Date:
Patient:
Admitting Physician:
Current Progress Note:
History of Present Illness:
Briefly describe the mechanism of injury leading to esophageal trauma (e.g., blunt trauma from motor vehicle accident, penetrating trauma from gunshot wound, iatrogenic injury during endoscopy)
Onset and nature of symptoms (e.g., chest pain, dysphagia – difficulty swallowing, hematemesis – vomiting blood, odynophagia – painful swallowing, subcutaneous emphysema – air under the skin)
Duration of symptoms
Past medical history relevant to esophageal injury (e.g., prior esophageal procedures, strictures)
Physical Examination:
Summarize the pertinent physical examination findings, including:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
Signs of chest wall injury (e.g., tenderness, bruising, subcutaneous emphysema)
Neck examination for crepitus (air under the skin)
Cardiopulmonary auscultation (listening to heart and lungs for abnormalities)
Imaging Studies:
Describe the type of imaging studies performed (e.g., chest X-ray, CT scan with contrast esophagram)
Summarize the findings, including:
Location and extent of esophageal injury
Presence of any mediastinal (chest cavity) air or fluid collections
Evidence of esophageal perforation or leak
Laboratory Studies:
List relevant laboratory tests performed (e.g., CBC, electrolytes, coagulation studies)
Briefly mention any abnormal findings (e.g., anemia from blood loss)
Assessment:
State the diagnosis of traumatic esophageal injury based on clinical presentation and imaging studies
Describe the severity of the injury (e.g., contained perforation, free perforation)
Identify potential complications (e. sepsis – infection, mediastinitis – inflammation of chest cavity, stricture – narrowing of esophagus)
Plan:
Outline the treatment plan, including:
NPO (nothing by mouth) status
Intravenous fluids and electrolytes
Broad-spectrum antibiotics (if perforation is suspected)
Pain management
Consideration for esophageal stenting or surgical repair (depending on injury severity)
Nutritional support (e.g., enteral feeding through a feeding tube)
Consultation with specialists (e.g., thoracic surgeon, gastroenterologist)
Follow-up:
Describe the planned follow-up for monitoring and evaluation (e.g., repeat imaging studies, esophagram)
Education:
Document patient education regarding the nature of the injury, treatment plan, dietary restrictions, and potential complications.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of traumatic esophageal injury