Introduction

The patient-physician encounter is an inquiry designed to disclose and test disease hypotheses. Physicians detect "cues" early in a patient interview and use them to generate predictions about a disease presence or state. They then ask questions to test the likelihood of hypothesized disease(s) and answers modify perceived probability. This process continues until a reasonable list of potential problems, a differential diagnosis, is shaped and decisions become more explicit. Physicians rely on their own experience, skill, and knowledge base to assign values to the presence or absence of key clinical features.

The purpose of this chapter is to identify those features in sleep history taking that are more likely to assign diagnostic value. The chapter will start by outlining some of the cues that physicians use to direct a general sleep history and then detail the contribution of other elements important in the consideration of obstructive sleep apnea (OSA). A sleep-specific physical examination will then be discussed. Adult and pediatric issues will be compared.

It is important to recognize that there are major limitations in the current literature. To a considerable extent, the recommendations in this chapter result from data from uncontrolled studies, case series, consensus guidelines, practice parameters, and other less rigorous forms of evidence like expert opinion; most of this literature is not focused on how a history and physical help in patient management or outcome. There is an enormous heterogeneity in study design, quality and in populations studied, so that a concordance among studies on the history and physical is difficult to discuss at more than a superficial level. Finally, clinical studies express associations in terms that are not always interchangeable, for example, relative risk (RR), odds ratio (OR), correlation coefficient (r), positive predictive value, likelihood ratio (LR), sensitivity, specificity, and so on. These features led to challenges in producing this review.

Yet, there is value still present in a general medical examination. No features or combination of features are ever fully sensitive and specific for sleep apnea or for sleep problems. A physician-patient encounter should do more than just capture a single suspected diagnosis. The process may involve not only a sleep outcome, but can disclose comorbid conditions and personal issues that could optimize testing and treatment.

Sleep Apnea

Sleep Apnea

Have You Been Told Over And Over Again That You Snore A Lot, But You Choose To Ignore It? Have you been experiencing lack of sleep at night and find yourself waking up in the wee hours of the morning to find yourself gasping for air?

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