Date:
Patient:
MRN:
Attending Physician:
Reason for Visit:
Admission for esophageal perforation
Post-operative follow-up for esophageal perforation
History of Present Illness:
Briefly describe the presentation of esophageal perforation:
Onset and nature of symptoms (sudden chest pain, fever, dysphagia, vomiting with blood)
Potential cause of perforation (iatrogenic [endoscopy, etc.], spontaneous, Boerhaave syndrome)
Prior diagnostic evaluations (chest X-ray, CT scan)
Past Medical History:
Include any relevant past medical conditions that may increase risk of perforation, such as:
GERD
Barrett’s esophagus
Previous esophageal surgery
Social History:
Tobacco use (current and past)
Alcohol use
Physical Exam:
General: Appearance of distress, vital signs (tachycardia, tachypnea, fever)
Chest: Respiratory exam for signs of pleural effusion (decreased breath sounds, dullness to percussion)
Neck: Lymph node palpation (possible submandibular adenitis)
Abdomen: Distension, tenderness
Labs:
List any recent laboratory tests, including CBC (elevated white blood cells may indicate infection), electrolytes, and inflammatory markers (CRP).
Imaging:
Mention any recent imaging studies:
Chest X-ray (pneumomediastinum, pleural effusion)
CT scan (confirmation of perforation location, extent of mediastinitis)
Procedure Notes: (if applicable)
Briefly summarize the details of the surgical intervention for perforation repair (thoracoscopic, open surgical approach).
Assessment:
Confirm the diagnosis of esophageal perforation.
Describe the location and severity of the perforation.
Assess for presence of complications (mediastinitis, sepsis).
Summarize the patient’s current clinical status.
Plan:
Outline the treatment plan:
Antibiotics (broad-spectrum coverage)
Nutritional support (enteral or parenteral)
Drainage of any collections (chest tube for pleural effusion)
Follow-up imaging to assess healing
Consideration for repeat endoscopy to evaluate repair site
Prognosis:
Briefly discuss the patient’s prognosis based on the severity of the perforation and presence of complications.
Notes:
Include any additional relevant information not covered above.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.