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Sarah Johnson

sarah@smithreporting.com

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Medical Records Analysis

Martinez_Transcript_2025-01-10.docxMedical_Records_2025-01-08.pdf

What were the patient's main symptoms?

10 minutes ago

Based on the medical records, the patient's main symptoms included: 1. **Chronic lower back pain** - The patient reported persistent pain in the lumbar region following the accident. 2. **Limited mobility** - Significant reduction in range of motion, particularly when bending or twisting. 3. **Radiating pain down left leg** - Symptoms consistent with sciatica, extending from the lower back through the buttock and down the posterior left leg. The symptoms began immediately after the accident on June 3, 2024, and have persisted despite treatment interventions.

Sources:

[Medical_Records_2025-01-08.pdf, p. 15][Medical_Records_2025-01-08.pdf, p. 18][Johnson_Depo_2025-01-15.pdf, p. 5]

9 minutes ago

What treatment was recommended?

5 minutes ago

The recommended treatment plan included multiple interventions: **Immediate Treatment:** - Emergency room evaluation and initial pain management - Prescription of muscle relaxants and anti-inflammatory medication **Ongoing Treatment:** - Physical therapy 3 times per week for 12 weeks - Chiropractic adjustments twice monthly - Pain management consultation **Specialist Referrals:** - Orthopedic surgeon consultation for evaluation - MRI of lumbar spine to rule out disc herniation The treating physician noted that surgical intervention may be necessary if conservative treatment fails to provide relief within 6 months.

Sources:

[Medical_Records_2025-01-08.pdf, p. 22][Medical_Records_2025-01-08.pdf, p. 28]

4 minutes ago