Source document: Cardiology Consultation — General Teaching Hospital (Dr. Richard Heartwell, MD) — cardiology_consult_1.pdf

Medical History — Cardiology Consultation (Case Summary)

This document is a formal cardiology consultation authored by Dr. Richard Heartwell, MD, FACC, generated on 11/02/2025 and directed by referral from the patient’s physical therapist for an urgent evaluation of exertional chest pain; the consultation header and date are recorded on the consultation cover page (page 1), and the electronic signature and attestation are documented within the report (page 6).

History of Present Illness

The patient, John A. Doe, a 40-year-old male born 01/15/1985, presented for urgent cardiology consultation following an episode of substernal chest discomfort during a physical therapy session on 11/01/2025; the consultation date is 11/02/2025 as noted by the referral and consultation timing (page 1) and the history describing the event is recorded in the history of present illness (page 2).

During a routine treadmill session at 2.5 mph for 15 minutes on 11/01/2025, the patient developed a substernal "tight, squeezing" pressure radiating to the left arm, with associated mild dyspnea and diaphoresis; the episode was described as lasting approximately 8 minutes and resolved with rest (page 2). The patient denied palpitations, syncope, nausea or vomiting during the event (page 2).

Relevant Past Medical, Surgical, and Social History

Past medical history is notable for hypertension diagnosed in 2018, reportedly well controlled on medication (page 2). He is 12 weeks status post motor vehicle accident (MVA) on 07/30/2025 with multiple traumatic injuries including a surgically repaired left hip fracture (ORIF on 07/31/2025) and ongoing cervical and lumbar strain; these facts are documented in the HPI and surgical history sections (page 1, page 2).

The medication list at the time of consultation included Lisinopril 10 mg daily for blood pressure control, tramadol 50 mg q6h PRN, gabapentin 600 mg TID, ibuprofen 600 mg TID, tizanidine 4 mg BID, and omeprazole 20 mg daily for GI prophylaxis; these medications and dosages are listed under current medications (page 3).

Family history is notable for a father with myocardial infarction at age 58 and diabetes, and a mother with hypertension (page 2). Social history includes a remote occasional smoking history (quit 2020) and minimal alcohol use; the patient has been largely sedentary since the accident (page 2).

Physical Examination

On examination in the cardiology clinic the patient appeared well and was comfortable at rest; clinic vitals included BP 148/88 (repeat 142/84), HR 78 bpm, RR 16, temperature 98.4°F, oxygen saturation 98% on room air, weight 185 lb as documented in the physical examination section (page 3).

The cardiovascular exam demonstrated regular rate and rhythm with normal S1 and S2, no murmurs, rubs, or gallops, no jugular venous distension, and a nondisplaced point of maximal impulse; peripheral pulses were 2+ and there was no peripheral edema (page 3).

Findings During the Index Event and Clinic Diagnostic Studies

Vital signs recorded during the exertional chest pain episode included blood pressure 165/95 mmHg, heart rate 125 bpm, respiratory rate 24/min, and oxygen saturation 96% on room air—these episode vitals were documented in the HPI section describing the PT event (page 2).

Twelve-lead electrocardiogram obtained in clinic demonstrated normal sinus rhythm at 78 bpm with PR 0.16 s, QRS 0.08 s, QT/QTc 420/435 ms, normal axis without ST-segment changes, T-wave abnormalities, or pathologic Q waves; this ECG interpretation is recorded in the diagnostic studies section (page 3).

Cardiac biomarkers and routine laboratories were non-diagnostic for myocardial injury: Troponin I <0.01 ng/mL (reference <0.04), CK-MB 1.2 ng/mL (reference <5.0), and BNP 45 pg/mL (reference <100). The basic metabolic panel and CMP were within normal limits; lipid panel demonstrated total cholesterol 195 mg/dL, LDL 118 mg/dL, HDL 48 mg/dL, triglycerides 145 mg/dL, and HbA1c 5.8% (pre-diabetic range). These laboratory results are summarized in the report’s laboratory section (page 4).

A chest radiograph revealed normal cardiac silhouette and clear lung fields without acute cardiopulmonary process (page 4), and transthoracic echocardiography showed normal left ventricular size and systolic function (EF 60–65%), normal wall motion in all segments, normal right ventricular function, and only trivial mitral regurgitation without pericardial effusion (page 4).

Cardiovascular Assessment and Differential Diagnosis

The consulting cardiologist’s primary impression was atypical exertional chest pain in a 40-year-old male with background hypertension and a positive family history for premature coronary artery disease. The report highlights that the initial cardiac evaluation—ECG, cardiac enzymes, and transthoracic echocardiogram—were reassuring and did not demonstrate acute ischemia or myocardial injury (page 4).

The differential diagnosis prioritized musculoskeletal chest pain related to the recent trauma and deconditioning as most likely, with exercise intolerance from deconditioning also strongly considered. Coronary artery disease was listed as less likely but not excluded given family history; medication-related causes and hypertensive response to exertion were also entertained (page 4).

Risk Stratification

The report provides a concise risk stratification noting the patient’s age (40 years), family history (father MI at 58), history of hypertension, pre-diabetes (HbA1c 5.8%), former smoking history, and severe deconditioning; these data points are recorded in the risk stratification section and in the prior laboratory and history fields (page 5, page 4, page 2).

Plan, Recommendations, and Follow-up

Immediate management recommendations included performance of an exercise stress test within 1–2 weeks to evaluate for exercise-induced ischemia; the consultation scheduled a stress test for 11/10/2025 (page 5). Temporary restriction from moderate-intensity physical therapy was advised pending stress test results, with allowance for low-intensity rehabilitation (walking <2.0 mph and light resistance exercises) (page 5).

Cardiovascular risk factor modification was explicitly recommended: increase Lisinopril from 10 mg to 15 mg daily with recheck in two weeks for blood pressure optimization, referral for nutrition/lifestyle counseling for pre-diabetes, dietary modification for borderline LDL, and a graduated activity prescription with heart rate monitoring. These recommendations and the emphasis on patient education and an emergency action plan are documented in the plan and education sections (page 5, page 6).

Follow-up instructions included cardiology clinic follow-up two weeks after the stress test and conditional clearance: if the stress test is normal, progressive physical therapy may resume; if abnormal, escalation to further diagnostic testing including possible coronary angiography was advised (page 6).

Diagnoses and Clinical Impression

Primary diagnostic impressions rendered in the consultation were: (1) Atypical exertional chest pain, (2) Hypertensive response to exercise, and (3) Musculoskeletal chest pain considered most likely given recent trauma and deconditioning; coronary artery disease was considered less likely but not excluded. These diagnoses and ranked differential considerations are provided in the cardiovascular assessment section (page 4).

