Celiac Disease Note (New Diagnosis)

Date: [Date]

Encounter Type: [new consult / post-endoscopy results visit / follow-up]

Service/Location: [Service or clinic location]

Source of History: [patient / parent-guardian / chart review / other]

Interpreter: [Interpreter name/ID and language / not used]

Chief Complaint

[Reason for visit] (Single line. If this is a results visit, note that.)

History of Present Illness

[Introductory summary identifying patient, reason for visit, and what established or is establishing the diagnosis] (If diagnosis is being made without biopsy, explicitly document the criteria used and that this was discussed with the patient/family.)

• Presentation and symptoms: [Key GI symptoms and extraintestinal features with duration and trajectory] (Include only clinically relevant findings affecting management.)
• Gluten exposure at testing: [Was patient consuming gluten at time of serology and biopsy? Yes/No/Unknown; approximate level if known; date and details if reduced/avoided gluten prior to testing] (If unknown, state "gluten intake at time of testing: unknown" and document plan to clarify.)
• Dietary baseline: [Current diet status: gluten-containing / gluten-restricted / strict GFD; since when; prior dietitian counseling; barriers to adherence]
• Relevant comorbidities: [Autoimmune conditions, bone health history, known nutritional deficiencies, liver enzyme abnormalities, pregnancy status or fertility goals if relevant]

Past Medical and Surgical History

• Past Medical History: [Pertinent diagnoses]
• Past Surgical History: [Pertinent procedures]
• Medications/Supplements/OTC: [List with doses; note products that may contain gluten]
• Allergies: [Allergen and reaction type] (If unknown, state "Allergies unknown" and note plan to confirm.)

Family History

[Family members with celiac disease and relationship] (If none, state "No known family history of celiac disease.")

Social History

• Household/kitchen: [Food preparation practices and cross-contact risk]
• Work/school eating environment: [Meal planning constraints]
• Access: [Access to gluten-free foods and dietitian services]
• Substances: [Alcohol and tobacco use] (Include only if clinically relevant.)

Review of Systems

(Targeted to systems reviewed; include relevant positives and pertinent negatives.)

• GI: [Pertinent symptoms]
• Constitutional: [Weight change, fatigue]
• Integumentary: [Rash, pruritus]
• Neurologic: [Neuropathy, cognitive symptoms]
• Musculoskeletal: [Bone pain, fractures]
• Reproductive: [Menstrual or fertility concerns] (Include only if relevant.)

Physical Examination

• Vitals: [BP, HR, RR, Temp, SpO2]
• Anthropometrics: [Height, weight, BMI; growth percentiles for pediatric patients]
• General/Nutritional status: [Appearance, hydration, evidence of malnutrition]
• Abdomen: [Inspection, tenderness, organomegaly, distention]
• Skin: [Findings suggestive of dermatitis herpetiformis or other rashes]
• Other signs of deficiency: [Pallor, glossitis, edema, neurologic signs]

Diagnostic Data

Celiac Serologies

• tTG-IgA: [Numeric value, units, ULN, date]
• Total serum IgA: [Value, units, date]
• EMA-IgA: [Positive/negative, titer if available, date]
• DGP-IgG/IgA: [Values, date] (Include if IgA deficient or otherwise indicated.)

(Do not state "positive" without the actual value; if unavailable, cite source and document plan to obtain.)

Endoscopy and Biopsy

• EGD date: [Date / pending / not performed]
• Biopsy details: [Locations sampled and adequacy]
• Pathology summary: [Villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis; Marsh classification]
• Other findings: [Alternative or associated findings]

(If pathology pending, state "pathology pending" and document plan for results communication.)

HLA Testing

HLA-DQ2/DQ8: [Results and interpretation context] (Use to support or exclude diagnosis; do not overstate positivity as diagnostic.)

Baseline Labs

• CBC: [Results, date] [normal / abnormal]
• Iron studies/ferritin: [Results, date] [normal / abnormal]
• CMP with liver enzymes: [Results, date] [normal / abnormal]
• Vitamin D: [Result, date] [normal / abnormal]
• Folate, B12: [Results, date] [normal / abnormal]
• Other vitamins/minerals: [Zinc, copper, fat-soluble vitamins if obtained]
• Ordered today: [Tests ordered now]
• Deferred: [Tests deferred and rationale]

Bone Health

• DEXA: [Prior results with date and T-scores / not done]
• Fracture history: [History of fractures and context]

Immunizations

Pneumococcal vaccination status: [up to date / due / unknown] (If unknown, document plan to verify.)

Assessment

• Celiac disease: [Confirmed celiac disease / Probable celiac disease / Celiac disease under evaluation]
  [Diagnostic basis summary: serology values with ULN context, biopsy results or no-biopsy criteria, gluten intake at testing. Note complications, deficiencies, and risk factors present.]
• [Additional problems as relevant]

(Do not label as confirmed unless objective criteria are documented.)

Plan

Gluten-Free Diet Initiation

• GFD start date: [Today / prior date with specific date]
• Counseling provided: [Key points discussed: hidden gluten sources, cross-contact prevention, label reading, medication/supplement gluten content]
• Oats: [Approach to oats consumption]
• Dietitian referral: [placed / existing / declined] (Target within 2–4 weeks for new diagnosis.)
• School/work accommodations: [Letters or forms needed and provided]

Nutritional Deficiencies

• Baseline labs ordered today: [List]
• Supplementation plan: [Iron, vitamin D, calcium, folate, B12, other as indicated] (Specific dosing in medication orders.)

(If no deficiencies identified, state that and note monitoring plan.)

Vaccinations

• Pneumococcal vaccine: [recommend / defer] (Document coordination plan. If recommending outside standard ACIP indications, note shared decision-making and rationale.)

Bone Health

• Calcium and vitamin D counseling: [Dietary and supplement targets discussed]
• Exercise: [Weight-bearing exercise recommendation]
• DEXA plan: [order now / schedule at specific time / not indicated] (Include rationale based on risk factors.)

Family Screening

Counseling provided: [Patient advised to inform first-degree relatives about increased celiac risk and recommendation for serology testing while on gluten-containing diet, coordinated through their PCP]

Monitoring and Follow-Up

• Short-term follow-up: [Timeframe, typically 3–6 months] (Focus on symptom response, adherence, lab correction.)
• Serology monitoring: [tTG-IgA at ~6 and 12 months, then annually]
• Criteria for earlier return: [Worsening symptoms, weight loss, persistent diarrhea, new deficiencies]
• Repeat endoscopy consideration: [Persistent symptoms despite confirmed adherence, persistently elevated serology, or diagnostic uncertainty]

If Symptoms Persist

[Plan for persistent symptoms: reassess original diagnosis, evaluate for ongoing gluten exposure, consider alternative or additional etiologies] (Include if symptoms not yet controlled.)

Patient Education

• Materials provided: [GFD resources, websites, dietitian contact information]
• Teach-back: [Patient/family demonstration of understanding]
• Psychosocial support: [Needs assessed; referrals if indicated]

Orders and Referrals

• Labs ordered: [List]
• Imaging ordered: [DEXA if applicable]
• Referrals: [Dietitian, GI follow-up, dermatology, other]
• PCP coordination: [Vaccinations, comorbidity management, record retrieval]

(If no new orders, state "No new orders today." If required diagnostic information is unavailable, explicitly state what is unknown and document the plan to obtain it.)