Microsoft word - janedoesample.doc

DOB: 03/06/****
Current Dr.: Dr. ***

Symptoms/Issue(s): Daily
Pressure/Pain behind breastbone into mid back, pressure in
esophagus, bloating, nausea, and pain causing her to bend forward.
Date When Symptoms Started:

Prior Diagnosis: IBS, Esophageal spasms, GERD, pulled muscle in the back, costal
chondritis, Posture, General Pain, Nerve Receptors, Gallbladder, and Sphincter of ODDI.
Procedures Performed from 3/01/2008 to 4/15/2009: Full laparoscopic hysterectomy,
Upper and lower GI, 3 and 9 probe esophageal manometry, Barium CT scan, Various blood work, Stress test, Echo cardiogram, Anorectal manometry, Abdominal scan, Spine X-Ray, MRI for the back, Physical exam, Gallbladder removal, Barium enema, Colonoscopy, Gastric Emptying, EKG, Endoscopic ultrasound, MRCP, and

Dr.’s Seen/Consulted (Approximate Dates = See Records)

03/01/2008: Dr. **** (GI located at ***)
Performed Upper GI Scope, diagnosed as IBS, said live with it because he’s out
04/01/2008: Dr. **** (GI located at ***)

3 Probe esophageal manometry diagnosed her with possible GERD and/or esophageal spasms, referred us to Mayo Clinic.
05/01/2008: Dr. **** (Internal Medicine located at ***)

10/01/2008: Dr. **** (GI located at ***)

Barium CT Scan, blood work, and said to continue Mayo Clinic.
11/01/2008: Dr. **** (GI located at ***)

9 probe esophageal manometry, blood work (Thyroid), stress test, echo cardiogram, and anorectal manometry. 1st visit was diagnosed as esophageal spasms, 2nd visit was costal chondritis. Various meds prescribed.
01/01/2009: Dr. **** (GI located at ***)

Blood work, abdominal scan, and prescribed Cymbalta.
01/01/2009: Dr. **** (Sports Medicine (GI located at ***)

Order Back/Spine X-Rays, MRI, then referred us to Dr. **** and Dr. ****.
01/01/2009: Dr. **** (Internal Medicine located at ***)

Physical exam, prescribed Syrica and anti-flam medication, was diagnosed as
3/01/2009: Dr. **** (General Surgeon - ****)

Removed gallbladder, barium enema, blood work, colonoscopy, upper scope, and reviewed case in detail. Referred to **** GI for ERCP (Bile duct to Pancreas. He believes Sphincter of ODDI is causing this problem.
3/23/2009: Dr. **** (GI located at ***)

Gastric Emptying, otherwise was completely useless.
4/14/2009: Dr. **** (Internal Medicine located at ***)
Pre-Op exam, chest x-ray, blood work, and EKG Latest Update
4/21/2009: Dr. **** (GI/SOD Dr. **** (Internal Medicine located at ***)
Endoscopic ultrasound, MRCP, and a sphincertomy including 2 stints in main
Prior Surgeries:
• Laparoscopic Hysterectomy on Jan 2007 (Ovaries Remain)

• Upper GI Scope (Performed at ****** and on 00/00/0000) • Lower GI Scope (Performed at ****** and on 00/00/0000) • 3 Probe Manometry (Performed at ****** and on 00/00/0000) • 9 Probe Manometry (Performed at ****** and on 00/00/0000) • Various blood work (Performed at ****** and on 00/00/0000) • Stress Test (Performed at ****** and on 00/00/0000) • Echo Cardiogram (Performed at ****** and on 00/00/0000) • CT Scan with Barium (Performed at ****** and on 00/00/0000) • Colonoscopy (Performed at ****** and on 00/00/0000) • Lower Abdominal Scan (Performed at ****** and on 00/00/0000) • Ultrasound and MRI of back (Performed at ****** and on 00/00/0000) • Barium Enema (Performed at ****** and on 00/00/0000) • Anorectal Manometry (Performed at ****** and on 00/00/0000) • Endoscopic Ultrasound x 2 (Performed at ****** and on 00/00/0000) • Chest X-Ray (Performed at ****** and on 00/00/0000) • EKG (Performed at ****** and on 00/00/0000) • MRCP (Performed at ****** and on 00/00/0000) • Sphincterotmy (Performed at ****** and on 00/00/0000)
Medicines Prescribed and Taken:

• Pepcid, Peptol-Bismol. Alka-Seltzer, Maalox, Mylanta (over-the-counter
Current Medications: Pain reliever as needed


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