Prognosis and Anticipated Course Relevant to Life Care Planning

Given the absence of objective evidence of myocardial injury (normal troponin, CK-MB) and preserved left ventricular function on echocardiography (EF 60–65%), the short-term cardiac prognosis is favorable pending results of exercise stress testing (page 4). The primary ongoing concerns for functional limitation relate to deconditioning following traumatic injury and the potential for hypertensive response to exertion; these are explicitly discussed in the risk stratification and plan sections (page 5).

From a life care planning perspective, if the stress test is normal, a structured graded return-to-activity program with heart rate monitoring and blood pressure control is likely to permit progressive resumption of therapy and activities of daily living with minimal long-term cardiac interventions (page 6). If the stress test identifies ischemia, additional interventions including invasive coronary angiography, potential revascularization, and secondary prevention pharmacotherapy would be required, and thus contingency planning for those scenarios is appropriate (page 6).

Recommended Future Medical and Rehabilitation Interventions

Short-term recommended actions for this patient include: scheduling and completion of the exercise stress test (scheduled 11/10/2025), temporary modification of physical therapy to low-intensity activity pending results, uptitration of antihypertensive therapy (Lisinopril 15 mg daily) with close follow-up in two weeks, nutrition and lifestyle counseling for pre-diabetes, and close communication between cardiology, physical medicine & rehabilitation (PM&R), and physical therapy for graded exercise progression (page 5, page 6).

For life care planning projections, anticipate the need for: - Short-term cardiology follow-up and stress testing (page 5); - Possible ambulatory blood pressure monitoring and medication adjustment for optimization of blood pressure control (page 5); - Ongoing physical therapy with cardiac-safe protocols and heart-rate-guided progression (page 6); - Nutritional counseling and diabetes prevention interventions given HbA1c 5.8% (page 4).

Limitations, Clinical Reasoning, and Medico-legal Considerations

The consulting cardiologist appropriately documented a low immediate likelihood of acute coronary syndrome based on absence of ischemic ECG changes, normal serial cardiac biomarkers in the acute setting, and normal ventricular function on echocardiography; however, because exertional chest pain with radiation to the left arm in a patient with hypertension and a positive family history carries non-zero risk for obstructive coronary disease, the recommendation for exercise stress testing is reasonable and necessary to fully exclude inducible ischemia prior to escalation of physical activity (page 3, page 4, page 5).

For purposes of life care planning and future medical cost estimates, the plan should incorporate the near-term stress test and clinic follow-up as discrete events, with contingency budgeting for noninvasive imaging (nuclear or echo stress) or invasive coronary angiography and possible revascularization if ischemia is demonstrated. The clinician’s documentation of specific planned timelines (stress test 11/10/2025 and cardiology follow-up two weeks thereafter) is cited in the follow-up recommendations (page 6, page 5).

Physician Attestation

The author, Dr. Richard Heartwell, electronically attested to personal examination of the patient and review of available data, with an electronic signature dated 11/02/2025 at 14:00; the attestation and signature block are included within the report (page 6).

Report prepared from: Cardiology Consultation — General Teaching Hospital (Dr. Richard Heartwell, MD, FACC), cardiology_consult_1.pdf. Refer to the source document for verbatim text, original signatory, and full enumerated data: Open source PDF (page 1).

Source: Electromyography & Nerve Conduction Study — General Teaching Hospital (complete PDF)

1. Nature of Source Document

This narrative is based on an electrodiagnostic study report titled "ELECTROMYOGRAPHY & NERVE CONDUCTION STUDY" performed in the Department of Neurology — Electrodiagnostic Laboratory at a tertiary teaching hospital; the report is dated 09/10/2025 and signed by Dr. Michael Neuro, MD (performing physician) (report front page, attestation page).

2. Identifying and Event History

The subject of the study is John A. Doe, DOB 01/15/1985 (age listed as 40 years on the document) with MRN 1234567890; these demographic details appear on the report header (PDF page 1). The study was performed on 09/10/2025 as recorded on the report header and again in the physician attestation (PDF page 1, PDF page 4).

3. Mechanism of Injury and Clinical Presentation

The clinical history documents a motor vehicle accident (MVA) occurring on 07/30/2025 that resulted in a surgically repaired left hip fracture and cervical/lumbar strain; the patient reports persistent neck pain radiating to the right shoulder and arm with intermittent numbness and tingling in the thumb and index finger, worse with neck extension and right rotation. Symptom duration is recorded as approximately six weeks post-trauma (PDF page 1).

4. Referring and Performing Clinicians

The study was requested by the referring physician, Dr. Amanda Rehab, MD (Physical Medicine & Rehabilitation), and the testing was performed and interpreted by Dr. Michael Neuro, MD, Department of Neurology — Electrodiagnostic Medicine; these provider names and affiliations are listed on the report header (PDF page 1).

5. Objective Diagnostic Data — Nerve Conduction Studies

Motor and sensory nerve conduction data for the right upper extremity are reported and summarized in tabular form. Motor conduction values include right median to APB with wrist latency 3.2 ms and amplitude 12.5 mV, and at the elbow latency 7.8 ms with amplitude 11.8 mV and conduction velocity 58 m/s; right ulnar to ADM wrist latency 2.8 ms amplitude 11.2 mV and elbow latency 6.9 ms amplitude 10.5 mV with velocity 62 m/s; right radial EIP forearm latency 2.1 ms amplitude 8.9 mV (PDF page 2). Sensory studies include right median digit-to-wrist latency 3.1 ms amplitude 18.5 µV velocity 56 m/s, right ulnar digit-to-wrist latency 2.9 ms amplitude 22.1 µV velocity 58 m/s, and right radial snuffbox latency 2.2 ms amplitude 25.8 µV velocity 61 m/s (PDF page 2).

6. Needle Electromyography Findings

Needle EMG sampling is reported for multiple right-sided cervical myotomes and peripheral muscles. Key findings include increased insertional activity and 1+ spontaneous denervation (fibrillation potentials and positive sharp waves) in the right C6 paraspinal musculature and in the right biceps brachii, with associated mildly reduced recruitment and mild polyphasic motor unit morphology in the biceps. Other muscles sampled (right C5 and C7 paraspinals, right deltoid, right triceps, right pronator teres, right flexor carpi radialis, right abductor pollicis brevis and right first dorsal interosseous) demonstrated normal insertional activity, absence of spontaneous activity, and generally full recruitment or normal motor unit characteristics as reported (PDF page 2, PDF page 3).

