25 male presented towards the sleep clinic using a key complaint
25 male presented towards the sleep clinic using a key complaint of extreme daytime somnolence and witnessed nocturnal “choking episodes” dating back again a couple of years. background was positive for the dad with obstructive rest apnea. His physical exam revealed normal vital indications having a physical body mass index of 23.5. Head ears eye throat and nose exam were unremarkable as was the cardiopulmonary exam. An over night diagnostic polysomnogram (PSG) was acquired using the hypnogram demonstrated in Shape 1 and a listing of pertinent leads to Desk 1. Shape 1 Hypnogram displaying the overview of rest phases for the rest period. Notice the massive amount REM rest (as specified by R in the y axis) using the arrows directing to these regions of curiosity. Desk 1 Diagnostic Polysomnogram Overview of Rest Time Statistics Rest Stage Figures and Respiratory Event Figures A multiple rest latency check (MSLT) was eventually obtained following a PSG to judge objectively his intensity of somnolence (Desk 2). Desk 2 Results from the Multiple Rest Latency Test Query: What more information would be vital that you request from the individual MC1568 to help clarify the results seen for the PSG and MSLT? Response: A summary of any medicines or recreational medicines recently began or stopped. One may consider drug screening to ensure that the findings are not pharmacologically induced. Sleep logs for 1 week prior to the MSLT to assess prior sleep-wake schedules can sometimes be helpful to look for insufficient sleep. DISCUSSION Although clinical depression can present with hypersomnia our patient’s complaint of nocturnal choking episodes warranted further polysomnographic evaluation to rule out sleep disordered breathing as a contributing cause. In addition to the mild sleep disordered breathing seen on the polysomnogram the significant increase in the percentage of REM sleep on his hypnogram termed REM rebound and the 2 2 SOREMPs seen on MSLT were important findings of the case. Each of these will be addressed in turn. In healthy adults REM sleep makes up 20% to 25% of total sleep time. REM sleep occurs every 90-120 min of a night’s sleep and increases in duration with each period of REM. There may be 4 to 5 periods of REM sleep per night time.1 Inside our patient in comparison 58 of the MC1568 full total rest time was composed of REM rest. There are many factors behind the improved REM rest percentage as observed in Desk 3.1-8 Desk 3 Factors behind an elevated REM Rest Percentage on PSG The patient’s report MC1568 of disabling hypersomnia appeared out of proportion to his overnight PSG findings and therefore we elected to execute and interpret the MSLT even though a number of the MSLT recommendations weren’t precisely met.9 10 MSLT guidelines recommend the very least 2-week GATA6 withdrawal period from any drugs with unwanted effects that disrupt rest including alcohol antidepressants or narcotics;9 10 nonetheless it was experienced upon consultation with the principal care physician that his psychiatric state didn’t permit preventing his antidepressant medications. MSLT recommendations suggest the MC1568 1st nap begin 1.5 to 3 h following the termination from the preceding nocturnal research with least 360 min of nocturnal rest have to be documented for meaningful MSLT effects. Although AASM recommendations are routinely adopted in our sleep laboratory an inadvertent early “Light On” resulted in a sleep time of 357 min which we believe still permitted meaningful clinical interpretation of the data in this case. Our patient had a mean sleep latency of 14 min which falls into the normal range despite his complaints of excessive hypersomnolence. Note that the mean sleep latency may have been skewed by the fact that the patient was not able to nap during nap V. Our patient also experienced 2 SOREMPs during the study. While 2 or more SOREMPs could raise a question of narcolepsy this diagnosis also requires a mean sleep latency of < 8 min which our patient did not have. SOREMPs can occur in other clinical situations as well as seen in Table 4.1-8 Table 4 Causes of Sleep Onset REM Periods on MSLT We conducted further questioning to explain the surprising amount of REM sleep and the presence of SOREMPs in the framework of his normal mean rest latency. Although he didn't report adjustments in his medicine routine to us before the PSG or MSLT he disclosed at a.