Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with severe obstructive sleep apnea (OSA), confirmed by polysomnography (AHI >30 events/hour). Reports chronic excessive daytime sleepiness (Epworth Sleepiness Scale score: [Score]), loud habitual snoring, witnessed apneas, and morning headaches. Patient describes unrefreshing sleep, nocturia, and significant impairment in daytime cognitive function and concentration. No history of central sleep apnea or complex sleep-disordered breathing.
Clinical Examination Findings
Physical examination reveals a BMI of [Value] kg/m². Oropharyngeal assessment shows Mallampati class [Class] with redundant soft palate tissue, enlarged tonsils (grade [Grade]), and a narrow oropharyngeal airway. Neck circumference is [Value] cm. Cardiovascular exam: regular rate and rhythm, no murmurs. Pulmonary exam: clear to auscultation bilaterally. Nasal examination reveals [e.g., deviated septum/turbinate hypertrophy].
Treatment Protocol
Initiate CPAP therapy at [Pressure] cm H2O with a [Type] mask. Emphasize strict adherence to therapy for a minimum of 4 hours per night. Recommend weight loss program, positional therapy (avoiding supine position), and smoking cessation. Schedule follow-up in 4 weeks to review compliance data and symptom improvement. Consider referral to ENT for evaluation of upper airway anatomy if CPAP intolerance occurs.