Dashboard
One page, the whole case. Who the patient is, what happened, every documented encounter in sequence, how treatment intensity moved over time, which disciplines carried the care, where the record goes quiet, and how strong the resulting proof actually is. Every figure on this page derives from the medical chronology and is reconciled against the Radiology, Brain Injury, Narrative and Life Care Plan tabs.
Basic case background
What this case is about
On November 9, 2023, Rosalind Vega tripped over an unsecured stack of tires in a retail store aisle and fell forward onto her face and outstretched hands, sustaining bilateral distal radius fractures, facial and dental trauma, bilateral shoulder injury and a head strike with brief disorientation.
Over the following nineteen months she accumulated 112 documented encounters across eleven disciplines and twenty-two treating providers — escalating from urgent care and orthopedics into physical therapy and chiropractic care, then into interventional pain management after EMG confirmed bilateral C5-C6 radiculopathy and advanced neuroimaging documented post-traumatic microhemorrhages and axonal shearing that a conventional brain MRI six months earlier had not shown.
Care culminated in multi-level cervical and lumbar surgery on October 29, 2024, followed by speech, behavioral and brain-injury rehabilitation, with the treating surgeon documenting approaching maximum medical improvement and permanent, progressive disc injury on February 3, 2025.
Case facts
Key statistics
Treatment timeline, end to end
Treatment intensity and care mix
Encounters per month from date of loss
Care mix
Care episodes by discipline
When each discipline entered and exited the case
Documented care gaps
4 care gaps of 21 days or more detected across the 19-month treatment span: 35, 26, 28 and 30 days. Two are attributable to payer authorization delay, one to a physician-directed bracing interval, and one to documented discharge from therapy.
Evidence hierarchy, proof strength and care-gap audit
Evidence hierarchy
Separation discipline
Life Care Plan
This illustrative Life Care Planning Chronology packages the five preceding tabs into future-care planning categories. Costs are illustrative planning ranges only, benchmarked to Usual, Customary and Reasonable rates at the 75th–80th percentile. This document is educational in nature and is not a certified Life Care Plan.
This Life Care Planning Chronology packages the documented record for Ms. Vega into future-care planning categories following a slip and fall on November 9, 2023. It consolidates what the other five tabs establish: 112 documented encounters, 11 disciplines, a confirmed cervical radiculopathy, an advanced-imaging brain injury finding, multi-level spine surgery, and a treating-surgeon permanency statement.
Ms. Vega is a 46-year-old female who fell forward onto her face and outstretched hands over an unsecured stack of tires. Treatment has included urgent and orthopedic care, physical therapy, chiropractic care, interventional pain management, multi-level cervical and lumbar surgery, speech-language pathology, behavioral health and brain-injury rehabilitation. She currently reports chronic cervical and lumbar pain limiting childcare duties, bilateral wrist pain with sensory deficit, chronic post-traumatic headache, and residual cognitive fatigue with light and noise sensitivity.
Planning categories below are illustrative and are not treatment recommendations. Costs are illustrative planning ranges only. The plan is subject to change if the client's condition changes or additional records become available, and it must be reviewed by a certified life care planner and treating physicians before any use.
Records Reviewed
- Brightpath Urgent Care — 11/10/2023
- Cascade Orthopaedic Institute — 11/13/2023 – 07/15/2024
- Cascade Orthopaedic Physical Therapy — 04/11/2024 – 05/22/2024
- Lakeshore Neurology Associates — 01/22/2024 – 07/17/2024
- Meridian Radiology Group / Northgate Imaging — 02/04/2024 – 04/14/2024
- Vertex Advanced Imaging — 05/12/2024 & 09/18/2024
- Cedar Ridge Chiropractic — 04/28/2024 – 09/04/2024
- Summit Spine & Joint Centers — 08/27/2024 – 02/03/2025
- Northfield Surgery Center — 10/29/2024 – 10/30/2024
- Clearpath Telecare (speech-language) — 11/24/2024 – 02/22/2025
- Stillwater Behavioral Health — 12/15/2024 – 03/25/2025
- Vantage Brain Health — 12/16/2024
- Willow Creek Family Medicine — 12/19/2023 – 05/22/2025
Related Medical Documentation Categories
- Post-traumatic facetogenic pain C3-C7 with disc herniations of record
- Bilateral C5-C6 cervical radiculopathy — EMG confirmed
- Multi-level cervical disc osteophyte complex with moderate stenosis C4-C5, C5-C6
- Status post ACDF C4-C5 / C5-C6 and cervical facet ablation C3-C7
- Facetogenic pain L2-S1; status post L5-S1 discectomy and lumbar ablation
