History of Present Illness: Nathan reported a 10-year history of long working hours and lack of personal activities, such as exercise and vacation, in pursuit of a promising law career and hopes of making partner. During this time, Nathan had developed a habit of snacking to stay awake during late nights at work. Coupled with the lack of exercise, Nathan gradually gained 95 pounds. His current weight is 278 pounds (height = 69 inches; BMI = 41.05).
Nathan described increased fatigue throughout the previous 6 years. Recently, this has become “an embarrassment” as he occasionally falls asleep in important meetings. Nathan previously attempted to restart an exercise program but reports he simply lacked the energy. Friends describe him as “burned out.”
Medication History: Previous treatment with the stimulant Modafinil was not effective.
Social History: Single. Intensely focused on his career with no time for any other pursuits. Does not smoke or drink alcohol, except on rare social occasions. Nathan drinks at least 12 cups of coffee per day to stay awake.
Family History: Father snores heavily.
Review of Sleep Pattern: Nathan has a normal sleep schedule (11:30 PM – 7:00 AM) and reports he sleeps soundly. However, he arises from bed un-refreshed and occasionally awakens during the night gasping for air. Presence of snoring could not be confirmed by interview because Nathan sleeps alone and has no recent bed partners.
Evaluation and Diagnosis: Nathan spent a night in a sleep lab. He fell asleep almost instantly and slept soundly for about 3.5 hours. However, his AHI was 49 with O2 saturation frequently dipping into the low 80s.
Treatment and Follow-up: Nathan was prescribed nightly CPAP at 13 cm H2O. Within one week he had regained much of his former mental sharpness and physical energy. However, his nostrils and his throat felt excessively dry the morning following CPAP use. Although an added heated humidifier helped alleviated some discomfort, Nathan never became entirely comfortable with CPAP treatment. Despite his discomfort, he continued to use it nightly. His regained energy allowed him to begin an intensive weight loss program through diet and exercise.