Date:
Patient:
MRN:
Clincian: (Gastroenterologist, Primary Care Physician)
Reason for Visit:
Follow-up for gastroparesis
Evaluation of symptoms and response to treatment
Review of laboratory and imaging results
Discussion of dietary management
History of Present Illness:
Briefly describe the patient’s current status:
Duration of symptoms (nausea, vomiting, early satiety – feeling full after eating a small amount, abdominal bloating, weight loss)
Frequency and severity of symptoms
Impact of symptoms on daily activities and nutrition
Response to previous treatment approaches (dietary modifications, medications)
Past Medical History:
Underlying conditions that may contribute to gastroparesis:
Diabetes mellitus (most common cause)
Postsurgical complications (abdominal surgeries)
Viral or bacterial infections (rare)
Neurologic disorders (e.g., Parkinson’s disease)
Idiopathic (no identifiable cause)
History of gastrointestinal surgeries
Social History:
Smoking (may worsen symptoms)
Physical Exam:
Vital Signs: May be normal or abnormal depending on the severity of symptoms and dehydration.
Abdominal: Distention, succussion splash (rushing sound on palpation suggestive of fluid in the stomach), normal bowel sounds.
Labs:
Electrolytes: May be deranged due to dehydration from vomiting (low potassium, sodium imbalances).
Complete Blood Count (CBC) – to assess for anemia or signs of infection.
Basic Metabolic Panel (BMP) – to assess kidney function and electrolytes.
Hemoglobin A1c (HbA1c) – to assess diabetes control if applicable.
Gastric emptying study (GES) or scintigraphy scan (used for diagnosis but not routinely performed for follow-up).
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Upper GI series or CT scan may be used to rule out other causes of symptoms (e.g., bowel obstruction).
Assessment:
Summarize the diagnosis based on symptoms, response to treatment trials, and investigations (if performed):
Confirmation of gastroparesis diagnosis.
Severity of symptoms based on validated questionnaires (e.g., Gastroparesis Patient Assessment Questionnaire – GPAQ) if used.
Plan:
Outline the treatment plan based on the assessment:
Dietary management:
Small, frequent meals
Low-fiber diet
Avoiding fatty and greasy foods
Liquids before or after meals (not with meals)
Nutritional counseling may be beneficial.
Medications:
Prokinetic agents (metoclopramide, erythromycin) – to stimulate gastric emptying (use with caution due to potential side effects).
Antiemetics (ondansetron) – to control nausea and vomiting.
Nutritional support:
Enteral nutrition (feeding tube) – for patients who cannot meet nutritional needs orally.
Parenteral nutrition (IV fluids) – in severe cases.
Botulinum toxin injection (pyloric Botox): May be considered for some patients with severe gastroparesis who don’t respond to other treatments.
Gastric electrical stimulation (GES): An implantable device that stimulates the stomach muscles to improve emptying – considered for highly selected cases.
Prognosis:
Briefly discuss the prognosis. Gastroparesis is a chronic condition, but symptoms can be managed with dietary modifications, medications, and sometimes nutritional support.
Early diagnosis and treatment can help prevent complications like malnutrition and dehydration.
Emphasize the importance of ongoing communication with the healthcare provider to adjust the treatment plan as needed.
Education:
Document any education provided to the patient regarding:
The nature of gastroparesis and its causes
The importance of dietary management and following a recommended meal plan
The use of medications and potential side effects
Warning signs of complications that may require further evaluation (severe vomiting, inability to keep fluids down)
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication adherence or dietary changes.