Sleep Apnea: History of Present Illness

When we choose to treat sleep-disordered breathing (SDB) in our dental offices, we take on a set of increased responsibilities. Thorough data collection is important in dentistry; it’s even more important in dental sleep medicine.

To efficiently and effectively treat our patients for sleep apnea, we have to follow a certain protocol and we must be aware of our patient’s medical history. A history of present illness (HPI) is a key component to this algorithm of treating our patients who’ve been diagnosed with SDB.

The HPI is simply the chronology of the patient’s health issues since the first sign of sleep apnea or their most recent visit. The HPI consists of eight different elements:

• Location
• Severity
• Quality
• Context
• Timing
• Duration
• Modifying factors
• Associated signs

There are two levels of the HPI: brief and extended. One to three elements must be included in the write-up to meet the requirement of a brief HPI, while an extended HPI must include at least four. An extended HPI looks similar to the clinical example below:

CC: Sleep Apnea

HPI: Patient was told of snoring and gasping by bed partner since 1995. No complaints unless supine. He does not notice any daytime sleepiness. PCP noted HTN and referred to sleep doc. Sleep study found mild OSA and tried CPAP for three nights but discontinued use due to discomfort.

In that example, four elements are covered: severity, context, duration, and associated signs.

There aren’t any shortcuts when it comes to the HPI; this information must be recorded by you, not by a member of your staff. It’s OK for the patient to fill out a questionnaire, as long as the doctor notes specifically that he or she reviewed it. More informative is the doctor simply mastering this short list of topics and recording the findings of a conversation during the preclinical interview.