Date:
Patient:
MRN:
Clinician: (Physician, Gastroenterologist, etc.)
Reason for Visit:
Evaluation for symptoms suggestive of esophageal stricture (dysphagia, odynophagia, chest pain, weight loss)
Follow-up for diagnosed esophageal stricture
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, weight loss)
Impact on nutrition and hydration
Past Medical History:
Include any relevant past medical conditions that may contribute to esophageal stricture, such as:
Gastroesophageal Reflux Disease (GERD)
Eosinophilic esophagitis
Caustic injury
Radiation therapy
Previous esophageal surgery
Schistosomiasis (in some regions)
Medications:
List any medications that may contribute to symptoms or stricture formation, such as PPIs (proton pump inhibitors) for GERD or medications causing stricture as a side effect.
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).
Consider inflammatory markers (CRP) if infection is a concern.
Imaging:
Mention any recent imaging studies:
Upper endoscopy with biopsy (gold standard for diagnosis, may reveal stricture location and cause)
Barium swallow (may show esophageal narrowing)
CT scan (may assess for complications like perforation)
Esophageal manometry (may show decreased motility above the stricture)
Assessment:
Confirm or rule out the presence of esophageal stricture based on diagnostic findings.
Describe the location and severity of the stricture.
Identify the suspected cause of the stricture (if possible).
Assess for complications (aspiration pneumonia, malnutrition).
Plan:
Outline the treatment plan based on severity, cause, and symptoms:
Dietary modifications (liquid diet, mechanical soft diet)
Nutritional support (enteral feeding if oral intake insufficient)
Medications (continued PPIs for GERD, steroids for eosinophilic esophagitis)
Endoscopic balloon dilatation for relief of stricture
Self-expandable metal stents (temporary or permanent placement)
Surgery (esophagectomy, for severe strictures or malignancy)
Management of underlying cause (e.g., treating GERD)
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 stricture.
Education:
Document any education provided to the patient regarding:
Importance of following the prescribed diet
Techniques for using feeding tubes (if applicable)
Signs and symptoms of complications
Importance of medication adherence
Notes:
Include any additional relevant information not covered above, such as patient’s emotional well-being and support system.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.