UCSF Medical Center at Mount Zion
Dear Doctor XX,
Thank you for requesting sleep consultation for this pleasant but challenging 65-year-old man with chronic depression and insomnia issues for a chief complaint of daytime fatigue. The patient complains that he is fatigued after his daytime activities, and this has been true both when he was working and also since he retired 2 years ago. Typically, he is tired enough in the evening that he will lie down in bed at 6 o'clock and stay in bed until 9 o'clock when he takes his sleep medications. He usually takes 2 to 3 hours to fall asleep but often complains that once he falls asleep, he will still wake up early in the morning and occasionally have insomnia for this reason.
He finds his sleep patterns to be somewhat unpredictable but stable. There has been no dramatic change in this pattern, and he did find Lamictal as an additional medication several years ago to be helpful. He has been on Provigil for what he estimates as 5 years taking it in the morning, and that gives him move energy.
He has been pleased with Dr. XX as his new psychiatrist for the past 1-1/2 years and has found gabapentin to be helpful medicastion with sleeping and also Ritalin in the morning seems to give him more dayatime energy. He thinks that even though he lies in bed for many hours, that he is not dozing off in the evening, and he is careful to avoid this as a problem.
He lives and sleeps alone. He states that he has really never been around friends or family at nightime while sleeping to have any information about snoring, and he never hears himself snore and has no history of gasping or choking episodes. He never naps in the daytime as he is careful about this issue and does not have a sense of leg kicking or twitching while he is sleeping, but again, there are no friends or family to observe his sleep patterns.
The patient does complain of having to urinate 4 to 5 times per night with some prostate hypertrophy issues, but no desire for further workup as he does not view any of these sleep or urinating problems as bad enough to need any further intervention.
Past Medical History: Depression, asthma as a child, electroconvulsive therapy in 2004.
Current Medications: Lipitor, asprin, bupropion, Cymbalta, gabapentin, Geodon, Provigil in the morning, and Ritalin in the morning.
Allergies: No known drug allergies.
Family History: He is retired, single, and lives alone. No pets.
Review of systems: Constitutional: No fevers, chills, sweats, or involuntary weight loss. HEENT: No nasal congestion, sinus pain, drainage, or epistaxis. GI: No nausea, vomiting, abdominal pain, or GERD symptoms. Endocrine: No history of hypothyroidism or diabetes and apparently even though he has been on Lipitor, he believes that there is no evidence of any muscle problems from the Lipitor. The remainder of the review of systems is negative.
Physical Examination:
General: Alert, pleasant, and in no distress.
Vital Signs: Blood pressure 100/60, pulse 80, respirations 16.
HEENT: Mildly elongated soft palates. Small tonsils. No thrush or overbite. Eyes anicteric, Extraocular movements are intact.
Lungs: Clear without rales or wheezes.
Cardiac: Normal S1 and S2 without murmurs or gallops.
Abdomen: Nontender without hepatosplenomegaly.
Extremities: No clubbing, cyanosis or edema.
Neurologic: Alert and oriented x4. Normal gait. Nonfocal exam.
I personally reviewed his sleep diary data which does show on average that he sleeps 7 to 7 1/2 hours per night, although there can be fluctuations to either 8 or 9 hours or as low as 2 to 3 hours, but these are not common.
Impression:
1. Disorder initiating and maintaining sleep. The patient certainly does have poor sleep hygiene as he spends many hours in bed. I encouraged him to try to reduce the number of hours in bed, but he is reluctant to make this change as he does feel tired in the daytime, and he is careful to stay awake so he does not doze off. He continues to be active in the daytime, and I encouraged him to work on relaxation techniques, although he does feel that watching television is helpful in this regard.
2. Depression as a significant chronic issue which is certainly a major contributor to his insomnia, and he will continue his ongoing care with Dr. XX.
3. Obstructive sleep apnea seems unlikely under the current clinical circumstances. Since the patient is thin and has long-term sleep issues, I have not recommended a sleep study at this time, but if those clinical issues change, the patient should contact me, and we could certainly perform a study in the future if clinically indicated.
4. Chronic fatigue as a nonspecific symptom, but the patient does feel that Provigil and Ritalin in the mornings have helped him to have more energy.
Sincerely,
Dr ZZ
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