Narrative_Summary_exercise.pdf

Narrative Summary exercise:

Alert, cooperative, in no apparent distress 54 year old Caucasian male reports with Diabetes Mellitus Type II (DMII) and Obstructive Sleep Apnea (OSA). DMII maintained on diet and exercise. CPAP was previously started on metformin, but no longer on per the guidance of his treating provider. Sleep Study conducted due to poor sleep, constantly tired and high Epworth score of 18/24. AHI was 23.2 before CPAP. During titration of sleep study on 8 cm of H20, his AHI went to 0.0. Indications for sleep study conducted on 1/5/2015 include loud snoring, gasping for air, daytime sleepiness. During the diagnosis period: total recording time of 137.2 minutes with a total sleep time of 123.8 minutes. Sleep efficiency was 90.2%. Average O2 saturations were 97.0% with the minimum being 82%. The patient had a total of 48 respiratory events for an AHI of 23.2. There were 38 obstructive apneas, 0 mixed apneas, 0 central apneas, and 10 hypopneas. 11 events occurred in Stage REM, and 37 were noted in NREM. 90 day CPAP compliance: AHI 1.23, used 68% of the time, with an average of 4.5 hours used at a time.

Vitals: BP 124/78, P 72, Temp 96.6, Weight 205 lb, Height , BMI 32.1 Eye Exam: Normal monofilament exam with no diabetic retinopathy

Medications: Esomeprazole 20 mg po qd, Atorvastatin 10 mg po qd

Exam: HEENT: PERRL, react to light and accommodation, EOMI, conjunctiva clear; lips, mouth and throat are unremarkable.

Pulmonary: normal respiratory effort, chest clear, breath sounds equal bilaterally Cardiovascular: Regular rhythm normal S1 and S2 without murmur. Peripheral pulses full. Extremities with no cyanosis, clubbing or edema Abdomen: soft, non-tender, bowel sounds normal. No masses or organomegaly Mental Status: alert, oriented x3, thought content appropriate, good insight, speech clear, no suicidal thoughts Neurologic: station and gait normal, CN 2-12 intact Foot exam: Monofilament 5/5 in both feet, 2+pedal pulses bilaterally. No trophic, hypertrophic changes Labs:

Cholesterol: 176

Triglycerides: 299

HDL: 31

LDL: 85

A1C:

(06/26/2017 -6.0

02/23/2017 – 6.1

08/20/2016 – 6.3

02/02/2016 – 6.2

His microalbumin/creatinine ratio was normal at 3.

6/29/2017; glucose 96, A1C 6.0 2/25/2017; phosphorous 3.0 (2.5-4.5), PTH intact 67 (14-95), serum electrophoresis no monoclonal gammopathy present, chloride 95, CO2 29, calcium, glucose 124, BUN 16, creatinine 1.50, sodium 132, potassium 3.9, calcium 9.6, microalbumin/creatinine ratio 3 (0-29), cholesterol 176, triglyceride 299, HDL 31, LDL 85, A1C 6.1, UA within normal limits