Station 89
James Bennett
Age: 38 year old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask the patient to clarify what he means by “having problems sleeping” and “feeling tired all the time”
- Ask when the symptoms started and whether they have worsened over time
- Ask about snoring and whether it has been reported as loud or disruptive
- Ask about possible episodes of apnoea, such as choking or gasping during sleep, or whether his wife has noticed pauses in breathing while sleeping.
- Ask about restless sleep or waking frequently during the night.
- Ask if the patient experiences early morning headaches.
- Ask whether he wakes up feeling unrefreshed despite sleeping.
- Ask about daytime sleepiness or tiredness throughout the day.
- Ask if patient has noticed any lumps or swelling in the neck area.
- Ask how these symptoms are affecting daily life, mood, and functioning.
- Ask about his job and whether symptoms are affecting performance, particularly if he operates machinery or performs safety-critical tasks.
- Ask if he drives and whether his sleepiness affects his ability to drive safely.
- Ask about any recent weight changes, especially weight gain.
- Ask about social lifestyle, including smoking and alcohol intake; explore how much he drinks, how often, and whether he has ever tried to cut down, and what happened when he did, to assess for possible alcohol dependence and whether he may need support to stop.
- Make a diagnosis of Obstructive sleep apnoea.
Example of explanation to patient
Thanks for sharing everything with me today, James. From what you’ve told me, the tiredness, poor sleep, snoring, and even dozing off during the day, I’m concerned you may have a condition called obstructive sleep apnoea.
Have you ever heard of this before? [Pause to allow him to respond]
Obstructive sleep apnoea is a common condition where the walls of the throat relax and narrow during sleep. This leads to interruptions in breathing, snoring and brief pauses in breathing during sleep. Are you following me so far?
Given that your job involves lorry driving, and you’re experiencing daytime sleepiness, this is something we must take seriously for your own safety and that of others. That’s why I would like to refer you to a sleep clinic for further assessment. They will likely offer a sleep study, which is usually done at home. You wear a small monitor overnight that checks things like your breathing, oxygen levels, and sleep position.
If sleep apnoea is confirmed, the usual treatment is a CPAP machine. It’s a device that gently pumps air through a mask while you sleep to keep your airway open. Most people start to feel much more alert and rested once they start using it.
I would strongly recommend that you stop driving until the sleep clinic has assessed you and advised that it is safe to resume, as it could be unsafe to continue driving with your current level of sleepiness. This is to ensure both your safety and the safety of others. I will issue a fit note to cover time off work, and I will refer you to our social prescriber, who can help explore any financial support available while you are not working. Does that all sound okay to you?
In the meantime, there are a few things we can start working on together. You mentioned that you usually have around two cans of beer a day, which adds up to about 30 units a week. We know from research that alcohol can make sleep apnoea worse by relaxing the muscles in the airway. Gradually cutting back could make a real difference in improving your sleep and daytime energy. What are your thoughts on that?
A lot of people with sleep apnoea find that their symptoms improve when they make changes to their lifestyle, like adjusting diet or getting more active. It is never easy, especially with a busy job, but we are here to support you if that is something you would like to work on.
Management
Management
- Offer a face-to-face assessment to examine the neck, mouth (including the back of the throat), nostrils, and check blood pressure.
- Inform the patient that you will send him a questionnaire called the Epworth Sleepiness Score form to help assess the severity of his symptoms and advise that this can also be completed during the face-to-face appointment today if he prefers.
- Offer to refer him to the sleep clinic for further assessment. Explain that, as he is a Group 2 driver and his job depends on this, you will request that he is seen within four weeks to avoid delay in diagnosis and treatment.
- Inform the patient that at the sleep clinic, he will undergo sleep studies, which are usually carried out at home but can sometimes be done in hospital.
- Inform the patient that they will be given a lightweight device to take home and wear overnight, with sensors attached to the body to monitor breathing, oxygen levels, heart rate, sleep position, and movement.
- Advise the patient that if sleep apnoea is confirmed, they will be offered a CPAP device; a machine that gently pumps air through a mask into the nose and mouth to help keep the airway open during sleep.
- Advise the patient to stop driving immediately due to possible sleep apnoea and excessive daytime sleepiness.
- Issue a fit note to cover time off work and offer referral to a social prescriber or welfare advisor to explore possible financial support or benefits while off work.
- Provide lifestyle advice including reducing alcohol intake, improving diet, and engaging in regular physical activity.
- Advise the patient to avoid sleeping on his back and instead try sleeping on his side to reduce snoring and breathing interruptions.
- Offer a follow-up appointment after he has been seen in the sleep clinic to discuss what has been offered, review progress with lifestyle changes, and provide any further support needed.
Learning point from this station:
This case highlights the importance of recognising symptoms of obstructive sleep apnoea (OSA), particularly in patients presenting with loud snoring, daytime sleepiness, and poor-quality sleep. It also reinforces the need to consider driving safety in all patients with suspected OSA.
Anyone who drives and has excessive daytime sleepiness that is likely to impair driving must be advised to stop driving. In this case, the patient is a Group 2 driver, which carries higher risk and responsibility, and should be advised to stop driving immediately.
Note that a person does not need to notify the DVLA if they have suspected OSA without excessive sleepiness that is not affecting driving. However, if sleepiness is present and likely to impair driving, driving must stop.