Answer targeted questions : PSY-Q

Question : 1 / 258

A 40 year old man presents with complaints of “low energy” and daily headache. He says most days, he feels pretty “tired” and frequently gets bilateral, dull frontal headaches in the morning that are improved when he takes ibuprofen. He feels sleepy when he wakes up in the morning and that feeling continues throughout the day. He admits to falling asleep during the day, even a few times during meetings at work. He reports getting 8 hours of sleep “as far as I know” and having a healthy appetite. He says he sometimes feels down, especially when he is tired. He denies chest pain, shortness of breath (unless he is heavily exerting himself), and history of migraines. He enjoys hunting on his friend’s ranch every weekend and works as an engineer on oil rigs. He does not know if he snores, but says his ex-wife told him that he snored sometimes-- however, that was over 5 years ago. Vitals are temperature of 98.4, heart rate of 83, respiratory rate of 13, and blood pressure of 144/92. His BMI is 44. Physical exam is significant for obesity, neck diameter of 17.5 inches, and slightly distant normal heart sounds. Which of the following is most likely to reveal the cause of his symptoms?

Further psychiatric history
Echocardiography
Blood test for lead levels
Polysomnography

The answer is D, polysomnography. This patient’s presentation is consistent with the disordered sleep breathing of Obstructive Sleep Apnea (OSA). Patients with OSA typically complain of daytime sleepiness and are noted snorers/chokers/frequent gaspers during sleep. This patient has a remote history of snoring and a collection of other findings on exam that make the pre-test probability of OSA very high. Men are more likely to have OSA than women. Obesity is an important risk factor, as is neck circumference (even more closely associated than BMI, in fact). Many patients with OSA have morning headaches as this patient does, as well as clinically significant hypertension. Physical examination of the oropharynx may reveal some form of a narrowed airway, which can be caused by several things (macroglossia, tonsillar hypertrophy, microthagnia, etc). Any patient with complaints of “fatigue,” “low energy,” or feeling “tired” should cause the physician to include sleep disorders in the differential. Polysomnography is a clinical evaluation of many facets of sleep (the patient stays the night at a sleep center.) It is indicated in patients with moderate to high pretest probability of a sleep disorder. If diagnosed with OSA, the treatment would likely include the use of a continuous positive airway pressure (CPAP) machine to keep the airways unobstructed during sleep. OSA has been associated with a variety of other medical problems, including heart and kidney disease, and should prompt close monitoring of a patient’s general health. A, Further psychiatric history is likely not warranted as the patient does not meet the criteria for a mood disorder, despite having some symptoms that could be explained by depression on the surface. While this patient may be at risk for cardiovascular problems, his distant heart sounds with no symptoms of heart problems are likely due to fat on his torso “muffling” sound, so B, echocardiography is not indicated. His work as an engineer in the petroleum industry does put him at risk for exposure to environmental toxins, and an anemia caused by lead exposure could theoretically cause a fatigue syndrome. However, his “fatigue” is more of a daytime sleepiness and is likely better explained by a sleep disorder.

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