7. Electrodiagnostic Interpretation and Diagnostic Impression

The interpreting physician states the nerve conduction studies of the right upper extremity are within normal limits and that the needle EMG demonstrates mild acute denervation changes localized to the right C6 myotome (right C6 paraspinals and biceps muscle) characterized by 1+ fibrillation potentials and positive sharp waves. The report explicitly documents no evidence of peripheral nerve entrapment or generalized polyneuropathy and no evidence of a more widespread cervical radiculopathy; the final electrodiagnostic diagnosis is "Mild right C6 radiculopathy, likely post‑traumatic, with electrodiagnostic evidence of acute denervation" (PDF page 3).

8. Clinical Correlation, Functional Implications, and Prognosis

The interpreting physician correlates the electrodiagnostic findings with the patient's reported symptoms of neck pain radiating to the right arm and sensory symptoms in the thumb/index distribution, consistent with a C6 radicular distribution; the report states that the mild nature of the denervation suggests a favorable prognosis for recovery with conservative management (PDF page 3).

9. Recommendations and Future Treatment Planning

The report recommends continuation of physical therapy with emphasis on cervical stabilization exercises and avoidance of provocative maneuvers (specifically repetitive neck extension and right rotation). Additional management recommendations include consideration of an epidural steroid injection if symptoms persist beyond 8–10 weeks, obtaining an MRI of the cervical spine to assess for structural abnormalities if there is no improvement within 4–6 weeks, clinical follow‑up with the referring physician in 4 weeks, and repeat EMG/NCS in approximately 3 months if symptoms persist or worsen (PDF page 4).

10. Short‑ and Long‑term Care Considerations Relevant to Life Care Planning

Given the documented mild acute denervation limited to the C6 myotome and otherwise normal peripheral nerve conduction studies, the immediate care plan should prioritize structured outpatient conservative management (targeted cervical stabilization physical therapy, activity modification) and short‑term interventional options if conservative care fails (cervical epidural steroid injection). Imaging (MRI cervical spine) is reasonable to identify surgically remediable compressive pathology if symptoms persist. Repeat electrodiagnostic testing is reasonable at roughly three months to document resolution or progression of denervation and to guide potential further interventions, including surgical referral if progressive denervation or clear structural compression is demonstrated on imaging (PDF page 4, PDF page 3).

11. Dates, Signature, and Documentation Integrity

The report is electronically signed by Dr. Michael Neuro, MD on 09/10/2025 at 15:45, and includes a license number (24680, noted as fictional on the document) in the attestation; these details are included on the attestation page (PDF page 4). The document header explicitly states that the file is a fictitious testing document; this caveat appears on multiple pages of the report and should be noted when considering admissibility or external validation (PDF page 1, PDF page 4).

12. Concise Medical History Entry for Life Care Plan

John A. Doe (DOB 01/15/1985) presented approximately six weeks after a motor vehicle collision (07/30/2025) with persistent right‑sided cervical radicular symptoms. Electrodiagnostic testing performed 09/10/2025 demonstrated normal right upper extremity nerve conduction studies but needle EMG evidence of mild acute denervation localized to the right C6 myotome (right C6 paraspinals and biceps) with 1+ fibrillation potentials and positive sharp waves, consistent with a mild post‑traumatic right C6 radiculopathy. The treating electrodiagnostic physician recommended conservative management including targeted physical therapy, activity modification, consideration of epidural steroid injection if symptoms persist, cervical MRI if no improvement in 4–6 weeks, and repeat electrodiagnostic testing in 3 months if symptoms persist (PDF page 1, PDF page 2, PDF page 3, PDF page 4).

Prepared by: [Physician Life Care Planner]. Source document: Electromyography & Nerve Conduction Study, General Teaching Hospital, 09/10/2025; original PDF viewed for this summary: Full electrodiagnostic report (PDF).

Summary of Presenting History

The patient is John A. Doe, male, DOB 01/15/1985 (age 40 at the time of evaluation), who underwent a functional capacity evaluation 10 weeks after a motor vehicle collision that occurred on 07/30/2025; these demographic and timing data are recorded on the intake face sheet of the FCE report (page 1). The evaluation was completed as a two‑day, 12‑hour FCE (6 hours per day) on 10/15/2025 (evaluation date and duration documented on the intake) (page 1). The referral source is noted as Dr. Patricia Painfree, MD (Pain Management), and the evaluation was performed by Mark Function, OTR/L (evaluating therapist) for the stated purpose of determining return-to-work capacity for a sedentary staff accountant position (page 1).

Mechanism of Injury and Initial Clinical Course

According to the FCE narrative, the patient sustained injuries in a motor vehicle accident on 07/30/2025, with documented diagnoses following the event that include surgically repaired left hip fracture, cervical strain, and lumbar strain; this history and these diagnoses are specifically recorded in the background section of the FCE report (page 1). The report indicates the patient has been participating in physical therapy and pain management programs with gradual improvement but persistent activity limitations at the time of the FCE on 10/15/2025 (page 1).

Occupational Context and Job Analysis

The FCE contains a job analysis for the claimant’s incumbent position of staff accountant, characterized as sedentary (DOT level 1). Job demands listed include prolonged computer work (6–7 hours/day), desk sitting (6–8 hours/day), occasional filing (15–30 minutes/day), walking (10–15 minutes/day), and occasional lifting of files/binders up to 20 pounds; these job demand data are recorded on the job description analysis page of the report (page 2).

Evaluation Methods and Examination Procedures

The examiner conducted a standardized, two‑day FCE using baseline testing, material handling protocols (including NIOSH-based lifting protocols), postural tolerance testing, sustained work simulation, and cardiovascular and symptom monitoring throughout; the evaluation methods are set forth in the FCE methodology section (page 2). The report documents use of pain and fatigue scales (0–10), validity indicators, and behavioral observation during testing to assess effort and reproducibility of findings (page 2).

Objective Functional Findings — Material Handling and Strength

Material handling capacity testing demonstrated the following safe maximums relative to job requirements: floor-to-waist lifting to 15 lbs (compared to job requirement 20 lbs; 75% match), waist-to-shoulder lifting to 12 lbs (job requirement 15 lbs; 80% match), overhead lifting to 8 lbs (job requirement 10 lbs; 80% match), carrying 20 lbs for 25 feet (job requirement carrying 20 lbs for 50 feet; 50% match), and pushing/pulling measured at 25 lbs force (job requirement 15 lbs force; 167% match). These data are presented in tabular form under Material Handling Capacity in the results portion of the report (page 3).

Objective Functional Findings — Postural Tolerances and Work Simulation

Postural tolerance testing revealed limitations for sustained sitting and bending/stooping: the patient tolerated 45 minutes of continuous sitting (job expectation 2–3 hours continuous; noted as Does Not Meet), 20 minutes continuous standing (meets an occasional 15-minute job requirement), and walking 200 feet without rest (meets office distances). Bending/stooping was limited to five repetitions with rest (job requirement 10 occasional repetitions; Does Not Meet). Work simulation tasks showed the patient could tolerate 45 minutes of computer work before requiring a 10‑minute break, completed filing simulation at 60% of normal pace with frequent position changes, tolerated phone work with cervical support, and required a cushioned chair and position changes every 30 minutes for meeting simulation. These postural results and simulation observations are reported in the Work Simulation and Postural Tolerances sections of the FCE (page 3).

