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Chronology in 24 hours
De-identified synthetic case. All patient data fictional.
The AI flagged these items for attorney review
| Date | Visit type | Notes | Page |
|---|---|---|---|
| 02/09/2025 | Emergency | 36-year-old restrained driver, rear-ended. NSAIDs and Cyclobenzaprine prescribed. Pain 7/10 cervical, 6/10 lumbar. Discharged stable at 21:10. | p. 2 |
| ⚠ Gap — 18 days (02/09 – 02/27) | |||
| 02/27/2025 | Imaging | MRI cervical spine — C5-C6 disc protrusion with mild right foraminal narrowing; C6-C7 disc bulge without stenosis. Signed A. Feldman, MD. | p. 3 |
| 03/03/2025 | Physical Therapy | Visit 1. Initial eval — decreased cervical ROM, positive right Spurling. Pain 6/10. Manual therapy begun. | p. 4 |
| 03/05/2025 | Consultation | Cervical radiculopathy, C6 distribution, post-traumatic. Gabapentin trial started. Light duty — no lifting >10 lbs. Consider ESI if no improvement. | p. 5 |
| 03/10/2025 | Physical Therapy | Visit 2. Cervical/thoracic mobilization, postural re-education. Pain 5/10. | p. 4 |
| 03/17/2025 | Physical Therapy | Visit 3. Cervical traction tolerated. ROM improving. Pain 4/10. | p. 4 |
| 03/24/2025 | Physical Therapy | Visit 4. Pain flare after lifting at work. Pain 6/10. E-stim applied. | p. 4 |
| ⚠ Gap — 19 days (03/24 – 04/12) | |||
| 04/12/2025 | Follow-up | Symptoms improved ~60%. NRS 3/10. Negative Spurling. 5/5 grip. Full ROM. Off gabapentin. Did not proceed to ESI. MMI not yet reached. Full duty release effective 04/21/2025. | p. 7 |
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