Dr. Patel — Family Medicine
Thu, May 21 · 10:30 AM · in 4 days
- Daily check-in within 3 days
- Body map updated this week
- Medication log current
SM
PI-2026-0418
Sarah Mitchell
MVC — rear-end · Day 44 since incident
Engagement
86%
Entries logged
42
PT sessions
4
Open flags
2
Chronology
Treatment & symptom narrative
- Treatment
PT session 8
- Missed activity
Left son's soccer game at halftime
- Symptom
Severe migraine — 7/10
Lasted full day. Sumatriptan helped after 90 minutes.
- Note
Best day so far — 4/10 pain
- Treatment
PT session 6
- Treatment
Gabapentin prescribed for nerve pain
- Treatment
Neurology consult — Dr. Ngu
Post-traumatic migraines diagnosed.
- Symptom
New symptom — left arm tingling
- Treatment
Physical therapy intake
- Imaging
Lumbar MRI
L4-L5 disc bulge, facet inflammation.
- Missed activity
Missed work — 2 days
Unable to sit at desk.
- Expense
Pharmacy receipt — $42.18
- Treatment
Family medicine follow-up
Started cyclobenzaprine + naproxen.
- Photo
3 photos — bruising on chest from seatbelt
- Treatment
ER — St. Luke's
Whiplash, lumbar strain. Cervical collar issued.
- 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
Pre-appointment readiness
What's missing before each visit
1 items missing across 3 appointments
Ready
Bay Physical Therapy
Sat, May 23 · 9:00 AM · in 6 days
- Daily check-in within 3 days
- Body map updated this week
- Medication log current
- Mileage log for travel
Dr. Chen — Orthopedic Spine
Tue, Jun 2 · 2:00 PM · in 16 days
- Pre-visit questions drafted — Prompt client to send before visit
- Daily check-in within 3 days
- Body map updated this week
- Medication log current
- Symptom photos uploaded
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
- Drowsiness
Cyclobenzaprine
10 mg · Nightly
- Stomach upset
Naproxen
500 mg · Twice daily with food
- Flushing
Sumatriptan
50 mg · As needed for migraine
- Drowsiness
Gabapentin
300 mg · Three times daily
Pain trend — 7 days
Average 5.6/10 · trending steady