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Reyes & Vance · Firm view

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ER

PI-2026-0501

Elena Ramirez

MVC — T-bone intersection · Day 16 since incident

Export chronology

Engagement

94%

Entries logged

42

PT sessions

4

Open flags

0

Chronology

Treatment & symptom narrative

  1. Treatment

    PT session 8

  2. Missed activity

    Left son's soccer game at halftime

  3. Symptom

    Severe migraine — 7/10

    Lasted full day. Sumatriptan helped after 90 minutes.

  4. Note

    Best day so far — 4/10 pain

  5. Treatment

    PT session 6

  6. Treatment

    Gabapentin prescribed for nerve pain

  7. Treatment

    Neurology consult — Dr. Ngu

    Post-traumatic migraines diagnosed.

  8. Symptom

    New symptom — left arm tingling

  9. Treatment

    Physical therapy intake

  10. Imaging

    Lumbar MRI

    L4-L5 disc bulge, facet inflammation.

  11. Missed activity

    Missed work — 2 days

    Unable to sit at desk.

  12. Expense

    Pharmacy receipt — $42.18

  13. Treatment

    Family medicine follow-up

    Started cyclobenzaprine + naproxen.

  14. Photo

    3 photos — bruising on chest from seatbelt

  15. Treatment

    ER — St. Luke's

    Whiplash, lumbar strain. Cervical collar issued.

  16. Incident

    Rear-end collision on I-280

    Stopped at red light. Defendant struck at ~35 mph.

Defense risk surfacing

Patterns to discuss

Conceptual — not legal advice.

  • Treatment gap risk

    If May 23 PT session is missed, gap reaches 14 days.

  • Prior injury disclosure

    Client noted lumbar tweak in 2023 — verify in records.

  • Reporting consistency

    Pain progression coheres across 42 entries.

  • Social media risk

    Conceptual scan — client posts photo of 5K signup last week.

Current body map

5 areas marked

6547

Pre-appointment readiness

What's missing before each visit

0 items missing across 1 appointments

Bay Physical Therapy

Wed, May 20 · 2:00 PM · in 3 days

Ready
  • Daily check-in within 3 days
  • Body map updated this week
  • Mileage log for travel
  • Medication log current

Upcoming care

  • Dr. Patel — Family Medicine

    Thu, May 21 · 10:30 AM

  • Bay Physical Therapy

    Sat, May 23 · 9:00 AM

  • Dr. Chen — Orthopedic Spine

    Tue, Jun 2 · 2:00 PM

Active medications

  • Cyclobenzaprine

    10 mg · Nightly

    Drowsiness

  • Naproxen

    500 mg · Twice daily with food

    Stomach upset

  • Sumatriptan

    50 mg · As needed for migraine

    Flushing

  • Gabapentin

    300 mg · Three times daily

    Drowsiness

Pain trend — 7 days

Average 5.6/10 · trending steady