Sleep Studies & Neurodiagnostics; “Why did this patient experience angina during sleep” Custom Essay

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Scenario 1
A 40-year-old morbidly obese non-smoker called EMS after waking up at 0500 with chest pain. The pain has resolved by the time he reaches the ED. The patient doesn’t know how long he was having the pain before he yelled out for his wife. The patient states that his wife sleeps in a separate bedroom because he snores very loudly every night. The patient also reports dyspnea on exertion, but no chest pain prior to this occurrence. Also, he says that he often gets indigestion at night, but that wasn’t what he experienced this time.
Medical History: HTN, GERD. No cardiac disease. Cardiac Cath 1 year ago was normal.
Meds: Lasix once daily, Tagamet at bedtime, Captopril twice daily
Exam: Mildy diaphoretic obese white male
Clear BS bilaterally
Heart: regular rate and rhythm
Abdomen: soft, normal bowel sounds, obese
Extremities: 3+ pitting edema
Vitals: BP 160/90
HR 100
T 98.6 F
RR 18
Labs: ABG – 7.36, PaCO2 37, PaO2 62, SaO2 92%
CXR: pulmonary congestion
ECG: sinus tachycardia
Questions:
1. Why did this patient experience angina during sleep?
2. Given the limited information above, would you recommend any further tests to rule out a cardiac event?
3. If all of the cardiac tests came back negative, would you recommend any further tests to determine the cause of his chest pain?
4. Base on your answer to question 1, what treatments (more than 1) would you recommend for this patient?
Scenario 2
A 29-year-old non-smoker male has been involved in a motor vehicle accident, occurred at approximately 1500 on his drive home from work on a clear sunny day. The patient states he was feeling sleepy when he left work and remembers waking up when his car hit the guardrail. He also reports that he owns an old car with no air bag, so his chest hit the steering wheel. The patient states that he is having some pain in his anterior chest wall, but no anginal pain.
Medical History: Negative
Meds: None
Exam: well-nourished white male
Chest: contusion in the anterior chest
Clear BS bilaterally
Heart: regular rate and rhythm
Abdomen: soft, normal bowel sounds
Extremities: no clubbing, cyanosis or edema
Skin: multiple lacerations
Vitals: BP 140/88
HR 100
T 98.6 F
RR 16
Labs: ABG – none ordered
CXR: no pneumothorax, mass, infiltrate or effusion
ECG: sinus tachycardia
Questions:
1. What caused this patient to fall asleep at the wheel?
2. Based on your answer to the first question, what treatments do you recommend? What tests would need to be completed in order to optimize his treatment?
Scenario 3
A 63-year-old former smoker is admitted to the cath lab for a heart catheterization. A recent echocardiogram revealed pulmonary hypertension. The patient states she has some dyspnea on exertion that has been worsening and that she has always had a nagging non-productive cough. Also, she denies any angina, chest discomfort, or taking any diet pills.
Medical History: HTN & allergic rhinitis; Negative for cardiac disease
Meds: Nifedipine three times daily
Lasix once daily
KCl twice daily
Exam: mildly obese white female
Clear BS bilaterally
Heart: regular rate and rhythm, increased second heart sound
Abdomen: obese, soft, normal bowel sounds
Extremities: 2+ pitting edema
Vitals: BP 140/88
HR 92
T 98.6 F
RR 14
Labs: ABG – 7.45, PaCO2 41, PaO2 54, SaO2 84% on room air
CXR: mild cardiomegaly
ECG: normal sinus rhythm
Cardiac Cath results: no significant CAD; normal EF
PA pressures: 75/25 mmHg; PAWP 23 mmHg
PFT: FVC = 55% predicted; FEV1 55% predicted; FEF25-75% 37% predicted; no change after bronchodilator.
Questions:
1. What diagnosis can you generalize from her PA pressures?
2. What do you think is causing your answer to #1?
3. What other things could be causing your answer to #1 and what test(s) would you order to rule out those cause(s)?
4. What treatment do you think she needs? What improvements would you expect her to have if she is compliant with this treatment?
Scenario 4
A 54-year-old former smoker is admitted to the hospital with worsening SOB and BLE swelling. He denies having any chest pain or any change in his chronic productive cough of clear sputum.
Medical History: HTN & chronic bronchitis – FEV1 0.9L/30% predicted; Negative for cardiac disease
Meds: O2 at 2 lpm via NC continuously for the past 4 months
Albuterol MDI 4 puffs QID
Theophylline 300 mg BID
Exam: mildly obese white male, SOB
Decreased but clear BS bilaterally
Heart: regular rate and rhythm
Abdomen: obese, soft, normal bowel sounds
Extremities: 3+ pitting edema to the knees; dusky feet
Vitals: BP 148/92
HR 104
T 98.6 F
RR 20
Labs: ABG – 7.36, PaCO2 44, PaO2 56, SaO2 89% on 2 lpm NC
CXR: pulmonary congestion
ECG: sinus tachycardia
Echocardiogram: limited study revealing normal left ventricular function
Bilat lower extremity Doppler: negative for DVT
Questions:
1. What further history/information would you like to ask this patient?
2. This patient undergoes polysomnography, which reveals an AHI of 40 and a low SaO2 of 60%. What diagnosis would you make? Think about this one…it’s a little tricky.
3. Based on your answer to #2, why do you think this patient has 3+ pitting edema to the knees; dusky feet?
Scenario 5
58-year-old male with a 60 pack-per-year history of smoking cigarettes fell asleep while driving one afternoon, and was involved in a motor vehicle accident. The ED physician referred him to a sleep laboratory upon discharge. The patient denies any chronic sleep problems, but does state that he is often very sleepy during the day. His wife adds that he snores at night and feels like his has become more restless during his sleep the passed few months. She even jokes that his snoring is almost as loud as the train that goes by their house. She adds that they like to have a drink before going to bed and this often makes the snoring even louder.
Questions:
1. What history and physical findings suggest this patient may have OSA?
2. What strategy do you suggest to properly diagnose this patient?
Scenario 6:
The following polysomnography tracings were obtained from a 44-year-old female referred to a sleep lab for the diagnosis of possible sleep apnea. She reports restless sleep, morning headaches, chronic fatigue, and daytime sleepiness.
Question:
1. How do you interpret these findings?

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