sleep apnoea
Doctor Information
John Roberts
48 year old man
Last seen 4 months ago by nurse
Entry: seen for health check, long standing weight problems. BP:140/85, pulse 80, BMI 40, urine dip negative. Advised to see GP re weight.
Bloods done 4 months ago for health check
FBC, U+E, hba1c: normal. Cholesterol raised at 6.4
48 year old man
Last seen 4 months ago by nurse
Entry: seen for health check, long standing weight problems. BP:140/85, pulse 80, BMI 40, urine dip negative. Advised to see GP re weight.
Bloods done 4 months ago for health check
FBC, U+E, hba1c: normal. Cholesterol raised at 6.4
Patient Information
John Roberts, age 48
Opening line: Doctor I'm having a terrible problem with tiredness
You have a 6 month history of tiredness, initially you felt it might be due to long hours at work, but you now don't think that's the case, as workload has settled down and you are still tired.
You don’t have a problem sleeping, In fact you can fall asleep any where. This is now a problem as your wife thinks you're being lazy and using it to get out of doing house work.
If asked reveal that you don't have any symptoms of thyroid disease ( no weight change, no change in hair, no change in temperature sensation, no change in bowels ) no symptoms of low mood (concentration fine, enjoying life, looking forward to things, not depressed) no shortness of breath, no recent viral illness. You have no symptoms of diabetes.
You find you can fall asleep any time, frequently after meals or in front of the television. If asked you will also admit to falling asleep at the wheel several times. You do not wish the Doctor to tell any one about this, as you are concerned it will affect your ability to work. Money is tight at the moment, and you can't afford to be off work.
You do snore loudly, but suspect that's due to your weight which has been creeping up. Your wife has mentioned that you pause during your breathing at night, but you suspect she's worrying over nothing.
You don't smoke, you eat well in terms of volume. You work as a HGV driver, so don't have much time for healthy eating and exercising. You don't drink any alcohol during the week, but go out at weekends and have a few in the evening.
Ideas: you have read about glandular fever, and suspect you may have that. Simply because the daily mail said it was a missed diagnosis by many GPs for people like me who have been tired for a while.
Concern: you read that glandular fever can make people tired for years, you don't want this. You also don't want work to find out about the sleeping at the wheel
Expectations: you want a test for glandular fever.
If the doctor is nice and caring, and empathises with your difficult situation, you will agree to inform the DVLA and work about the problem. You will be more likely to agree if the doctor reassures that through lifestyle and other methods that symptoms can be controlled.
You will agree to go to the sleep clinic if offered.
Opening line: Doctor I'm having a terrible problem with tiredness
You have a 6 month history of tiredness, initially you felt it might be due to long hours at work, but you now don't think that's the case, as workload has settled down and you are still tired.
You don’t have a problem sleeping, In fact you can fall asleep any where. This is now a problem as your wife thinks you're being lazy and using it to get out of doing house work.
If asked reveal that you don't have any symptoms of thyroid disease ( no weight change, no change in hair, no change in temperature sensation, no change in bowels ) no symptoms of low mood (concentration fine, enjoying life, looking forward to things, not depressed) no shortness of breath, no recent viral illness. You have no symptoms of diabetes.
You find you can fall asleep any time, frequently after meals or in front of the television. If asked you will also admit to falling asleep at the wheel several times. You do not wish the Doctor to tell any one about this, as you are concerned it will affect your ability to work. Money is tight at the moment, and you can't afford to be off work.
You do snore loudly, but suspect that's due to your weight which has been creeping up. Your wife has mentioned that you pause during your breathing at night, but you suspect she's worrying over nothing.
You don't smoke, you eat well in terms of volume. You work as a HGV driver, so don't have much time for healthy eating and exercising. You don't drink any alcohol during the week, but go out at weekends and have a few in the evening.
Ideas: you have read about glandular fever, and suspect you may have that. Simply because the daily mail said it was a missed diagnosis by many GPs for people like me who have been tired for a while.
Concern: you read that glandular fever can make people tired for years, you don't want this. You also don't want work to find out about the sleeping at the wheel
Expectations: you want a test for glandular fever.
If the doctor is nice and caring, and empathises with your difficult situation, you will agree to inform the DVLA and work about the problem. You will be more likely to agree if the doctor reassures that through lifestyle and other methods that symptoms can be controlled.
You will agree to go to the sleep clinic if offered.
Examination Findings
BMI 40, no signs of thyroid disease, no signs of anaemia,
Urine dip negative.
BP 138/78
Urine dip negative.