Pain, Symptom Response, and Behavioral Observations

Pain scores (0–10) were recorded at baseline and at peak during testing: baseline pain was reported as hip 3/10, neck 4/10, and back 5/10; peak pain during testing increased to hip 6/10, neck 7/10, and back 8/10, with pain recovery time documented as 15–20 minutes between demanding tasks (page 3). Behavioral observation noted consistent and appropriate effort, occasional grimacing with movement, excellent cooperation and motivation, good safety awareness, and validity indicators consistent with valid and reliable effort during testing (page 4).

Assessment: Functional Limitations and Diagnoses

The examiner concluded the claimant demonstrates light work capacity (DOT Level 2) with primary limitations related to sustained postures (particularly sitting and bending/stating) rather than global strength deficits; this overall physical demand assessment and the attribution to postural endurance deficits are directly stated in the Assessment and Recommendations portion of the report (page 4). The working diagnoses carried forward in the functional assessment derive from the history and include post-operative left hip fracture residuals, cervical strain, and lumbar strain as limiting factors (background and summary sections) (page 1).

Recommendations, Restrictions, and Return-to-Work Plan

Specific functional restrictions recommended by the examiner include: sitting limited to maximum 45 minutes continuous with a 10‑minute break thereafter; lifting limited to 15 lbs floor-to-waist and 12 lbs waist-to-shoulder; carrying limited to 20 lbs for distances up to 25 feet; bending/stooping limited to five repetitions with rest; and avoidance of sustained downward neck gaze greater than 30 minutes. These restrictions are itemized under Specific Work Restrictions in the report (page 4).

Recommended accommodations include ergonomic workstation assessment, sit/stand adjustable desk, lumbar and cervical supports, a flexible break schedule (10 minutes every 45 minutes), assistance with filing tasks requiring bending, and a modified duty schedule beginning at 6 hours/day with progressive increase to 8 hours over four weeks. A detailed phased Return-to-Work plan is provided with week-by-week expectations (Week 1–2: 4–6 hours/day; Week 3–4: 6–7 hours/day; Week 5–8: progress to full 8-hour day) and a recommendation for re-evaluation in 8 weeks to reassess capacity; these accommodations and the RTW timetable are documented in the Recommendations and Return to Work Plan sections (page 4 and page 5).

Prognosis

The evaluator opined a fair-to-good prognosis for full return to the pre-injury sedentary job with continued rehabilitation and workplace accommodations; this prognostic statement appears in the closing assessment of the FCE and is conditional upon adherence to recommended therapy, ergonomic intervention, and graduated work exposure (page 5).

Planned and Recommended Future Treatment

The FCE recommends continuation of physical therapy with focus on postural endurance and core strengthening, referral to occupational therapy for a 2–3 week work‑hardening program, ergonomic evaluation of the actual workstation prior to return, optimization of pain management for sustained activities, education for the employee regarding pacing and self‑management, employer education regarding accommodations, and re-evaluation in 8 weeks to determine progression; these future treatment and follow-up recommendations are enumerated in the Additional Recommendations section of the report (page 5).

Documentation Quality, Limitations, and Forensic Considerations

The FCE document provides standardized, structured data regarding observable functional capabilities and symptom response with contemporaneous effort and validity statements, which support its use for functional and vocational planning; the methods, job analysis, and discrete numeric outcomes for lifting and postural tolerance strengthen objective inferences regarding work capacity (page 2, page 3, page 4).

Limitations for use in a life care plan include absence of imaging or operative reports within this FCE document (no radiographic studies or surgical reports were appended to the FCE file itself), lack of longitudinal follow-up data beyond the recommended 8-week interval, and the explicit vendor‑supplied notation that the file supplied is a fictitious testing document for software testing purposes; these constraints should be considered when assigning permanence or long‑term prognostic certainty (page 6, page 1).

Evaluator Attestation and Credentials

The FCE is signed and attested by Mark Function, OTR/L, who documents personal conduct of the two‑day evaluation and provides license/certification details (License #: OT‑55555 and CEAS certification). The completion date/time of the report is recorded as 10/15/2025, 16:00 in the Evaluator Attestation section (page 5).

Conclusions for Life Care Planning

For the purposes of a life care plan, the FCE documents current functional limitations that will reasonably justify near-term interventions: continued physical therapy focused on core and postural endurance, occupational therapy work‑hardening, ergonomic accommodations (sit/stand workstation, lumbar/cervical supports), graduated return to work with activity restrictions on sitting duration and lifting, and ongoing pain management. The FCE explicitly recommends a follow-up functional re-evaluation in 8 weeks to document response to interventions and potential expansion of work capacity; these recommendations and timelines are set forth in the report’s Return to Work Plan and Additional Recommendations (page 5).

Prepared by: [Physician Life Care Planner — reviewing clinician]. References to the primary source FCE are provided throughout the narrative using direct links to the original FCE PDF at the source repository (page 1–page 6).

Source: Emergency Department Report — General Teaching Hospital (fictional_er_report_1.pdf)

Document type and provenance: This narrative is based exclusively upon the Emergency Department Report authored and electronically signed by Dr. Sarah Medical, MD, designated as the Emergency Medicine Attending on the visit dated 07/30/2025; the document is identified within the source as a fictitious teaching document for educational purposes (page 1, page 3).

Identifying and encounter data

The patient is John A. Doe, DOB 01/15/1985, male, age 40 years at presentation (page 1). The documented emergency department arrival for the index event was 07/30/2025 at 14:30, via EMS, with the stated chief complaint of motor vehicle collision (MVC)-related injuries (page 1). The record specifically notes that the patient was the vehicle driver, struck on the driver's side, was restrained by a seatbelt, and that airbags deployed; the patient denied loss of consciousness at the scene (page 1).

History of present illness (HPI)

According to the reported history of present illness, the patient presented approximately 45 minutes after the collision with acute pain localized to the left hip, neck stiffness, and lower back pain. Pain intensity was documented as 8/10 for the left hip, 6/10 for the neck, and 7/10 for the lower back at triage and initial evaluation (page 1). The triage acuity was recorded as Level 2 (Urgent) (page 1).

Initial vital signs and general clinical status

On arrival the patient was hemodynamically stable with measured vital signs as follows: blood pressure 142/88 mmHg, heart rate 98 beats per minute, respiratory rate 20 per minute, temperature 98.6°F, oxygen saturation 98% on room air; overall pain at assessment was charted as 8/10 (page 2).

