A 35-year-old man comes to the office due to worsening daytime sleepiness over the last 6 months. He says, "I keep falling asleep during inappropriate times of the day. I regularly fall asleep in staff meetings and even fell asleep while talking to a customer." The patient has not fallen asleep while driving and has had no episodes of sudden weakness, inability to move, or restless legs. Although he has no difficulty falling asleep and sleeps 7-8 hours a night, he rarely feels rested. The patient lives alone and does not know if he snores. He does not report gasping for air. He is not depressed but says he is "under stress" at work after receiving a negative performance evaluation, and he worries he will be fired for falling asleep. His medical history is significant for hypertension treated with lisinopril. He smokes a pack of cigarettes a day and consumes an average of 2-5 alcoholic drinks a week. He does not use illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 129/88 mm Hg, pulse is 84/min, and respirations are 14/min. BMI is 36 kg/m². Physical examination is within normal limits. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_c001_1731_8f63_9fb6374bb850_MD0005_00 This patient's history of excessive daytime sleepiness is suspicious for obstructive sleep apnea (OSA), given his risk factors of gender, hypertension, and obesity. The STOP-Bang survey can help quantify risk for OSA; in this case, even without clarification regarding snoring or witnessed apneas, the patient has a STOP-Bang score of 4 and would be considered at intermediate risk. Other common causes of excessive daytime sleepiness include narcolepsy, periodic limb movements of sleep, insufficient sleep, depressive disorders, general medical conditions, and the effects of prescription or recreational drug use. The next step in evaluation of excessive daytime sleepiness with suspected OSA is polysomnography (PSG). PSG evaluates the quality of sleep, and the recorded tracings of physiologic variables can assist in the diagnosis of obstructive sleep apnea, periodic limb movements, and narcolepsy. (Choice A) Continuous positive airway pressure is the appropriate treatment once the diagnosis of OSA is confirmed. (Choice B) For patients with suspected narcolepsy, management also involves an initial evaluation with PSG to rule out other sleep disorders. In such cases PSG is followed by a multiple sleep latency test to confirm shortened sleep latency and sleep-onset rapid eye movement periods. Although narcolepsy is part of the differential diagnosis, it is less likely in this patient without episodes of sudden weakness (cataplexy) or inability to move (sleep paralysis). (Choice D) A psychiatric evaluation would be the next step if there were strong suspicion that the patient's excessive daytime sleepiness is a symptom of depression or other psychiatric disorder. This patient has denied depression; his stress is related to impairment due to his sleep disorder. (Choice E) The stimulant modafinil would be appropriate for a confirmed diagnosis of narcolepsy. Educational objective: Common causes of excessive daytime sleepiness include obstructive sleep apnea (OSA), narcolepsy, periodic limb movements, and depressive disorders. The classic presentation for OSA is an overweight, hypertensive male with excessive daytime sleepiness, snoring, and apneic spells. Polysomnography is indicated in the diagnostic evaluation of patients with suspected OSA and can assist in the diagnosis of other sleep disorders. References: Office evaluation of the "tired" or "sleepy" patient. (http://www.ncbi.nlm.nih.gov/pubmed/21321832) Management of common sleep disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23944726)

A 35-Year-Old Man Comes to the Office Due to Worsening