From the Guidelines
To document a patient with a history of achalasia who experienced a resolved food impaction episode in a SOAP note, I would recommend focusing on the key elements of the presentation, resolution, and follow-up plan, as outlined in the most recent guidelines 1. In the Subjective section, document the patient's description of the episode, including onset, duration, associated symptoms (chest pain, regurgitation, dysphagia), and how it resolved (spontaneously or with intervention). Note any triggers they identified and whether this is a recurrent issue. In the Objective section, include vital signs, physical exam findings focusing on the chest, abdomen, and hydration status, and any relevant diagnostic studies performed. The Assessment should clearly state "Food impaction, resolved, in patient with history of achalasia." The Plan should outline immediate management if any is needed, preventive strategies such as dietary modifications (eating slowly, thorough chewing, avoiding large pieces of food), medication adjustments if applicable (such as calcium channel blockers or nitrates), and follow-up recommendations including potential referral for endoscopic evaluation if this represents a change in their disease pattern, as suggested by the guidelines 1. It is also important to consider the possibility of eosinophilic oesophagitis, especially if the patient has a history of food bolus obstruction, and to follow the guidelines for diagnosis and management of this condition 1. Additionally, the patient should be booked for an endoscopy and outpatient review after spontaneous resolution of food bolus obstruction, as recommended by the guidelines 1. Maintenance therapy with topical steroid may also be considered to reduce the risk of recurrent food bolus obstruction, as suggested by the guidelines 1. Overall, the documentation approach should capture the acute episode while placing it in context of their underlying esophageal motility disorder, and should be guided by the most recent and highest quality evidence available 1.
From the Research
Describing a Patient with a History of Achalasia
To describe a patient with a history of achalasia who had an episode of food blockage that has already resolved in a soap note, consider the following points:
- The patient has a history of achalasia, a primary esophageal motor disorder characterized by degeneration of the myenteric plexus, leading to impaired relaxation of the esophagogastric junction (EGJ) and loss of organized peristalsis in the esophageal body 2.
- The patient experienced an episode of food blockage, which is a common symptom of achalasia, resulting from the inability of food to pass through the esophagus due to the impaired relaxation of the EGJ 3, 4.
- The episode of food blockage has already resolved, which may have occurred spontaneously or with treatment, such as pneumatic dilation or other therapeutic interventions 5, 6.
- The patient's current symptoms and treatment should be documented, including any ongoing symptoms of achalasia, such as dysphagia, regurgitation, or chest pain, and any treatments being used to manage these symptoms, such as botulinum toxin injection, pneumatic dilation, or Heller myotomy 3, 4, 6, 2.
Key Points to Include in the Soap Note
- History of achalasia and any previous treatments
- Description of the episode of food blockage, including any symptoms experienced and how it was resolved
- Current symptoms and treatment being used to manage achalasia
- Any plans for future treatment or follow-up appointments to monitor the patient's condition 5, 2.