Medical Chronology Services for Personal Injury Law Firms

Jane Doe is a 42-year-old woman who, before this collision, worked full-time in a physically demanding commercial facilities position and managed her household independently. The collision produced immediate neck, thoracic, low-back, headache, cognitive, and anxiety symptoms. Her treatment has included emergency evaluation, medication, active rehabilitation, diagnostic imaging, interventional pain care, cognitive rehabilitation, and trauma-focused psychological treatment. The following summarizes her post-collision course:

February 26, 2026: Ms. Doe presented to Sample Medical Center on the date of loss with neck pain, upper- and low-back pain, headache, nausea, dizziness, and left shoulder soreness after the side/front-quarter impact. She rated her pain 8/10. Examination documented cervical and lumbar tenderness with painful range of motion and paraspinal spasm. CT imaging of the head and cervical spine showed no acute fracture or intracranial hemorrhage. She was diagnosed with acute cervical strain, lumbosacral strain, post-traumatic headache, and concussion without loss of consciousness. She was discharged with anti-inflammatory medication, muscle-relaxant therapy, activity precautions, and instructions for close outpatient follow-up.

February 27, 2026: Ms. Doe presented to Sample Injury & Rehabilitation Center for a comprehensive post-collision evaluation with chief complaints of neck, upper-back, and lumbosacral pain, headaches, brain fog, sleep disruption, and intermittent paresthesias into the left upper extremity. She reported pain of 8/10 and difficulty bending, lifting, turning her head, driving, sleeping, and completing her normal work tasks. Examination demonstrated restricted cervical and lumbar motion, positive cervical compression and facet-loading maneuvers, thoracic hypertonicity, lumbar instability, bilateral sacroiliac tenderness, and pain with provocative hip and lumbar testing. Diagnoses included cervical strain, cervicalgia, thoracic strain, lumbosacral strain, sacroiliitis, concussion, post-concussion syndrome, and bilateral occipital neuralgia. She was placed on modified work duty.

March 2, 2026: At follow-up with Sample Injury & Rehabilitation Center, the emergency imaging was reviewed along with office radiographs. The provider documented persistent loss of normal cervical lordosis, muscle guarding, and early degenerative disc-height changes at C5-C7 and L5-S1. Because Ms. Doe had been functioning at full duty without active spine treatment before the crash, the provider considered the degenerative findings pre-existing but clinically aggravated and made symptomatic by the collision. A plan was established for physical therapy, occupational/cognitive rehabilitation, home exercise, TENS therapy, and cervical and lumbar MRI studies if symptoms persisted. Modified-duty restrictions continued.

March 3, 2026: Ms. Doe underwent a physical therapy initial evaluation at Sample Injury & Rehabilitation Center. She reported worst pain of 9/10, headaches, sleep interruption, fear and anxiety while driving, numbness and tingling in her hands, and difficulty looking over her shoulders. Objective findings included forward-head posture, decreased cervical stability, weakness of the scapular stabilizers and rotator cuff musculature, hypomobility in the upper cervical and thoracic segments, and painful lumbar movement. Her treatment plan emphasized therapeutic exercise, neuromuscular re-education, manual therapy, graded functional activity, and return-to-work tolerance.

March 5-30, 2026: Ms. Doe attended a regular course of physical therapy and rehabilitation at Sample Injury & Rehabilitation Center. Treatment included manual therapy, therapeutic exercise, therapeutic activities, neuromuscular re-education, postural retraining, and a home exercise program. Pain frequently increased to 7-8/10 with activity. She continued to report difficulty sleeping, driving, turning her head, bending, pushing, pulling, lifting, carrying, and performing the repetitive physical demands of her job. She was also fitted with an LSO lumbar brace, a cervical support collar for limited therapeutic use, and a TENS unit for home pain management.

March 6, 2026: Ms. Doe underwent an occupational/cognitive rehabilitation evaluation because of persistent post-concussive symptoms. She described confusion, slowed processing, difficulty focusing, forgetfulness, dizziness with positional changes, and daily headaches. ACE-III cognitive testing produced a score of 74/100, with deficits most apparent in attention, verbal fluency, memory retrieval, and visuospatial tasks. The clinician recommended cognitive pacing strategies, structured task management, sleep hygiene, and continued monitoring of post-concussive symptoms.

