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.
Publication reference : Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2009;5(3):263-276.
Reference URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699173/