Sleep Apnea
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
Worsening factors:
Alleviating factors: ,
Contributing factors:
no history of: , , , ,
no use of: ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: obstructive sleep apnea, central sleep apnea, sleep-related hypoventilation disorders, nocturnal asthma, cardiac arrhythmias, GERD, COPD, heart failure, obesity hypoventilation syndrome, narcolepsy, periodic limb movement disorder, restless legs syndrome, primary insomnia, psychiatric disorders, hypothyroidism, medication side effects, substance abuse, upper airway resistance syndrome, tonsillar hypertrophy, adenoidal hypertrophy, nasal obstruction, craniofacial abnormalities
PLAN:
Investigations:
- Epworth sleepiness scale
- Polysomnography
- Blood work: , , , , , ,
- ECG
- Chest X-ray
- Pulmonary function tests
Treatments:
- Lifestyle modifications: weight loss, alcohol moderation
- Positional therapy
- Continuous positive airway pressure
-
-
-
Further care:
- Referral to pulmonologist
- Referral to ENT specialist
- Referral to dietitian
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as excessive daytime sleepiness, observed episodes of stopped breathing during sleep, or abrupt awakenings accompanied by gasping or choking
HISTORY: EXAM: ASSESSMENT: PLAN: