A 57 year old man presents with excessive daytime sleepiness and constant exhaustion. While present for several years, these symptoms have worsened in the last few months. He also snores significantly, disturbing his wife's sleep. There are no symptoms suggestive of psychiatric or psychological issues. He was diagnosed with hypertension one year ago, which is well controlled with Ramipril. He works for around 40 hours per week as a manager. The work does not involve nighttime shifts. Assessment with the Epworth Sleepiness Scale gives a score of 10.
WBC/DC: 7,200/mm3 (4,600 - 11,000) Hb: 16.2 g/dL (13 - 18) Hematocrit: 45% (42% - 52%) Platelets: 250,000/mm3
TSH: 0.9 mU/L (0.4 - 4.0) Free T4: 1.3 ng/dL (0.7 - 2.0)
There are episodes of desaturations (upto 74%), which coincide with snoring and apnea. The apnea-hypopnea index was 32. There is fragmentation of sleep, predominance of the superficial phases of sleep, and reduction of deep sleep and REM phase.
The echocardiogram appears normal, with an ejection fraction of > 70%.