Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for celiac disease (CD) or evaluation of new symptoms.
SOAP
Subjective (S):
Gastrointestinal Symptoms (New or Ongoing):
Inquire about any gastrointestinal symptoms suggestive of active CD, such as:
Diarrhea (chronic or intermittent)
Abdominal pain or cramping
Bloating
Flatulence
Constipation (less common)
Nausea or vomiting
Weight loss (unintentional)
Fatigue
Dietary Changes:
Investigate adherence to a gluten-free diet (GFD) since the last visit.
Explore for any challenges or accidental gluten exposures.
Past Medical History:
Briefly summarize relevant past medical history, including:
Age at diagnosis of CD
Past hospitalizations or surgeries related to CD complications
Associated autoimmune conditions (e.g., type 1 diabetes mellitus, autoimmune thyroiditis)
Past Treatments:
Briefly note any medications or supplements currently being used to manage CD symptoms.
Objective (O):
Physical Exam:
Perform a focused physical exam to assess for:
Signs of malnutrition (e.g., pallor, glossitis) – uncommon with strict GFD adherence
Abdominal distention or tenderness
Dermatitis herpetiformis (itchy, blistering skin rash – less common)
Anthropometrics (if applicable):
Consider recording weight and height to monitor growth and development in children with CD.
Assessment (A):
Disease Activity:
Based on the presence and severity of symptoms, adherence to GFD, and physical exam findings, assess the current activity level of CD:
Well-controlled (no symptoms on GFD)
Partially controlled (mild, intermittent symptoms)
Active disease (persistent or worsening symptoms)
Nutritional Status:
Evaluate the patient’s nutritional status based on physical exam findings and consider additional assessments if malnutrition is suspected (e.g., laboratory tests).
Differential Diagnosis:
Briefly consider other conditions that might mimic CD symptoms (e.g., lactose intolerance, irritable bowel syndrome, microscopic colitis).
Plan (P):
Dietary Management:
Reinforce the importance of strict adherence to a GFD for long-term management.
Address any challenges or concerns regarding the GFD and provide education or resources as needed.
Laboratory Tests (if indicated):
Depending on disease activity and clinical suspicion, consider laboratory tests such as:
Celiac serology (antibody testing) – may remain positive despite GFD adherence
Tissue transglutaminase (tTG) IgA – more specific antibody test
Micronutrient testing (iron, vitamin D, folate) for potential deficiencies associated with malabsorption
Follow-up serology (if initially positive) to monitor response to GFD adherence
Treatment Adjustments (if needed):
If symptoms persist despite GFD adherence, discuss the need for further evaluation and potential adjustments to the treatment plan, which might involve:
Consulting a dietician for personalized dietary guidance
Considering additional medications to manage specific symptoms (e.g., antidiarrheal agents)
Follow-up:
Schedule follow-up appointments based on disease activity and the need for further monitoring.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., gastroenterologist, dietician)
Educational resources provided to the patient about CD management and potential complications of untreated disease
Discussion of the importance of long-term follow-up and potential need for periodic serological testing (varies depending on practice guidelines)