Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Caustic ingestion.
SOAP
Subjective (S):
History of Ingestion:
Inquire about the type, amount, and time of caustic substance ingested (if known).
Explore the circumstances surrounding the ingestion (accidental, intentional).
Investigate the time elapsed since ingestion.
Symptoms:
Ask about immediate symptoms after ingestion, such as:
Oral pain, burning sensation
Dysphagia (difficulty swallowing)
Drooling
Hematemesis (vomiting blood)
Odynophagia (painful swallowing)
Hoarseness
Chest pain
Abdominal pain
Vomiting
Explore for any respiratory symptoms like cough, shortness of breath, or wheezing.
Past Medical History:
Briefly summarize relevant past medical history, including:
Previous episodes of caustic ingestion
Underlying esophageal or gastrointestinal conditions (e.g., strictures, gastroesophageal reflux disease)
Psychiatric history (if relevant to intentional ingestion)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation.
Assess for signs of respiratory distress or dehydration.
Physical Exam:
Oral cavity: Inspect the lips, tongue, and mucosa for signs of burns, inflammation, or edema.
Neck: Evaluate for neck swelling or crepitus (crackling sound) suggestive of subcutaneous emphysema.
Respiratory: Assess for chest wall movement, breath sounds, and wheezing.
Abdominal: Examine for abdominal distension, tenderness, or guarding.
Mental Status: Briefly assess mental status and alertness.
Assessment (A):
Severity of Ingestion:
Classify the severity of caustic ingestion based on history and physical exam findings:
Grade I: Minimal injury, limited to mucosal erythema and edema.
Grade II: Superficial mucosal necrosis with deeper involvement.
Grade III: Transmural necrosis with potential perforation.
Grade IV: Full-thickness necrosis with charring.
Consider using a validated scoring system like the Ingestion Severity Score (ISS) for a more objective assessment.
Esophageal Involvement:
Based on the history, physical exam, and potential for esophageal injury, assess the likelihood of esophageal involvement.
Respiratory Compromise:
Evaluate for the presence of respiratory compromise due to laryngeal edema or aspiration pneumonia.
Differential Diagnosis:
Briefly consider other conditions that might cause similar symptoms (e.g., esophagitis from other causes, peptic ulcer disease).
Plan (P):
Initial Management:
Airway protection: Secure the airway if there is concern for upper airway compromise due to laryngeal edema.
Fluid resuscitation: Initiate intravenous fluids to address potential dehydration and electrolyte imbalances.
Pain management: Provide pain medication for oral and esophageal discomfort.
Gastrointestinal Consultation (consider): Consult a gastroenterologist for further evaluation and management recommendations, especially for suspected Grade II or higher injuries. This might involve:
Endoscopy: Upper endoscopy to assess the extent of esophageal injury and potential strictures.
Corticosteroids (controversial): The use of corticosteroids in caustic ingestion is controversial. Discuss with a gastroenterologist the potential risks and benefits in this specific case.
Antibiotics (prophylactic): Prophylactic antibiotics might be considered to prevent esophageal infection.
Nutritional Support: Enteral or parenteral nutrition might be needed depending on the severity of injury and swallowing ability.
Follow-up:
Schedule close follow-up visits to monitor for complications and potential need for esophageal dilatation procedures if strictures develop.
Consider outpatient gastroenterology follow-up for long-term management.
Additional Notes:
Document any other relevant information, such as:
Communication with referring physician or poison control center.
Need for additional tests (e.g., chest X-ray to assess for aspiration pneumonia).
Disposition (admit to hospital, discharge with close follow-up).
Patient education regarding the importance of follow-up and potential long-term complications.