- Mild traumatic brain injury with post-concussive syndrome
- Intractable migraine with aura
- Cognitive-linguistic deficits — memory, word retrieval, executive function
- Healed bilateral distal radius fractures with residual sensory deficit
- Right wrist ganglion cyst; mild left ulnar neuropathy at the wrist
- Post-traumatic stress disorder; adjustment disorder; prolonged grief disorder
- Chronic pain syndrome with sleep disruption
Imaging Observations Summary
| Date | Study | Key Observations |
|---|---|---|
| 11/10/2023 | Bilateral Wrist X-Ray | Subtle distal radius lucency bilaterally, suspicious for nondisplaced acute fracture. Independent second read concurred. |
| 02/04/2024 | Right Shoulder MRI | No rotator cuff tear; tendons intact. Minimal AC arthropathy. No acute fracture, labral tear or significant effusion. |
| 03/06/2024 | EMG / NCV | Moderate left C5-C6 radiculopathy with chronic and acute changes; mild-to-moderate right C5-C6. Mild left ulnar neuropathy at the wrist. Motor conduction normal. |
| 03/15/2024 | Brain MRI (conventional) | No acute intracranial abnormality or conventional evidence of TBI. Nonspecific partially empty sella. |
| 04/14/2024 | Bilateral Wrist MRI | Right ganglion cyst 10.4 × 7.0 × 5.5 mm; small effusions; degenerative subchondral cysts. No tendon tear or ligamentous injury. |
| 05/12/2024 | MRI Cervical Spine | Disc osteophyte complexes C3-C4, C4-C5, C5-C6 with moderate bilateral foraminal narrowing C4-C5; C6-C7 mild bulge. Neurology re-read: moderate stenosis C4-C5, C5-C6. |
| 05/12/2024 | MRI Lumbar Spine | Mild multilevel facet hypertrophy L3-S1. No herniation, canal stenosis or high-grade foraminal narrowing. |
| 09/18/2024 | Advanced Brain MRI (DTI / SWI / volumetrics) | Hemosiderin foci at gray-white junction frontal, parietal, occipital and right thalamus. DTI abnormality in 50% of white matter tracts. Abnormal regional volume change. |
| 07/15/2024 | Bilateral Wrist X-Ray | Healed nondisplaced distal radius fractures with early IP joint space narrowing. No scapholunate widening or avascular necrosis. |
Procedures & Interventions to Date
| Date | Provider | Procedure |
|---|---|---|
| 04/11 – 05/22/2024 | Cascade Orthopaedic PT | Physical therapy — 9 of 10 authorized sessions (therapeutic exercise, manual therapy, modalities) |
| 04/28 – 09/04/2024 | Cedar Ridge Chiropractic | Chiropractic care — 24 visits (manipulative therapy, EMS with hot packs, non-surgical decompression at 24 lbs) |
| 09/25/2024 | Summit Spine & Joint Centers | Bilateral diagnostic facet injections — cervical C3-C4 through C6-C7; lumbar L2-L3 through L5-S1 |
| 10/29/2024 | Northfield Surgery Center | Right ACDF C4-C5 and C5-C6; left L5-S1 discectomy; bilateral facet thermal RFA C3-C7 and L2-S1; iliac crest stem cell harvest and application |
| 11/24/2024 – 02/22/2025 | Clearpath Telecare | Speech-language pathology — 8 sessions, cognitive-linguistic rehabilitation to discharge |
| 12/15/2024 – 03/25/2025 | Stillwater Behavioral Health | Behavioral health — 20 encounters, CBT/DBT, grief counseling, psychiatric evaluation |
Medical Summary
Ms. Vega is a 46-year-old female who fell over an unsecured stack of tires on 11/09/2023. Urgent care on 11/10/2023 documented bilateral distal radius fractures on radiograph. Orthopedic evaluation on 11/13/2023 confirmed the fractures with reduced range of motion and bilateral radial styloid tenderness.
Post-concussive symptoms were first documented 12/19/2023 and formalized at neurology consultation on 01/22/2024 as post-concussion syndrome with intractable migraine. EMG/NCV on 03/06/2024 confirmed bilateral C5-C6 radiculopathy with chronic and acute changes. Cervical MRI on 05/12/2024 documented multi-level disc osteophyte complexes with moderate stenosis at C4-C5 and C5-C6.
Conservative care was exhausted first: nine physical therapy sessions and twenty-four chiropractic visits between April and September 2024. Two payer denials — the shoulder MRI on 01/28/2024 and the cervical MRI on 04/29/2024 — delayed diagnostic imaging by a documented 37 and 13 days respectively.
Pain management consultation on 08/27/2024 attributed posttraumatic facetogenic pain C3-C7 and L2-S1 to the index accident. Diagnostic facet injections on 09/25/2024 produced concordant relief, establishing the surgical plan of 10/03/2024. Multi-level surgery was performed 10/29/2024 without complication.
Advanced brain MRI on 09/18/2024 documented microhemorrhage and axonal shearing patterns not visible on the conventional study of 03/15/2024. The treating surgeon documented on 02/03/2025 that Ms. Vega was approaching maximum medical improvement and that the disc injuries are permanent and progressive with possible future repeat ablations. This is a treating-provider statement and is not a retained-expert opinion.
