🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-30 17:38:13

Transcript

[00:00 → 00:06] Good morning Mr. Davis, have a seat.
[00:06 → 00:08] What can I help you with today?
[00:08 → 00:09] Good morning Mr. Shen.
[00:09 → 00:13] I'm here because my husband is really concerned about my sleep.
[00:13 → 00:20] He says I snow very loudly and sometimes he notices I stop breathing for short periods.
[00:20 → 00:22] I see.
[00:22 → 00:28] Have you been feeling when you wake up and throughout the day?
[00:28 → 00:30] How have you been feeling?
[00:30 → 00:31] That's the other thing.
[00:31 → 00:38] I wake up feeling like I haven't slept all day, open with a dry mouth and a headache.
[00:38 → 00:40] And during the day I'm just exhausted.
[00:40 → 00:46] I find myself nodding off my desk and I even have trouble concentrating.
[00:46 → 00:50] Oh, how long has this been going on?
[00:50 → 00:54] The snoring has been a issue for years and I think it's getting worse.
[00:54 → 00:56] The tiredness and the pause is in breathing.
[00:56 → 01:05] My husband says he's noticing those more than more of them in last six months to a year.
[01:05 → 01:08] Has he described the pause in breathing?
[01:08 → 01:13] Yeah, like a gasp or a choking sound or when you start breathing again?
[01:13 → 01:14] Yes, exactly.
[01:14 → 01:17] He says I sometimes gasp loudly.
[01:17 → 01:22] It really worries him and I've been more elitable lately, which isn't like me, okay Mr.
[01:22 → 01:29] Davis, loud snoring, reported pauses in breathing, data and sleepiness, morning, headaches
[01:29 → 01:34] and irritability are all common indicators that we should investigate for something called
[01:34 → 01:35] sleep apnea.
[01:35 → 01:40] It's a condition where breathing repeatedly stops and starts during the sleep.
[01:40 → 01:42] That sounds serious.
[01:42 → 01:43] It can be afraid.
[01:43 → 01:47] It can be fixed and it can not be left untreated.
[01:47 → 01:52] It can affect your heart, overall health, overall health, when if it's not treated rightly,
[01:52 → 01:53] but it is manageable.
[01:53 → 01:56] The next step would be to arrange a sleep study.
[01:56 → 01:57] Thank you very much.
[01:57 → 01:59] We'll meet after the study results.
[01:59 → 02:00] Sure.
[02:00 → 02:01] Thank you very much.

Clinical Notes

Subjective

  • Patient: Mr. Shen.

  • Primary Concern: Husband's concern about loud snoring, observed pauses in breathing during sleep, excessive daytime sleepiness, waking up with a dry mouth and headache, and recent irritability.

  • Duration: Snoring issue for years, worsening in the last six months to a year.

Objective

  • No specific objective data provided.

Assessment

  1. Possible Sleep Apnea: Symptoms of loud snoring, observed pauses in breathing, daytime sleepiness, morning headaches, and irritability are indicative of sleep apnea.

Plan

  1. Diagnostic Testing:
  2. Arrange a sleep study to investigate and confirm the presence of sleep apnea.

  3. Follow-Up:

  4. Schedule a follow-up appointment to discuss the results of the sleep study and further management options.
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