Physical examination

The physical examination documented the patient as alert and oriented to person, place and time but in moderate distress due to pain (page 2). HEENT examination showed no obvious trauma with pupils equal and reactive (page 2). Cervical spine evaluation revealed C-spine tenderness and limited range of motion without palpable step-offs; chest auscultation was clear without crepitus, and the abdomen was soft and non-tender (page 2). Pelvic compression testing was recorded as stable (page 2).

Musculoskeletal findings

Pertinent musculoskeletal findings include a shortened and externally rotated left lower extremity with severe focal tenderness over the greater trochanter and limited active range of motion due to pain; lumbar spine exam disclosed focal tenderness with paraspinal muscle spasm. Distal pulses were noted to be intact and no other extremity deformity was recorded (page 2).

Diagnostic imaging and laboratory studies

Radiographic evaluation included left hip AP and lateral views, which demonstrated a displaced intertrochanteric fracture of the left femur; cervical spine five-view radiographs revealed no acute fracture or dislocation; lumbar spine AP and lateral films showed no acute fracture but mild degenerative changes; chest radiograph was negative for pneumothorax or hemothorax (page 2).

Laboratory testing reported a CBC with white blood cell count 12.3 x10^3/µL, hemoglobin 13.8 g/dL, platelet count 285 x10^3/µL; basic metabolic panel was documented as normal and coagulation studies (PT/PTT) were within normal limits. Type and screen was performed with patient typed as O positive (page 2, page 3).

Assessment, consultations and in‑hospital disposition

The emergency clinician’s primary assessment was a left intertrochanteric femoral fracture (ICD S72.141A) with secondary diagnoses of cervical strain (S13.4XXA) and lumbar strain (S33.5XXA). The record documents an orthopedic surgery consultation requested for operative management of the hip fracture and that the patient was admitted to the orthopedic service for definitive care (page 3).

The immediate ED treatment plan included analgesia with morphine 4 mg IV every 4 hours as needed, implementation of NPO status in preparation for surgery, application of a cervical collar for comfort, venous thromboembolism prophylaxis with sequential compression devices (SCDs), and completion of preoperative laboratory testing and consent procedures prior to transfer to the orthopedic service (page 3).

Documentation and attestation

The ED attending, Dr. Sarah Medical, MD, attested to personally examining the patient and reviewing the medical record; the electronic signature block indicates completion and attestation on 07/30/2025 at 16:45 prior to admission to orthopedics (page 3). The report contains clear labeling indicating the material is a fictitious teaching document and not an actual medical record (page 1, page 3).

Diagnosis, prognosis and anticipated course of care

The definitive diagnosis established in the ED for the index injury is a displaced intertrochanteric fracture of the left femur (S72.141A) confirmed radiographically and correlated with the clinical exam (page 2, page 3). Intertrochanteric fractures in an otherwise healthy 40‑year‑old typically require operative fixation (e.g., intramedullary nail or dynamic hip screw) with anticipated inpatient hospitalization for preoperative optimization, operative repair, and short‑term postoperative care followed by an inpatient or outpatient rehabilitation course depending on perioperative recovery and comorbid factors (page 3).

Prognosis following operative fixation is generally favorable in younger patients without polytrauma, though anticipated sequelae can include pain, reduced mobility during recovery, risk of surgical complications (infection, implant failure, thromboembolism), and potential need for prolonged physical therapy to restore baseline function. The ED documentation initiated standard perioperative measures to mitigate risk, including type and screen, coagulation testing, and DVT prophylaxis strategies (page 2, page 3).

Anticipated future treatment and recommendations for life care planning

Based upon the ED diagnosis and standard orthopedic practice, anticipated future care includes: urgent operative fixation of the left intertrochanteric fracture (preoperative evaluation and optimization already initiated per the ED record), inpatient postoperative care including analgesia, early mobilization as allowed by fixation stability, pharmacologic DVT prophylaxis (e.g., low molecular weight heparin or direct oral anticoagulant per orthopedics), and prescription of a tailored physical therapy program to address strength, gait retraining, and activities of daily living (page 3, page 2).

Additional expected services for life care planning include: orthopedic follow-up visits for wound and hardware assessment, radiographic surveillance to evaluate fracture healing, outpatient physical and possibly occupational therapy, home health nursing if mobility is significantly impaired postoperatively, durable medical equipment (e.g., walker, raised toilet seat) during the recovery phase, and potential secondary interventions for complications should they arise. Preoperative and intraoperative blood availability was addressed by type and screen showing O positive, which is relevant to perioperative transfusion planning (page 3, page 2).

Summary statement

In summary, the ED record documents a 40‑year‑old male involved in a side‑impact MVC on 07/30/2025 with acute severe left hip pain and radiographically confirmed displaced intertrochanteric fracture of the left femur, accompanied by cervical and lumbar strains. He was stabilized in the ED, received analgesia orders and supportive measures, had appropriate imaging and laboratory evaluation completed, and was admitted to the orthopedic service for operative management and further inpatient care (page 1, page 2, page 3).

Prepared by: [Physician Life Care Planner], MD — medical history and ED course based on the Emergency Department Report by Dr. Sarah Medical, MD (electronic signature 07/30/2025 16:45). Source record: fictional_er_report_1.pdf (page 1 — encounter details; page 2 — vitals/exam/imaging/labs; page 3 — assessment/plan/attestation).

Medical History and Clinical Summary — John A. Doe

Source Document: Independent Medical Examination Report (IME)

Source description: Independent Medical Examination report authored by Dr. Thomas Conservative, MD (Board Certified Orthopedic Surgery) dated 11/20/2025 (IME), with review of contemporaneous records including emergency department, orthopedic operative report, rehabilitation notes, diagnostic studies, and consultation reports. See the IME cover and examinee identifiers on the source document (page 1) and physician certification (page 5).

Document retrieval: Full source IME: https://records.kaplanlifecareplan.com/files/Fake/unzipped9/ime_report_1_1.pdf (see in-document references by PDF viewer page number as linked above).

Source of Document: Independent Medical Examination Report (IME) — Kaplan Records (IME_Report_2_1.pdf)

Document type and authorship: Independent Medical Examination Report authored and electronically signed by Dr. Helen Optimistic, MD (Board Certified in Physical Medicine & Rehabilitation), dated 12/05/2025; the report is titled "Independent Medical Examination Report" and documents an examination of John A. Doe related to a motor vehicle accident on 07/30/2025 (primary source: IME cover and signature page). See the IME cover for demographics and administrative details (page 1) and the signature block (page 7).

