DATE OF SERVICE: MM/DD/YYYY
HISTORY: The patient is a (XX)-year-old male known to our clinic for evaluation of sleep apnea. He states he has been on his device for about 10 years. Unfortunately, we could not get his card to read today. He tells me that he feels like he is doing well with his device; although, he feels like he may need more pressure, as he is not feeling as rested as he once was. He denies any difficulty staying awake while driving. He denies napping during the day. He does have issues with depression.
REVIEW OF SYSTEMS:
GENERAL: The patient denies any difficulty with fever, chills or night sweats.
HEENT: He denies any changes in his visual acuity. He denies any difficulty with tinnitus, nosebleeds, sinusitis or seasonal allergies.
RESPIRATORY: He denies any difficulty with cough, sputum, hemoptysis or dyspnea.
CARDIOVASCULAR: He denies any chest pain or dyspnea on exertion.
GASTROINTESTINAL: He denies any nausea, vomiting or abdominal pain.
GENITOURINARY: He denies any polyuria, dysuria, nocturia or incontinence.
MUSCULOSKELETAL: He denies any joint pain, swelling or stiffness.
NEUROLOGIC: He denies any headaches, blackouts or seizure activity.
PSYCHIATRIC: He denies any anxiety or depression.
SKIN: He denies any changes in his skin integrity. He denies any rashes or itching.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight is 192 pounds. Pulse is 60. Respirations are 18. Blood pressure is 158/98. O2 saturation is 96% on room air.
GENERAL: The patient is alert and oriented x3, in no acute distress.
HEENT: Pupils are equal and reactive to light and accommodation. Extraocular movements are intact. Posterior pharynx is free of erythema. Dentition is good.
LUNGS: Respirations are even and unlabored. Lungs are clear to auscultation.
HEART: Heart rate is regular. No murmur is appreciated.
ABDOMEN: Bowel sounds are positive in all four quadrants. No hepatosplenomegaly is appreciated.
MUSCULOSKELETAL: Strength is 4+ bilaterally with good range of motion.
NEUROLOGIC: The patient is alert and oriented and cooperative with exam.
PSYCHIATRIC: Affect is appropriate.
GENITOURINARY: Deferred.
SKIN: Dry. Turgor is good.
ASSESSMENT: Obstructive sleep apnea with good stated compliance to continuous positive airway pressure therapy, however feeling he needs more pressure.
PLAN: We have the patient report to his DME company to see if they can provide him with a new card. He was counseled in regard to proper care and maintenance of the device with mask, tubing and filter changes. He was also counseled in regard to the importance of not operating a motor vehicle or heavy machinery while drowsy for his safety, as well as for the safety of others. We did discuss, as it has been greater than 10 years, that we might need to repeat a sleep study in order for him to obtain a new machine if his DME company feels that it is time for a new device. He is in agreement with this plan. We have requested that he return in six to eight weeks for re-evaluation with Dr. John Doe or sooner if needed. He was encouraged to call with any questions or concerns.
