Comprehensive Treatment Timeline
December 6, 2023
Facility: [Redacted] Medical Center · Emergency Department
Provider: Dr. [Redacted], MD · Emergency Medicine
Type of Encounter: Emergency evaluation following motor vehicle collision
Key Findings: Patient c/o 9/10 cervical pain, 7/10 lumbar pain, post-traumatic headache, left shoulder tenderness. No loss of consciousness reported. Ambulatory on scene.
History: Restrained driver, rear-end collision at moderate speed. Airbag deployed. No prior cervical or lumbar complaints per patient report.
Vitals: BP 142/88 · HR 96 · RR 18 · SpO2 98% · Temp 98.4°F
Diagnosis: Cervical sprain/strain; lumbar sprain/strain; contusion, left shoulder; post-traumatic headache
Treatment/Intervention: Soft cervical collar. Plain films ordered (c-spine, t-spine, l-spine). NSAID and muscle relaxant administered. Discharge instructions provided.
Medications: Ibuprofen 600mg PO · Cyclobenzaprine 10mg PO · Acetaminophen 1000mg PO
Outcome/Progression: Discharged in stable condition. Follow-up with primary care in 3–5 days. Orthopedic referral if symptoms persist beyond 2 weeks.
December 18, 2023
Facility: [Redacted] Orthopedic Associates
Provider: Dr. [Redacted], MD · Orthopedic Surgery
Type of Encounter: New patient consultation, post-MVC evaluation
Key Findings: Persistent cervical pain 7/10. Radicular symptoms into left shoulder and upper arm. Reduced cervical range of motion on extension and left rotation. Pain exacerbated by overhead activity.
History: Referred from [Redacted] Medical Center ED (12/6/23). Conservative management since discharge. Symptoms unchanged despite NSAID and muscle relaxant therapy.
Vitals: BP 128/82 · HR 78
Diagnosis: Cervical disc herniation, suspected; rule out rotator cuff pathology, left shoulder
Treatment/Intervention: MRI ordered (cervical spine without contrast; left shoulder without contrast). Physical therapy prescription, 3x/week. Activity modification counseling.
Medications: Continue ibuprofen PRN. Meloxicam 15mg PO daily (new prescription).
Outcome/Progression: Imaging required prior to next visit. Return in 2 weeks with MRI results for treatment planning.
January 8, 2024
Facility: [Redacted] Imaging Center
Provider: Dr. [Redacted], MD · Radiology (reading)
Type of Encounter: MRI cervical spine, without contrast
Key Findings: C5–6 disc protrusion measuring 2.8mm, central/left paracentral. Mild flattening of the ventral thecal sac. No cord compression. Facet hypertrophy at C4–5. No acute fracture.
History: MVC 12/6/2023. Persistent cervical symptoms despite conservative management.
Diagnosis: C5–6 disc herniation, confirmed
Treatment/Intervention: Report transmitted to ordering provider (Dr. [Redacted], [Redacted] Orthopedic Associates).
Outcome/Progression: Findings consistent with traumatic disc herniation. Clinical correlation recommended. No acute findings requiring emergent intervention.
February 4, 2024
Facility: [Redacted] Physical Therapy · Outpatient Rehabilitation
Provider: [Redacted], DPT
Type of Encounter: Physical therapy progress note, session #8 of 12
Key Findings: Pain reduced from 8/10 to 5/10 over course of treatment. Cervical ROM improving on flexion. Left shoulder impingement signs diminishing with eccentric loading protocol. Patient reports persistent radicular symptoms down left arm, intermittent.
History: Compliant with home exercise program. Attending scheduled sessions per protocol.
Treatment/Intervention: Cervical traction (manual, 5 minutes); soft tissue mobilization; therapeutic exercise (McKenzie protocol, scapular stabilization); modalities (ultrasound, e-stim); home exercise program progression.
Outcome/Progression: Progressing toward functional goals. Plateau noted at 5/10 pain level. Recommend continued treatment with formal re-evaluation in 4 weeks. Consider pain management consult if plateau persists.
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GAP IDENTIFIED: No documented treatment records between 04/15/2024 and 06/02/2024. Follow-up with primary care required for causation continuity. Flagged for attorney review.