Summary of Events and Records Reviewed

The examinee, John A. Doe, DOB 01/15/1985, age 40 at the time of the IME, was examined for injuries sustained in a motor vehicle collision occurring on 07/30/2025; the IME was performed on 12/05/2025 by Dr. Helen Optimistic, MD (report identifies the examinee demographics, date of loss and the date of examination) (page 1). The examining physician documents review of a comprehensive set of medical records, including hospital/ED records, operative reports, specialty consults, physical therapy notes, diagnostic imaging, electrophysiological testing, pain management records, a prior IME, and a functional capacity evaluation (FCE) (record review summary) (page 1, page 2).

History as Reported and Symptom Description

The examinee reported ongoing pain involving the left hip, cervical spine, and lumbar spine following the motor vehicle collision of 07/30/2025; specifically, pain intensity was recorded as hip pain 4–5/10 at rest and 7/10 with activity, neck pain 4/10 constant, and back pain 6/10 constant (patient-reported pain scores documented in the IME history) (page 2). The examiner notes inconsistencies between subjective symptom reporting and observed function, and documents behavioral observations suggestive of symptom magnification, including inconsistent pain behaviors, ability to perform activities when not observed, and discrepant gait patterns during informal versus formal observation (behavioral observations and history) (page 2).

Physical Examination Findings

On formal examination the patient was a well-appearing 40‑year‑old male, cooperative but observed to exhibit symptom magnification during testing; vital signs recorded include blood pressure 138/84 mmHg, heart rate 76 bpm, and weight 190 lbs (general appearance and vitals) (page 3). Cervical spine range of motion was documented as forward flexion 45°, extension 45°, and rotation 70° bilaterally with minimal muscle spasm and normal strength; Spurling's test was reported negative when performed without patient anticipation (cervical examination) (page 3).

Lumbar spine examination demonstrated improved range of motion compared with prior records: forward flexion to fingertips 8 cm from the floor, extension 20°, and lateral bending 20° bilaterally, with minimal paraspinal tenderness and negative straight leg raise bilaterally; neurological examination of the lower extremities was normal on testing (lumbar exam and neuro exam) (page 3).

Examination of the left hip documented excellent surgical healing, near–normal range of motion (flexion 110°, extension 15°, abduction 40°), normal strength graded 5/5 in all tested muscle groups, no Trendelenburg sign, and an overall normal gait pattern when informally observed (left hip exam) (page 3).

Diagnostic Studies and Interpretation

The IME includes review and interpretation of diagnostic imaging and electrodiagnostic testing: hip imaging reportedly demonstrates excellent healing of the fracture with appropriate hardware placement and no evidence of infection or hardware failure (hip imaging report summary) (page 4). The examiner notes only minimal expected post‑surgical changes (hip imaging) (page 4).

Lumbar MRI is reported to show disc protrusion and muscle edema, but the IME physician characterizes these findings as relatively mild and of uncertain clinical significance given the examinee's age and the frequency of such findings in asymptomatic individuals; the physician emphasizes limited clinicopathologic correlation between the imaging and the claimant's reported disability (MRI lumbar spine interpretation) (page 4).

Electrophysiological testing (EMG/NCS) reportedly shows only mild C6 radiculopathy with good potential for recovery; the IME author states that the EMG/NCS findings do not support the magnitude of disability claimed by the examinee (EMG/NCS summary) (page 4).

Functional Testing and Surveillance

The IME documents review of a functional capacity evaluation (FCE) and notes that the FCE results appeared artificially low and inconsistent with observed abilities; the examining physician comments that the examinee demonstrated poor effort and symptom magnification during the FCE (FCE interpretation) (page 4).

Additionally, the report describes surveillance video footage provided by counsel that allegedly demonstrates significantly greater functional capacity than described in medical records, including normal ambulation, lifting activities, and recreational pursuits; the IME author uses this surveillance evidence to argue discrepancy between reported and observed function (surveillance evidence) (page 2, page 4).

Medical Opinion: Causation, Maximum Medical Improvement, and Impairment

Causation: The examining physician concludes that Mr. Doe sustained legitimate injuries in the motor vehicle collision of 07/30/2025 but opines that the acute injury phase has largely resolved by 20 weeks post‑accident and that ongoing complaints are disproportionately driven by deconditioning, psychological factors, and secondary gain rather than active, unresolved pathology (causation statement; date of loss and report timeline) (page 1, page 5).

Maximum Medical Improvement (MMI): The IME author states that Mr. Doe reached MMI at approximately 12–16 weeks post‑accident and that at the time of the IME (20 weeks post‑injury) the acute healing phase is complete (MMI estimate) (page 5).

Permanent impairment: Using the AMA Guides, 6th Edition, the examining physician assigns whole person impairment estimates of 3% for the cervical spine, 2% for the lumbar spine, and 5% for the left lower extremity (hip), yielding a combined total approximate whole person impairment of 8–10% (impairment ratings) (page 5).

Functional Capacity, Work Restrictions, and Prognosis

Work capacity: The IME author opines that Mr. Doe has the physical capacity to return to his pre‑accident employment as a staff accountant without restrictions and recommends immediate return to full duty; this opinion is supported in the report by the combined evidence of objective exam findings, surveillance, and the FCE interpretation (work capacity assessment and recommendation) (page 5, page 6).

Prognosis: The examining physician gives an excellent long‑term prognosis for return to pre‑injury activities, and states that any residual symptoms are not medically justified on the basis of the reported injuries (prognosis and long‑term outlook) (page 6).

Recommended Future Medical Care and Non‑Medical Interventions

The IME concludes that no ongoing medical treatment is medically necessary specifically related to the motor vehicle accident; the examiner recommends non‑medical and rehabilitative interventions, including psychological evaluation and counseling, a supervised return to work program, and a fitness/conditioning program, and advises discontinuation of pain medications and passive treatments for the alleged accident‑related complaints (future care recommendations) (page 6).

Optional workplace accommodations are noted as not medically necessary but could include ergonomic assessment or a graduated increase in hours over 1–2 weeks if employer desires due to deconditioning following absence (workplace recommendations) (page 6).

Relevant Comparative Opinions and Discrepancies

The IME author contrasts her findings with a prior independent medical examination performed by "Dr. Conservative," noting that the prior IME allegedly over‑relied on subjective complaints and assigned higher impairment ratings without objective corroboration; the current report lists several specific discrepancies and states that prior recommendations for ongoing treatment lacked objective justification (discrepancies with prior IME) (page 6).

Formal Diagnoses as Recorded in the IME

The IME documents the following diagnoses and diagnostic impressions derived from the examination and record review: healed left hip fracture status post operative fixation with appropriate hardware and good healing, mild cervical strain with evidence of mild C6 radiculopathy on EMG, mild degenerative/protrusional lumbar findings on MRI with muscle edema but limited clinicopathologic correlation, and secondary issues regarding deconditioning and symptom magnification contributing to residual complaints (diagnostic impressions and related statements) (page 4, page 5).