BP 138/78
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Discusses implications for driving Manages risk effectively, safety netting appropriately Encourages the patient to participate in appropriate health promotion and disease prevention strategies |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient |
Management
Explanation: You could be describing a condition called sleep apnoea. This means that your breathing briefly stops many times overnight and you will wake up for a few seconds. In the morning, you won’t remember waking up but you will feel tired. The reason this happens is because your throat muscles relax too much overnight, narrowing the passage for air to get in and out.
During your assessment, take note of any modifiable risk factors for sleep apnoea - such as smoking, alcohol, sleeping tablets, weight gain or high BMI, thick neck circumference, or large tonsils. Find out the effects of sleepiness on day to day life - particularly with work and driving, and whether it has affected their mood. If you can history from a partner about snoring and choking, that would be helpful. In the CSA you might not have time to go through the Epworth sleepiness questionnaire, but could give it to a patient to complete themselves. Read below for the scoring system - just for reference
During your assessment, take note of any modifiable risk factors for sleep apnoea - such as smoking, alcohol, sleeping tablets, weight gain or high BMI, thick neck circumference, or large tonsils. Find out the effects of sleepiness on day to day life - particularly with work and driving, and whether it has affected their mood. If you can history from a partner about snoring and choking, that would be helpful. In the CSA you might not have time to go through the Epworth sleepiness questionnaire, but could give it to a patient to complete themselves. Read below for the scoring system - just for reference
The Epworth Sleepiness Scale (ESS)
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:SITUATION CHANCE OF DOZING (0–3)
- 0 = would never doze
- 1 = slight chance of dozing
- 2 = moderate chance of dozing
- 3 = high chance of dozing
Sitting and reading
Watching television
Sitting inactive in a public place (e.g. a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic
Interpretation:
0-7:It is unlikely that you are abnormally sleepy.
8-9:You have an average amount of daytime sleepiness.
10-15:You may be excessively sleepy depending on the situation.
16-24:You are excessively sleepy and should consider seeking medical attention.
Management:
Patients with suspected sleep apnoea should be referred to a local sleep clinic for sleep studies and further treatments (e.g. CPAP or mouth guards). Refer urgently those who are sleepy whilst driving, operating machinery or work in a hazardous environment.
In primary care, your job is to advise on lifestyle factors that can improve symptoms, and tackle the difficult issue of driving. Weight loss, reducing alcohol and smoking are the three most common culprits- offer advice and consider involving a health trainer or smoking/alcohol services if required. Falling asleep at the wheel is obviously a big deal. Whilst you can understand that a patient may need to drive for their living, if they fall asleep at the wheel, they risk their own life as well as everyone else out there. In addition, their insurance would be invalid if they were under investigation for a condition that they have been advised not to drive for. You should encourage patients to tell their own insurance company. Due to him having a Group 2 licence, you must advise him not to drive until we have controlled his symptoms. He must also inform the DVLA. You can assure him that this is likely to only be a temporary measure, as most peoples symptoms can be controlled with treatment.
In secondary care, once the diagnosis has been confirmed, then they can initiate overnight CPAP, which often helps greatly with symptoms.
What if a patient refuses to disclose to the DVLA:
Luckily the GMC has guidance for just such occasion. Please click here to read further.
Patients with suspected sleep apnoea should be referred to a local sleep clinic for sleep studies and further treatments (e.g. CPAP or mouth guards). Refer urgently those who are sleepy whilst driving, operating machinery or work in a hazardous environment.
In primary care, your job is to advise on lifestyle factors that can improve symptoms, and tackle the difficult issue of driving. Weight loss, reducing alcohol and smoking are the three most common culprits- offer advice and consider involving a health trainer or smoking/alcohol services if required. Falling asleep at the wheel is obviously a big deal. Whilst you can understand that a patient may need to drive for their living, if they fall asleep at the wheel, they risk their own life as well as everyone else out there. In addition, their insurance would be invalid if they were under investigation for a condition that they have been advised not to drive for. You should encourage patients to tell their own insurance company. Due to him having a Group 2 licence, you must advise him not to drive until we have controlled his symptoms. He must also inform the DVLA. You can assure him that this is likely to only be a temporary measure, as most peoples symptoms can be controlled with treatment.
In secondary care, once the diagnosis has been confirmed, then they can initiate overnight CPAP, which often helps greatly with symptoms.
What if a patient refuses to disclose to the DVLA:
Luckily the GMC has guidance for just such occasion. Please click here to read further.
What the DVLA have to say:
Group 1
Driving must cease until satisfactory control of symptoms has been attained.
Group 2
Driving must cease until satisfactory control of symptoms has been attained, with ongoing compliance with
treatment, confirmed by consultant / specialist opinion. Regular, normally annual, licensing review required
Click HERE for the full DVLA driving rules