Sleep Disorder Follow-Up Assessment

Sleep Follow-Up Note

Subjective

• Pt is a 44 yo M (MRN: 839-201-44) returning for 3-month f/u of severe OSA and comorbid chronic insomnia associated with MDD. Reports improved sleep continuity since initiating CPAP, though c/o residual sleep-onset insomnia on work nights and mild mask leak.
• PMH: MDD, HTN, GERD, Severe OSA. Prior PSG (12/01/2026) showed AHI 34.2/hr, nadir SpO2 82%. Previously trialed trazodone 50 mg PO QHS (d/c due to morning grogginess) and CBT-I.
• Meds: escitalopram (Lexapro) 20 mg PO daily, lisinopril 10 mg PO daily, omeprazole 20 mg PO daily, melatonin 3 mg PO QHS.
• Social Hx: Works as an accountant (mon-fri, 08:30–17:00). Drinks 2 cups of coffee daily (last at 13:00). Denies tobacco, EtOH, or illicit drug use.
• Allergies: NKDA.

PAP Therapy

• Uses auto-CPAP. Reports occasional sensation of air hunger at ramp start, requesting slight increase in minimum pressure. Uses ResMed AirFit P10 nasal pillows; fit is generally comfortable, though notes minor oral leak when congested. DME provider is Apria Healthcare. Pt and spouse report marked reduction in snoring and improved morning alertness.

  30-day compliance download (15/02/2026 to 16/03/2026): Used 28 of 30 days (93.3%). Used >= 4 hrs on 86.7% of days; average usage on days used is 6 hrs 42 mins. Current settings: 5–15 cm H2O. Median pressure 8.4 cm H2O, maximum pressure 12.2 cm H2O. Residual AHI 2.1/hr, CAI 0.4/hr, periodic breathing 0%. Vibratory snore index low; 95th percentile leak is 18 LPM.

ROS

• Denies morning headaches, recent weight changes, or stomach aches. Reports mild seasonal allergies with intermittent nocturnal nasal congestion.

Sleep / Circadian Pattern

• Sleeps in a dark, quiet bedroom at home with spouse; no pets in the bedroom. Head-of-bed position is flat. Uses two pillows under the head and one between the knees. Sleeps in a combination of side-lying and supine positions.

• Gets into bed at 22:00 on weeknights.

  Gets into bed at 23:30 on weekends.

• Lights out at 22:30 on weeknights. Uses smartphone in bed for 30 mins prior to lights out.

  Lights out at 23:45 on weekends. Watches TV in the living room prior to bed; no screen use in bed on weekends.

• Sleep latency is approx 45 mins on weeknights and 20 mins on weekends. Remains in bed tossing and turning when unable to sleep.

• Reports 1 nighttime awakening per night for nocturia, lasting < 10 mins, returning to sleep easily without associated symptoms.

• Wake times: Weekdays: 06:30 via alarm. Weekends: 08:00 naturally. Remains in bed for 15 mins after waking; rise time is 06:45 on weekdays and 08:15 on weekends. Estimated total sleep duration is 6.5 hrs on weeknights and 7.5 hrs on weekends. Estimated total time in bed is 8.75 hrs on weeknights and 8.5 hrs on weekends. Identifies as an evening chronotype, feeling more alert at night.

Daytime Symptoms

• Reports mild grogginess upon awakening on weekdays that resolves within 30 mins; feels refreshed on weekends.

• Mild daytime fatigue hits around 14:00 daily, lasting 2 hrs, without associated somatic symptoms.

• Denies planned daytime naps or inadvertent dozing.

• Reports mild difficulty concentrating at work during the mid-afternoon slump, occurring 2–3x/week.

• Denies sleepiness while driving, near misses, or history of MVA.

Objective

• Vitals: BP 124/78 mmHg, HR 72 bpm, BMI 29.4 kg/m2. HEENT: Mallampati Class III, mild inferior turbinate hypertrophy bilaterally, oropharynx clear, neck circumference 42 cm. MSE: Alert, cooperative, mood "good", affect euthymic, thought process linear, no SI/HI.
• CPAP SD card data reviewed today (see PAP Therapy section). ESS score: 6/24 (down from 14 at baseline). PHQ-9: 4.

Assessment

• Severe OSA (G47.33), compliant with CPAP therapy with good efficacy and resolution of hypersomnolence.
• Chronic sleep-onset insomnia (G47.00), improved, maintained by screen use in bed and slight circadian phase delay.
• MDD, in full remission (F33.42) on escitalopram.

Plan

• Increase auto-CPAP minimum pressure from 5 to 6 cm H2O (new range 6–15 cm H2O) to address initial air hunger. Start fluticasone propionate (Flonase) 50 mcg/actuation 2 sprays intranasally daily for nocturnal nasal congestion to reduce oral leak. Continue escitalopram 20 mg PO daily and melatonin 3 mg PO QHS (take 2 hrs prior to desired bedtime at 20:30).
• RTC in 6 months for routine sleep medicine/psychiatry follow-up, or sooner PRN.
• Counselled on strict stimulus control: discontinue smartphone use in bed and get out of bed if unable to sleep within 20 mins. Reviewed importance of maintaining a consistent wake time within a 1-hour window on weekends.