake.
• He also mentioned having episodes of sneezing post showering or after dusting any object, like his bed. (This could be a dust allergy) 

FAMILY HISTORY

 Insignificant

General Examination:

• Patient was examined in a well lit room after taking consent. 
• He was conscious, coherent, cooperative and well oriented to time, space, person.
• He was well built with central obesity and well nourished.
• No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
• He was afebrile.
• Pulse rate - 74 bpm
• Respiratory rate -  14 breathes per minute 
• Blood pressure - 120/80 mm Hg

SYSTEMIC EXAMINATION

1. Cardiovascular System - S1 and S2 heart  sounds heard, no murmurs.
2. Respiratory System - Normal Vesicular breath sounds heard and bilateral air entry present.
3. Per Abdomen - soft, no tenderness, no palpable mass, no organomegaly. Normal bowel sounds heard.
4. Central Nervous System - Intact.
5. On examination of oral cavity, 
   It was noticed that he had macroglossia, which could have been the cause for his problem.

PROVISIONAL DIAGNOSIS

Obstructive Sleep Apnea

TREATMENT PLAN

1. CPAP

2. Mandibular advancement device (MAD)