Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with symptoms consistent with mild-to-moderate obstructive sleep apnea, including habitual snoring, witnessed apneas, and daytime somnolence (Epworth Sleepiness Scale score: [Score]). Reports morning headaches, non-restorative sleep, and fatigue. No history of nocturnal choking or cardiac arrhythmias.
Clinical Examination Findings
Physical examination reveals BMI [Value] kg/m², neck circumference [Value] cm. Oropharyngeal exam: Mallampati score [Class], tonsillar hypertrophy [Grade], redundant soft palate, and retrognathia. Cardiovascular exam: Regular rate and rhythm, no murmurs. Pulmonary exam: Clear to auscultation bilaterally.
Treatment Protocol
Treatment plan: Initiate CPAP therapy with pressure titration [Value] cm H2O. Recommend weight loss program, positional therapy (avoiding supine position), and strict sleep hygiene. Follow-up polysomnography scheduled in [Time] weeks to assess compliance and efficacy.