Certifications, Limitations, and Forensic Considerations

The IME is electronically signed and certified under penalty of perjury by Dr. Helen Optimistic, MD on 12/05/2025; the author attests that the opinions are rendered to a reasonable degree of medical probability and are based on the totality of medical records, the in‑person examination, and ancillary data including surveillance (signature and certification) (page 7, page 1).

Summary for Life Care Planning

For the purposes of a life care plan, the IME indicates that no further accident‑specific surgical or medical interventions are recommended or required based upon current objective findings (hip hardware intact and fracture healed; no acute neurological deficits), and that recommended future needs are primarily rehabilitative and psychosocial (psychological evaluation/counseling, supervised return to work, and conditioning program) rather than ongoing invasive medical care (future care needs and rationale) (page 4, page 6).

Primary source: IME titled "Independent Medical Examination Report," examining physician Dr. Helen Optimistic, MD, dated 12/05/2025; electronic signature and certification page (page 7), demographic and exam data (page 1), history and behavioral observations (page 2), focused exam (page 3), diagnostic interpretation (page 4), and medical opinions including MMI and impairment ratings (page 5).

Medical History — Life Care Plan (John A. Doe)

Source of document: ABC Insurance Company — Medical Necessity Review / Utilization Review (insurance_review_1.pdf)

Nature of source: This report is an insurer-conducted medical necessity/utilization review (prospective utilization review) authored by Dr. Cost Saver, MD, board-certified in Physical Medicine & Rehabilitation, dated 12/15/2025, and documenting a utilization review of requested services submitted by treating providers (request dated 12/10/2025) for claimant John A. Doe; see the cover and administrative information (claimant identifiers, reviewer, review dates) on page 1 and the reviewer certification on page 7.

Summary of presenting problem and administrative data: John A. Doe (DOB 01/15/1985) is the claimant in this file (policy WC-123456789, claim CL-2025-789456) who sustained injuries in a motor vehicle collision with an acknowledged date of loss of 07/30/2025; these identifying data and the review timeframe are documented on page 1 and reiterated in the clinical summary and record inventory on page 3. The utilization review was completed 12/15/2025 and the request for pre-authorization was submitted by the treating physician (Dr. Patricia Painfree, MD) on 12/10/2025; these dates and the reviewer are reported on page 1.

Mechanism of injury and primary diagnoses: The claimant sustained injuries in a motor vehicle collision on 07/30/2025 resulting in a surgically repaired left hip fracture, cervical strain, and lumbar strain; the insurer’s clinical summary listing these diagnoses and the date of injury is on page 3. The report notes that the hip fracture underwent surgical fixation with "excellent healing" on follow-up assessment; see the clinical summary and rationale for MMI on page 3 and page 6.

Timeline and prior treatment: Over the 20-week review period (07/30/2025 through 12/10/2025) the claimant received a comprehensive course of conservative and interventional care, including 36 sessions of outpatient physical therapy over approximately 12 weeks, a lumbar epidural steroid injection on 09/25/2025, multiple specialist consultations, and a complete diagnostic workup that included radiography, MRI, and electrodiagnostic testing; these services and the record inventory are summarized on page 3 and the specific treatment requests and dates are described on page 2 and page 4.

Presenting clinical status and functional examination: At the time of the review the claimant is described as ambulatory with intermittent cane use and improved pain scores, with pain having decreased from an initial 9/10 to a current 4–6/10; this clinical status and the functional capacity evaluation demonstrating a light work classification are documented in the clinical summary and follow-up status on page 3 and in the recommendations on page 6.

Pertinent diagnostic studies: The insurer references an initial lumbar MRI dated 09/15/2025 that demonstrated mild disc protrusion, and electrodiagnostic testing (EMG/NCS) that showed only mild radiculopathy; these specific imaging and electrodiagnostic interpretations that inform the utilization decision are noted on page 4 and the record inventory of diagnostic studies is listed on page 3.

Interventions rendered and response: The claimant completed an extended course of structured physical therapy (36 sessions) and received a transforaminal epidural steroid injection at L4–L5 on 09/25/2025, the latter of which produced temporary symptomatic relief according to the record summary; these facts and the dates of intervention are recorded on page 2 and the treatment response is summarized on page 4.

Consultation and specialty evaluations: The reviewed documentation includes multiple specialist consultations, pain management evaluation and injection records, independent medical examinations (two IMEs), a neuropsychological evaluation, and a vocational rehabilitation assessment; the insurer’s inventory reflecting these consultative data and the total pages reviewed (247 pages) is documented on page 3.

Insurer’s medical necessity determinations (summary)

The reviewing physician applied evidence-based guidelines (including ACOEM and workers’ compensation treatment guidelines) in making specific denials: additional physical therapy was denied on the grounds that the claimant had completed 36 sessions over a 12–week period with plateaued gains; repeat lumbar MRI was denied because the initial MRI (09/15/2025) showed only mild protrusion and no progressive neurologic deterioration; an additional L4–L5 transforaminal epidural steroid injection was denied based on prior limited and temporary benefit and guideline-based limits on repeat injections; and requested psychotherapy was denied because the neuropsychological evaluation did not recommend ongoing psychotherapy and symptoms were characterized as reactive—these determinations and the applied review criteria are detailed on page 4 and the specific treatment request list (with CPT codes and dates) is on page 2.

The insurer documented that the review covered 247 pages of medical documentation spanning 07/30/2025 through 12/10/2025 and that the review applied national guidelines and peer-reviewed literature in making the above medical necessity determinations; see the records reviewed and methods on page 3 and the review criteria on page 4.

Prognosis, maximum medical improvement (MMI), and disposition

The reviewer concluded that the claimant had reached Maximum Medical Improvement (MMI) as of the review date 12/15/2025 and cited the timing (20+ weeks post-injury), radiographic/surgical healing of the hip, resolution of expected soft-tissue injury, plateau of objective gains, and concordant independent medical examinations as supporting evidence; the MMI opinion and supporting rationale are stated on page 6 and the reviewer certification and date appear on page 7.

Recommended disposition by the reviewer included closure of the active medical treatment phase, initiation of permanent impairment/permanent disability evaluation as appropriate, vocational/return-to-work planning consistent with a light-duty functional capacity classification, and reliance on a home exercise and self-management strategy in lieu of additional provider-based interventions; these recommended actions and alternatives to the denied requests are described on page 5 and page 6.

