Date:
Patient:
MRN:
Clinician: (Physician, Gastroenterologist, etc.)
Reason for Visit:
Evaluation for symptoms suggestive of esophageal rings or webs (dysphagia, odynophagia, chest pain)
Follow-up for diagnosed esophageal ring or web
Evaluation of treatment response
History of Present Illness:
Briefly describe the patient’s symptoms:
Onset and duration of dysphagia (solids, liquids, both)
Frequency and severity of chest pain or discomfort
Associated symptoms (regurgitation, heartburn)
Impact on nutrition and hydration
Past Medical History:
Include any relevant past medical conditions that may contribute to esophageal rings or webs, such as:
Gastroesophageal Reflux Disease (GERD)
Eosinophilic esophagitis
Prior esophageal surgery
Medications:
List any medications that may contribute to symptoms, such as PPIs (proton pump inhibitors) for GERD.
Social History:
Diet history (texture modifications)
Tobacco and alcohol use
Physical Exam:
General: Weight, nutritional status
Vital Signs: Temperature, pulse, blood pressure
Abdomen: Mild tenderness (possible, but not always present)
Labs:
List any recent laboratory tests, focusing on descarting other causes (eosinophilia for eosinophilic esophagitis, if suspected).
Imaging:
Mention any recent imaging studies:
Upper endoscopy with biopsy (gold standard for diagnosis, may reveal Schatzki ring or web)
Barium swallow (may show esophageal narrowing)
Esophageal manometry (may show decreased motility in the area of the ring or web)
Assessment:
Confirm or rule out the presence of esophageal rings or webs based on diagnostic findings.
Specify the type of ring or web identified (Schatzki ring, lower esophageal web, etc.).
Describe the severity of dysphagia and impact on quality of life.
Plan:
Outline the treatment plan based on severity and symptoms:
Dietary modifications (avoidance of problematic textures)
Medications (continued PPIs for GERD, steroids for eosinophilic esophagitis)
Endoscopic balloon dilatation for web or ring
Surgery (rarely needed)
Follow-up endoscopy to assess response to treatment
Prognosis:
Briefly discuss the potential for improvement in symptoms with treatment.
Discuss the risk of recurrence of esophageal rings or webs.
Education:
Document any education provided to the patient regarding:
Swallowing techniques to manage dysphagia
Dietary modifications
Importance of medication adherence
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.