Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Snoring (reported by patient or bed partner)
Witnessed apneas (periods without breathing during sleep)
Excessive daytime sleepiness (EDS) – feeling tired even after sufficient
sleep
Difficulty concentrating or memory problems
Morning headaches
Irritability
Witnessed nocturnal choking or gasping
History of Present Illness:
Duration and severity of symptoms.
Impact of symptoms on daily activities, work performance, and sleep quality.
Any recent changes in symptoms or weight.
Past Medical History:
(List any relevant medical conditions)
Obesity (major risk factor for OSA)
Hypertension
Diabetes mellitus
Heart disease
Chronic obstructive pulmonary disease (COPD) (may coexist with OSA)
Hypothyroidism
Social History:
Sleep habits (duration, quality, daytime napping).
Alcohol consumption (can worsen OSA).
Smoking history (irritates upper airway and increases OSA risk).
Family History:
Family history of sleep apnea.
Physical Exam:
General examination: Assess for signs of upper airway obstruction
(e.g.,
enlarged tonsils, large neck circumference).
Oropharyngeal examination: Look for anatomical features that may contribute
to obstruction (e.g., enlarged tongue, uvula, or soft palate).
Blood pressure measurement.
Laboratory Tests:
(Limited role in diagnosing OSA)
May be done to rule out other medical conditions (e.g., thyroid
function tests if hypothyroidism is suspected).
Sleep Study (Polysomnography):
Gold standard for diagnosing OSA.
Measures brain activity, breathing patterns, oxygen levels, muscle activity,
and sleep stages during overnight sleep.
Apnea-hypopnea index (AHI) – key diagnostic indicator. AHI is the number
of apneas and hypopneas (partial airway obstructions) per hour of sleep.
Assessment:
Obstructive sleep apnea (OSA): Diagnosed based on characteristic
symptoms and polysomnography findings (elevated AHI).
Severity of OSA: Based on AHI (mild, moderate, or severe).
Comorbid conditions: List any coexisting medical conditions
potentially related to or worsened by OSA.
Differential Diagnoses:
Consider other causes of symptoms:
Primary hypersomnolence (excessive sleepiness not due to OSA)
Nasal congestion (may disrupt sleep)
Restless leg syndrome (can disrupt sleep)
Depression (can cause fatigue and poor sleep)
Plan:
Weight management: If overweight or obese, weight loss is crucial for
improving OSA severity.
Continuous positive airway pressure (CPAP): Gold standard treatment
for most cases of OSA. CPAP delivers positive airway pressure through a mask
to prevent airway collapse during sleep.
Other treatment options (depending on severity and individual factors):
Oral appliance therapy (mandibular advancement devices)
Surgical procedures (e.g., uvulopalatopharyngoplasty (UPPP) to remove
excess tissue in the upper airway)
Behavioral modifications: Sleep hygiene practices (e.g., regular sleep
schedule, avoiding caffeine and alcohol before bed).
Treatment of comorbid conditions: Address any coexisting conditions
like hypertension or heart disease that may be worsened by OSA.
Follow-up: Schedule regular follow-up appointments to monitor
adherence to treatment, adjust settings if needed, and ensure improvement
in symptoms and sleep quality.
Patient Education:
Educate the patient about OSA, treatment options, and the importance of
adherence to therapy.
Discuss the risks of untreated OSA (e.
pen_spark
g., increased risk of accidents,
heart disease, stroke).