History of Esophageal Cancer

Patient presents with a history of esophageal cancer, status post esophagectomy performed on [Date of Surgery].  The patient reports [Current symptoms, e.g., dysphagia, odynophagia, reflux, weight loss, or asymptomatic].  Review of systems reveals [Pertinent positive and negative findings related to esophageal cancer and its treatment, e.g., changes in bowel habits, cough, hoarseness, chest pain, or fatigue].  Physical examination reveals [Objective findings, e.g., abdominal surgical scar, palpable masses, or lymphadenopathy].  Current medications include [List all medications].  Allergies include [List all allergies].  Surgical history is significant for esophagectomy with [Surgical technique, e.g., Ivor Lewis or transhiatal esophagectomy] for [Histological subtype of esophageal cancer, e.g., squamous cell carcinoma or adenocarcinoma] staged as [Tumor Node Metastasis (TNM) stage at diagnosis].  Prior treatment included [Neoadjuvant or adjuvant therapy details, e.g., chemotherapy, radiation therapy, or chemoradiation].  Patient is being monitored for recurrence with [Surveillance plan, e.g., imaging studies, endoscopy, or tumor markers].  Assessment: History of esophageal cancer.  Plan:  [Follow-up plan, e.g., continue surveillance, address current symptoms, referral to oncology, or nutritional counseling].  Differential diagnoses at initial presentation included GERD, achalasia, esophageal stricture, and esophageal spasm.  ICD-10 code: Z85.820 (Personal history of malignant neoplasm of esophagus).  Emphasis on quality of life and symptom management continues.