Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be:
Initial evaluation for suspected achalasia.
Follow-up visit for a patient with known achalasia.
Evaluation of treatment response for achalasia.
Pre-procedural evaluation for achalasia intervention.
Post-procedural management following achalasia intervention.
History of Present Illness (HPI)
Focus on symptoms suggestive of achalasia, including:
Difficulty swallowing (dysphagia) – solids or liquids? Progressive worsening?
Regurgitation of undigested food
Chest pain (non-cardiac) – related to swallowing or independent?
Weight loss (unintentional)
Nighttime cough due to aspiration
Mention the duration, progression, and any aggravating or alleviating factors for the symptoms.
Past Medical History (PMHx)
Briefly mention any relevant past medical history, such as:
Gastroesophageal reflux disease (GERD)
Scleroderma (autoimmune disease)
Chagas disease (parasitic infection)
Previous esophageal surgeries
Social History (SHx)
Include relevant social history that may be pertinent, such as:
Smoking history
Medications
List all current medications the patient is taking.
Mention any medications used to manage symptoms, such as proton pump inhibitors (PPIs) for presumed GERD.
Allergies
Document any known allergies, especially to medications.
Physical Examination
General: Assess overall health and appearance of malnutrition (if present).
Vital Signs: Document blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
Focused Abdominal Exam:
May reveal minimal findings unless complications are present.
Assessment
Summarize the key findings from the history and physical examination.
Formulate a differential diagnosis for the patient’s symptoms, including achalasia and other conditions that can mimic it (e.g., esophageal strictures, tumors).
Plan
Outline the next steps in the patient’s management. This may include:
Diagnostic Tests:
Upper endoscopy with esophageal manometry: Gold standard for diagnosing achalasia. Manometry assesses the pressure within the esophagus to identify characteristic patterns in achalasia.
Barium swallow X-ray (may be considered if endoscopy contraindicated)
Chest X-ray (to rule out other lung conditions)
Treatment Options: (Depending on severity and patient factors)
Dietary modifications and lifestyle changes (small frequent meals, avoid liquids with meals)
Medication trials (nitrates, calcium channel blockers) – to relax the lower esophageal sphincter (LES)
Minimally invasive endoscopic therapies (pneumatic balloon dilatation, POEM) – to disrupt the tight LES muscle
Laparoscopic Heller myotomy with Dor fundoplication (surgical intervention) – most definitive treatment; creates a small incision in the muscle surrounding the LES
Additional Considerations
Adapt this template based on the specific situation (initial evaluation, follow-up, pre/post-procedure management).
Use clear and concise language while maintaining medical accuracy.
Document the planned treatment approach and discuss risks and benefits with the patient whenever possible.
Include a discussion of potential complications of achalasia and treatment options.
This template provides a framework for documenting progress notes for patients with suspected or known achalasia. Remember to tailor it to your specific workflow and facility’s documentation standards.