Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Reason for Visit:
Document the reason for this visit. This may be:
Initial evaluation for suspected EoE.
Follow-up visit for a diagnosed case of EoE.
Visit to address specific symptoms or concerns related to EoE (e.g., worsening dysphagia, feeding difficulties).
History of Present Illness:
For suspected EoE:
Onset, duration, and severity of symptoms suggestive of EoE:
Difficulty swallowing (dysphagia) – may be for solids, liquids, or both.
Food impaction (getting food stuck in the esophagus).
Chest pain or discomfort with eating.
Nausea and vomiting (may occur secondary to dysphagia).
Feeding difficulties in children.
Inquire about associated symptoms (e.g., heartburn, regurgitation) – these may be less common in EoE compared to GERD.
Allergies (food allergies, atopic dermatitis).
For diagnosed EoE:
Changes in symptoms or development of new symptoms.
Response to previous treatment modalities (diet, medications).
Adherence to current dietary restrictions or medication regimen.
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially:
Atopic diseases (e.g., asthma, eczema)
Gastroesophageal reflux disease (GERD) – although EoE can sometimes mimic GERD symptoms.
Prior upper endoscopy findings (if any).
Social History:
Inquire about exposures to potential food triggers (if suspected).
Medications:
List all current medications, including:
Proton pump inhibitors (PPIs) – used for initial evaluation to differentiate from GERD, but typically not used long-term in EoE.
Swallowed steroids (if currently on this treatment).
Medications for other conditions (potential medication allergies).
Allergies:
Document any known allergies, especially food allergies that may be potential triggers for EoE.
Family History:
Inquire about a family history of atopic diseases or EoE.
Physical Exam:
Vital Signs: Include temperature (if concerning for infection).
Limited physical exam findings in uncomplicated EoE. Consider failure to thrive in children with feeding difficulties.
Laboratory:
Laboratory tests are not diagnostic for EoE, but may be helpful:
Peripheral eosinophil count: May be elevated, but not always.
Imaging:
Upper endoscopy with esophageal biopsy: The gold standard for diagnosis. Biopsy shows characteristic eosinophilic inflammation in the esophageal tissue.
Assessment:
Suspected EoE: Based on clinical presentation and ongoing evaluation (if biopsy not yet performed).
Eosinophilic esophagitis: If biopsy confirms eosinophilic inflammation in the esophagus.
Consider severity based on symptoms and endoscopic findings.
Differential diagnosis: Exclude other causes of dysphagia (e.g., GERD, esophageal strictures).
Plan:
The treatment plan will depend on the severity of EoE and response to initial interventions.
Possible treatment options include:
Dietary management: Elimination diet to identify food triggers, followed by reintroduction to identify specific allergens. Elemental diet (liquid formula) may be used in severe cases.
Proton pump inhibitors (PPIs): May be used initially to differentiate from GERD, but typically not used long-term in EoE treatment.
Swallowed steroids: The mainstay of treatment for EoE to reduce inflammation.
Other medications: Biologics or esophageal dilation may be used in some cases.
Discuss the prognosis and potential complications of EoE and the planned treatment.
Follow-up:
The follow-up schedule will depend on the severity of EoE and response to treatment.
Close monitoring of symptoms is necessary.
Repeat endoscopy may be needed to assess response to treatment and disease activity.
Consider referral to a specialist (e.g., allergist, gastroenterologist) for complex cases or dietary management.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding symptoms, duration, associated conditions, allergies, physical exam findings,