- Permanency documented: disc injuries described as permanent and progressive
- Repeat cervical and lumbar facet thermal ablation cycles — planning category
- Diagnostic medial branch blocks preceding each ablation cycle
- Cervical and lumbar epidural steroid injections as indicated
- Pain management follow-up 4 visits/yr — planning category
- Cervical and lumbar radiographs annually; MRI every 2–3 years
- Physical therapy and massage therapy maintenance
- NSAID and neuropathic agent management ongoing
- Mild TBI and post-concussive syndrome attributed to the 11/09/2023 fall
- Cognitive rehabilitation — planning category, 12 sessions/yr
- Speech-language booster sessions as needed following 02/22/2025 discharge
- Neuropsychological re-evaluation every 3 years — planning category
- Advanced brain MRI surveillance every 5 years
- Migraine prophylaxis and abortive therapy ongoing
- Home cognitive and balance exercise program
- Sensory management aids — tinted lenses, noise attenuation
- Referral issued for moderate cervical stenosis C4-C5 and C5-C6
- Adjacent-segment fusion — literature and planning reference, projected year 8
- Lumbar fusion L5-S1 if discectomy proves insufficient — projected year 12
- Spinal cord stimulator if fusion insufficient
- Hardware revision — projected year 20
- Post-operative physical therapy and medication management
- This column is a planning reference only until the consultation is obtained
Current Symptoms
- Cervical and lumbar pain — improved post-surgically, limits childcare duties
- Bilateral wrist pain with sensory deficit thumb through radial ring finger
- Chronic post-traumatic headache — 7/10 at last speech therapy encounter
- Cognitive fatigue with residual memory lapses and word-finding difficulty
- Light and noise sensitivity documented through 03/09/2025
- Sleep disturbance including nightmares (PTSD context)
Functional Limitations
- Unable to sustain prior childcare employment activities
- Loss of the client's daycare business documented 02/11/2025
- Difficulty performing household tasks independently
- Driving ceased 04/10/2024 by physician instruction following a disorientation episode
- Sensory-triggered limitation in crowded or noisy environments
Psychosocial & Planning Notes
- PTSD diagnosed 12/19/2024; adjustment disorder and prolonged grief disorder
- PHQ-9 trajectory: 18 at onset → 11 mid-course → 7 at 01/08/2025
- Pre-incident 2019 depressive episode relevant to apportionment
- Home exercise and cognitive strategy programs prescribed
- Illustrative WPI reference: 21–25% whole person — not a rating
- Vocational assessment outstanding
Conclusion
Based on the illustrative medical history and treatment documentation for Ms. Vega, the available record pattern is presented as internally consistent with the slip and fall of 11/09/2023 for educational planning purposes. This statement describes the documentation only and is not a causation opinion. The record reflects ongoing symptom patterns and functional limitations, and the example care categories are organized across the projected lifespan for planning discussion only.
A population-average remaining life span of 38 years is referenced for a 46-year-old female and was used as the planning horizon. This is a population figure, not an individualized prognosis. The cost tables below outline illustrative planning categories — not treatment recommendations — and are subject to revision if additional records are produced or the client's condition changes.
Future Medical Treatment & Cost
Radiology Review
AI-assisted visualization planning aid with physician-review workflow. Candidate findings are flagged and organized by region — cervical, intracranial, lumbar, wrist and shoulder — for educational documentation support only. Every finding below traces to a dated study in the Medical Chronology tab. This is not a radiologist report, diagnosis, or treatment recommendation.
Medical Chronology Report
Sequential documentation of medical encounters from Date of Loss forward. Treatment gaps are automatically flagged when no documented care is recorded for 14+ days. Key clinical events are highlighted. Provider types are categorized for rapid review.
4 care gaps of 21+ days detected: Nov 13 – Dec 18, 2023 (35 days, physician-directed bracing interval); Dec 20, 2023 – Jan 15, 2024 (26 days, pending shoulder MRI authorization, subsequently denied); Mar 25 – Apr 22, 2025 (28 days, post-discharge); Apr 22 – May 22, 2025 (30 days, scheduled recheck window). Two authorization denials are documented separately.
Narrative Medical Report
An illustrative objective narrative draft summarizing documented clinical records, treatment history, and planning references. This format supports medical-legal documentation organization only. Content here is educational and does not provide medical advice, legal advice, diagnosis, or treatment direction.
Brain Injury Analysis & Documentation
AI-assisted cognitive documentation and brain imaging organization prepared for physician-review workflow. This section organizes neuro-cognitive screening results, imaging observations, and symptom documentation for educational and medical-legal documentation purposes. Every item shown here is stated in the Narrative Report tab and traces to a dated entry in the Medical Chronology. Not a diagnostic report.
For educational demonstration only