Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Shortness of breath (may be worse on exertion or at night)
Excessive daytime sleepiness (EDS)
Difficulty sleeping (due to shortness of breath)
Morning headaches (may be a sign of sleep apnea)
Reduced exercise tolerance
History of Present Illness:
Duration and severity of symptoms.
Impact of symptoms on daily activities and sleep quality.
Any recent changes in symptoms or weight.
Past Medical History:
(List any relevant medical conditions)
Obesity (essential for diagnosis of OHS)
Sleep apnea (common comorbidity)
Asthma (may contribute to symptoms)
Chronic obstructive pulmonary disease (COPD) (may contribute
to symptoms)
Heart disease (may worsen with OHS)
Social History:
Similar to Obesity Progress Note Template
Dietary habits
Physical activity level
Social support
Family History:
Similar to Obesity Progress Note Template
Family history of obesity or weight-related complications
Physical Exam:
Similar to Obesity Progress Note Template
Vital signs (blood pressure, heart rate, oxygen saturation
(may be
decreased))
Body mass index (BMI) and weight circumference
Physical examination findings suggestive of OHS or comorbidities
(e.g., jugular venous distention – a sign of respiratory effort,
peripheral edema – fluid buildup in extremities).
Laboratory Tests:
(Similar to Obesity Progress Note Template with additional tests)
Arterial blood gas (ABG) – to assess blood oxygen and carbon
dioxide levels (elevated CO2 is a key finding in OHS)
Pulse oximetry – to monitor oxygen saturation throughout the day
(may
show desaturation during sleep)
Consider tests for comorbid conditions (e.g., thyroid function tests)
Imaging Studies:
Chest X-ray – may be normal or show signs of hyperinflation (increased
air trapping in the lungs)
Polysomnography (sleep study) – gold standard for diagnosing sleep apnea
and assessing sleep-related breathing problems.
Assessment:
Obesity hypoventilation syndrome (OHS): Diagnosed based on
presence of obesity, daytime hypercapnia (elevated CO2 in ABG), and symptoms
suggestive of respiratory insufficiency (shortness of breath, sleep problems).
Severity of OHS: Based on ABG results and clinical presentation.
Comorbid conditions: List any coexisting medical conditions
contributing to symptoms (e.g., sleep apnea, heart disease).
Differential Diagnoses:
Consider other causes of symptoms:
Chronic obstructive pulmonary disease (COPD)
Asthma
Heart failure
Plan:
Weight management: Similar to Obesity Progress Note Template,
emphasize
the importance of weight loss as a cornerstone of OHS treatment.
Non-invasive ventilation (NIV): May be necessary to supplement
breathing at night or during periods of worsening respiratory status.
Treatment of comorbid conditions: Address any coexisting
conditions like sleep apnea or heart disease that may be contributing to OHS
symptoms.
Medications: Bronchodilators (for asthma or COPD if present),
diuretics
(for heart failure if present), and medications to stimulate breathing
may be considered in select cases.
Respiratory therapy: Education on breathing techniques and
pulmonary
hygiene to improve lung function and manage secretions.
Nutritional counseling: Support with healthy eating habits to
promote
weight loss and overall health.
Follow-up: Schedule regular follow-up appointments to monitor
progress,
adjust the plan as needed, and ensure adherence to treatment.
Prognosis:
Prognosis depends on severity of OHS, weight loss success, and
management of comorbidities. Early diagnosis and treatment are crucial to
improve symptoms and prevent complications.