🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-30 22:33:20

Transcript

[00:00 → 00:10] Hi Doctor, my name is Shen and I'm here because my husband is really concerned about my
[00:10 → 00:12] sleep.
[00:12 → 00:20] He says I snore very loud and sometimes he notices I stop breathing for short periods.
[00:20 → 00:28] Now Doctor Shen, I see how have you been feeling when you wake up and throughout the day?
[00:28 → 00:33] How much other thing I wake up feeling like I haven't slept all, open with a dry mouth
[00:33 → 00:37] and a headache and during the day I'm exhausted.
[00:37 → 00:42] I find myself nodding off at the desk and I have trouble concentrating.
[00:42 → 00:44] How long that has been going on?
[00:44 → 00:48] The snoring has been there for years, I think, but it's getting worse.
[00:48 → 00:54] The tiredness and the pauses in breathing, my husband says he's noticed those more in
[00:54 → 00:56] the last six months to an ear.
[00:56 → 01:02] As he described the pauses in breathing, like a gasp or a chalking, sounds when you start
[01:02 → 01:03] breathing again?
[01:03 → 01:04] Yes, exactly.
[01:04 → 01:10] He says I sometimes gasp loudly, it really worries him and I've been more irritable lately
[01:10 → 01:12] which is, isn't like me.
[01:12 → 01:13] Okay.
[01:13 → 01:19] Misty Abyss, loud snoring, reported pauses in breathing, daytime sleepiness, morning
[01:19 → 01:24] headaches and irritability are all common indicators that we should investigate sometime, something
[01:24 → 01:25] called sleep apnea.
[01:25 → 01:32] It is a condition where breathing repeatedly stops and starts during sleep.
[01:32 → 01:34] That sounds serious.
[01:34 → 01:41] It can be if let left untreated as it can affect your heart and overall health, but it is manageable.
[01:41 → 01:44] Next step would be to arrange a sleep study for you.

Clinical Notes

Subjective

  • Patient: Shen.

  • Primary Concern: Husband's concern about loud snoring, observed pauses in breathing during sleep.

    • Reports waking up feeling unrested with a dry mouth and headache, experiencing daytime exhaustion, nodding off at the desk, and difficulty concentrating.

    • Husband noticed increased tiredness and breathing pauses in the last six months to a year.

    • Recent irritability noted, which is unusual.

Objective

  • Medical History: Not provided.

  • Behavioral Observations:

    • Common indicators of sleep apnea: loud snoring, reported pauses in breathing, daytime sleepiness, morning headaches, and irritability.

Assessment

  1. Suspected Sleep Apnea: Based on symptoms described by the patient, including loud snoring, observed pauses in breathing, daytime exhaustion, morning headaches, and irritability.

Plan

  1. Diagnostics:

    • Arrange a sleep study to confirm the presence of sleep apnea and determine the severity of the condition.
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