Sleep Follow-up Pediatrics

Subjective:
Chief Complaint:
Identification: Thank you for asking me to see Carter, 6.5, for evaluation of sleep disordered breathing. He is accompanied by his parent. Thank you for the kind referral. I will summarize history for my records.

History of Present Illness:
Symptom Changes: Since initiation of inhaled corticosteroid and intranasal corticosteroid therapy, there has been a decrease in frequency of night terrors. Caregiver reports that Carter no longer exhibits snoring and is no longer observed to be mouth breathing. He continues to be very active and has not demonstrated any decline in endurance or participation in physical activities. Sleep onset is described as variable, with occasional difficulty falling asleep. Carter continues to exhibit sleep talking, but has not had recent episodes of night terrors characterized by awakening with screaming.
Treatment Adherence: Caregiver reports variable adherence to inhaled corticosteroid and intranasal corticosteroid therapy, with ongoing use of two puffs twice daily and continued use of the nasal spray. Initial aversion to the nasal spray has improved, and no significant side effects are reported.
New Symptoms: No new symptoms have been reported since the last visit. There have been no further episodes of croup. Occasional headaches are reported, occurring a couple of times per month.
Modifying Factors: Improvement in parasomnias and airway symptoms is noted with consistent use of inhaled and intranasal corticosteroids. Sleep onset difficulty may be associated with timing of inhaled medication administration.
Associated Symptoms: Carter has a history of suspected asthma, croup, and enlarged tonsils and adenoids. He is described as a picky eater, with limited vegetable intake but adequate consumption of meat, dairy, and fruit. Growth parameters are within expected range for age and parental heights. No developmental concerns or clumsiness are reported. No complaints of morning headaches or other symptoms suggestive of sleep-disordered breathing. No recent dental issues reported, and no teeth have been lost to date.

Past Medical History:
Carter has a history of parasomnias, suspected asthma, and previous episodes of croup. He has a history of enlarged tonsils and adenoids, with associated airway swelling. He has undergone treatment with inhaled corticosteroids and intranasal corticosteroids, which has resulted in improvement of symptoms. No more croup.

Past Surgical History:
No surgical history was reported.

Current Medications:
Current Medications: Inhaled corticosteroid, two puffs twice daily; intranasal corticosteroid spray, administered daily.
Any Changes: No changes in medication regimen since the last visit. Initial aversion to the nasal spray has improved, and adherence remains variable but ongoing.

Family History:
There is a maternal history of snoring. No other family history of sleep apnea, asthma, or other relevant conditions was discussed.

Social History:
Carter resides with his family. His father is currently at home due to a rotator cuff injury. His mother is employed full-time at xxx xxx xxx xxx, Permanent Support Housing. Carter is in grade two but is not currently attending school. He is described as very active and participates in physical activities.

The Review of Systems:
General: No fatigue, fever, weight loss, or night sweats reported.
Neurological: He does not complain of headaches often; no dizziness or seizures reported.
Cardiovascular: No chest pain or palpitations reported.
Respiratory: No shortness of breath; his cough did not sound murky or concerning.
Gastrointestinal: No nausea, vomiting, diarrhea, or constipation reported.
Musculoskeletal: No joint pain or muscle pain reported.
Psychiatric: No anxiety, depression, or mood swings reported.

Sleep History:
Carter's sleep has improved with the use of inhaled and intranasal corticosteroids. He is not snoring, does not mouth breathe anymore, and has not been waking up screaming from night terrors recently. Sleep onset is occasionally difficult, which may be related to the timing of inhaled medication administration. He continues to exhibit sleep talking but has not had recent episodes of night terrors characterized by awakening with screaming. There are no complaints of morning headaches or symptoms suggestive of sleep-disordered breathing. No excessive daytime sleepiness or nonrestorative sleep was reported.

Development:
Carter's growth parameters are within the expected range for his age and parental heights. Bone age is consistent with chronological age. He is not clumsy. No developmental concerns have been reported, and he is meeting expected milestones for physical, cognitive, and social-emotional development.

Objective:
Physical Examination:
Physical Examinations:
Temperature: 
Pulse: 
Blood Pressure: 
Respiratory Rate: 
Oxygen Saturation: 
Weight: 
Height: 
BMI: 
Head Circumference: 
General: Carter appears well and is very active.
HEENT: Tonsils and adenoids are enlarged; minimal narrowing of the airway observed. Oral examination reveals a slight crossbite. No wiggly teeth or lost teeth yet. No clumsiness or developmental concerns noted.
Cardiovascular: Not assessed.
Respiratory: No abnormal respiratory effort observed.
Neurological: No abnormalities noted.
Musculoskeletal: No abnormalities noted.

Test Results:
Sleep Study: Sleep study performed within the last month; results pending review.
Polysomnography Results: EEG was negative for sleep disordered breathing.
Actigraphy: 
Laboratory Tests: Iron and ferritin levels are within expected range for age. He does not have celiac disease. TSH is trending down. Inflammatory markers are non-specific and not elevated.
Imaging Studies: Chest x-ray demonstrates minimal airway narrowing, compatible with history of croup, but Carter was well at the time of imaging. Tonsillar and adenoidal tissue at the back of the nose is mildly enlarged. His breathing test was completely good and normal. Bone age closely resembles seven years of age, consistent with his chronological age of six years and six months.

Plan:
Orders, Instructions, Referrals, Patient Education:
Continue current inhaled corticosteroid and intranasal corticosteroid therapy. Referral to otolaryngology (ENT) for further airway evaluation, including possible in-clinic endoscopic assessment. Recommendation to seek consultation with a dietician for guidance on increasing dietary fat and protein intake, and for support with selective eating behaviors. Patient education provided regarding the importance of protein and fat in the diet, and strategies for incorporating these nutrients. Suggestions provided for alternative gluten sources and methods to increase vegetable intake.
Treatments:
Medications: Continue current regimen; refills provided for inhaled and intranasal corticosteroids.
CPAP/BiPAP: 
Behavioral Therapy: 
Lifestyle Modifications: Recommendations for dietary adjustments, including increasing fat and protein intake, and reducing gluten as tolerated.
Follow-Up:
Follow-up with ENT as arranged. Continue monitoring for changes in sleep, behavior, and growth. No specific interval for return visit stated.

Assessment and Plan:
Impression:
Parasomnia, unspecified (327.4)
Suspected asthma, stable on inhaled corticosteroids (493.90)
Hypertrophy of tonsils and adenoids (474.10)
Headache, unspecified (784.0)

Differential Diagnosis:
Obstructive sleep apnea: Considered due to history of airway narrowing, enlarged tonsils and adenoids, and prior symptoms, but currently not supported by absence of snoring, mouth breathing, or sleep-disordered breathing on EEG.
Gluten intolerance: Considered due to borderline allergy markers and dietary history, but not confirmed; may contribute to growth or gastrointestinal symptoms.
Primary headache disorder: Considered due to intermittent headaches, but frequency and severity are mild and not associated with other neurological symptoms.