March 27, 2026: Cervical and lumbar MRI studies were obtained at Sample Diagnostic Imaging. The cervical MRI demonstrated straightening of the normal cervical lordosis, a small broad-based disc protrusion at C5-6, and a disc bulge at C6-7 with mild foraminal narrowing. The lumbar MRI demonstrated mild multilevel degenerative changes, facet hypertrophy at L4-5, and a small central protrusion with annular fissuring at L5-S1. No acute fracture was identified. The treating providers considered the degenerative component pre-existing, but correlated the new post-collision symptoms, muscle spasm, restricted motion, and facet-mediated pain with a traumatic aggravation of previously non-disabling changes.

April 29, 2026: Ms. Doe presented to Sample Pain & Spine Institute for an interventional pain consultation. She described persistent posterior neck, upper-back, and low-back pain as sharp, tight, and throbbing, with severity up to 8/10. Examination showed painful cervicothoracic and lumbar range of motion, taut paraspinal musculature, positive lumbar facet loading, sacroiliac tenderness, and a positive straight-leg raise for back pain. The provider diagnosed cervicalgia, lumbar strain, lumbar facet-mediated pain, and sacroiliac pain, and expressly related the symptomatic condition to the February 26 collision. Diagnostic lumbar medial branch blocks were recommended.

May 5, 2026: Ms. Doe underwent psychological and neurobehavioral testing at Sample Behavioral Health because driving anxiety, intrusive recollections, sleep disturbance, and cognitive complaints had persisted despite improvement in some physical symptoms.

May 7, 2026: At Sample Pain & Spine Institute, Ms. Doe underwent fluoroscopically guided bilateral lumbar medial branch blocks at L3-L4, L4-L5, and L5-S1 using local anesthetic and corticosteroid medication. She tolerated the procedure without complication and reported substantial temporary reduction in her axial low-back pain, supporting a facet-mediated pain generator.

May 15, 2026: At post-procedure follow-up, Ms. Doe reported approximately 70% temporary improvement in low-back pain after the medial branch block, followed by recurrence with bending, prolonged standing, and work activity. The provider reaffirmed collision-related causation and discussed a confirmatory block followed by radiofrequency ablation if the response remained reproducible.

May 20, 2026: Ms. Doe completed a comprehensive psychological evaluation at Sample Behavioral Health. She described intrusive memories, nightmares, anxiety and freezing while driving, avoidance of unnecessary driving, irritability, hypervigilance, diminished interest in activities, fatigue, poor concentration, and disrupted sleep. Standardized testing produced a PCL-5 score of 49, a GAD-7 score of 18, and a PHQ-9 score of 14. The psychologist diagnosed post-traumatic stress disorder with associated anxiety and depressive symptoms and identified the motor vehicle collision as the precipitating traumatic event. A course of trauma-focused psychotherapy was recommended.

May 28, 2026: Sample Pain & Spine Institute reevaluated Ms. Doe for persistent lumbar and sacroiliac pain. She remained functionally limited despite rehabilitation and the temporary benefit from the first diagnostic block. The plan included a confirmatory medial branch block, possible lumbar radiofrequency ablation, and bilateral sacroiliac joint injections if symptoms continued.

June 1, June 8, June 22, and July 6, 2026: Ms. Doe participated in individual trauma-focused psychotherapy at Sample Behavioral Health. Sessions addressed accident-related re-experiencing, autonomic arousal while driving, avoidance, sleep disruption, irritability, grounding techniques, paced breathing, and gradual return to independent driving. She improved in her use of coping skills but continued to experience clinically significant anxiety and sleep disturbance.

July 13, 2026: Sample Injury & Rehabilitation Center completed a rehabilitation discharge/MMI evaluation. Ms. Doe had improved from her acute presentation but continued to report neck pain of approximately 4/10 and low-back pain of approximately 5/10 with prolonged activity. Range of motion and work tolerance had improved but had not returned to baseline. The provider concluded that she had reached a plateau and maximum medical improvement from active conservative rehabilitation, while specifically noting that interventional pain care and behavioral-health treatment remained medically appropriate.

July 16, 2026: At her most recent pain-management follow-up, Ms. Doe continued to report activity-dependent lumbar pain, intermittent cervical pain and headaches, and difficulty tolerating repetitive lifting and prolonged standing. The provider recommended proceeding with the second diagnostic lumbar block and, if again successful, bilateral radiofrequency ablation. Continued psychotherapy and a limited maintenance rehabilitation program were also recommended. Her prognosis was characterized as guarded-to-fair for complete resolution but favorable for additional functional improvement with the recommended care.