Future treatment plan considerations for life care planning

Based on the insurer’s documentation and the claimant’s clinical course, the reasonable components of an ongoing care plan (consistent with the insurer’s recommendations) include structured self-directed conditioning/home exercise with periodic supervised reassessment, primary care or physiatry follow-up at routine intervals, continued analgesic medication management as previously prescribed, and facilitation of graded return-to-work and work conditioning per the documented light-duty capacity; these recommended elements are enumerated as alternatives on page 5 and the return-to-work rationale is on page 6.

Contingent interventions that should remain in the life care plan as conditional items (medical necessity contingent upon new clinical findings) include: repeat advanced imaging (MRI) only if there is new or progressive neurologic deficit or objective change from baseline (the insurer specifically denied routine repeat MRI absent change: see page 4), and consideration of additional interventional pain procedures only if there is demonstrable functional deterioration or objective findings supportive of a pain generator not amenable to conservative measures (the insurer noted limited evidence supporting repeated injections and referenced prior injection on 09/25/2025 that produced temporary benefit: page 2, page 4).

Psychosocial considerations

Although the insurer denied ongoing psychotherapy (noting that the neuropsychological evaluation did not recommend it and characterizing symptoms as reactive), the record does document reported depression and anxiety related to chronic pain in the treatment request; the treating request for 8 sessions of individual psychotherapy and the insurer’s rationale for denial are on page 2 and page 4. For life care planning purposes, a conditional allocation for brief evidence-based psychological intervention (cognitive behavioral therapy or pain-coping skills training) is reasonable to include if functional impairment attributable to mood or pain-related disability persists despite primary interventions; the insurer suggests community resources as alternatives (see page 5).

Limitations of the source and appeals information

This source is an insurer-generated utilization review document (explicitly marked as a medical necessity review and, in this fictional file, for software testing purposes); it provides summary conclusions and administrative denials but is not a substitute for the primary treating clinicians’ contemporaneous examination notes, operative reports, or the full diagnostic imaging and electrodiagnostic reports. The appeal rights and timelines for dispute (internal appeal within 30 days and external appeal thereafter) are described on page 6, and the reviewer’s certification including name and date are on page 7.

Forensic and life care planning implications — expert opinion summary

In preparing a life care plan, the treating record summary and the insurer’s utilization review should be integrated such that medically necessary, evidence-based, and individualized ongoing needs are projected while recognizing the insurer’s determination that active in-office rehabilitation and additional injections or repeat imaging are not presently supported by documented medical necessity. Specifically, beyond the MMI determination dated 12/15/2025 (page 6), the life care plan should conservatively include periodic physician follow-up, maintenance-level home exercise and conditioning, ongoing analgesic medications where indicated, workplace accommodations consistent with light-duty functional capacity (per the FCE), and conditional or contingency items (repeat MRI, interventional pain procedures, structured psychotherapy) that are triggered only by new objective findings or documented functional deterioration (see the insurer’s alternatives and rationale on page 5 and denials on page 4).

Final comment: The insurer's utilization review provides a comprehensive administrative assessment and denial rationale authored by Dr. Cost Saver, MD (12/15/2025). Any life care plan or expert opinion intended for adjudicative or compensation purposes should explicitly reference the primary treating records and diagnostic reports in addition to this utilization review, and should document objective findings that would meet accepted criteria for escalation of care should such findings emerge after the review period; the administrative and reviewer statements are cited on page 1, page 3, and page 7.

Document reference: ABC Insurance Company — Medical Necessity Review / Utilization Review, insurance_review_1.pdf (review completion 12/15/2025); original file available at https://records.kaplanlifecareplan.com/files/Fake/unzipped9/insurance_review_1.pdf.

Medical History and Diagnostic Summary for Life Care Planning

Source of the document: MRI Lumbar Spine Report (complete PDF)

The primary source for the following medical history is an institutional radiology report titled "MAGNETIC RESONANCE IMAGING - LUMBAR SPINE" (an MRI Lumbar Spine report), interpreted and electronically signed by Dr. Lisa Radiology, MD on 09/15/2025 as documented in the file (see page links: page 1, page 4).

Summary of Presenting History

The patient is a 40-year-old male, John A. Doe, born 01/15/1985, who presented with persistent lower back pain following a motor vehicle accident occurring approximately six weeks prior to the imaging study; this clinical history is documented on the radiology intake (see page 1). The referring clinician is Dr. Amanda Rehab, MD (Physical Medicine & Rehabilitation), per the study requisition (see page 1).

Pertinent Clinical History and Symptoms

The recorded clinical history indicates persistent lower back pain rated 6/10 with associated paraspinal muscle spasms, exacerbation with prolonged sitting and forward flexion, and reported partial improvement with physical therapy but a plateau in progress; the intake specifically notes no radicular symptoms or neurologic deficits at the time of imaging (see page 1). The record additionally documents that the patient sustained a surgically repaired left hip fracture and cervical strain as part of the same mechanism of injury (see page 1).

Physical Examination and Clinical Correlation (as documented)

The radiology report itself does not contain an extended physical examination but documents the absence of objective neurological deficit and the presence of symptomatic paraspinal spasm on the referring history (see page 1). Clinical correlation by the treating clinician was recommended in the report to determine whether the imaging findings correspond to the patient’s symptoms (see page 3).

Diagnostic Study Details and Technique

The diagnostic study is an MRI of the lumbar spine performed on a 3.0 Tesla magnet without intravenous contrast on 09/15/2025; multiplanar sequences included sagittal T1, sagittal T2, sagittal STIR, axial T2 through the lumbar discs, and axial T1 through symptomatic levels, as documented in the examination technique (see page 2). The study date and times of dictation and transcription are explicitly recorded (study performed and report dictated/transcribed on 09/15/2025; see page 1, page 4).

Imaging Findings — Detailed

Global spinal alignment is maintained and vertebral heights are preserved without evidence of acute compression fracture or osseous abnormality; bone marrow signal is normal throughout (see page 2, page 3).

At the intervertebral disc levels: L1–L2 and L2–L3 demonstrate normal disc height and signal without bulge or herniation (see page 2). L3–L4 demonstrates mild loss of disc height and decreased T2 signal consistent with early degenerative disc disease with a small central disc bulge and no significant canal or foraminal stenosis recorded (see page 2).

The L4–L5 level demonstrates more pronounced degenerative change with moderate loss of disc height and decreased disc signal, broad-based posterior disc bulge and a superimposed right paracentral disc protrusion. The report documents mild bilateral facet arthropathy, mild ligamentum flavum thickening, small bilateral facet joint effusions, and mild central canal narrowing at this level; the right paracentral protrusion contacts but does not significantly compress the right L5 nerve root. Bilateral foraminal narrowing at L4–L5 is described as mild (see page 2, page 3).

The L5–S1 disc is reported as preserved in height and signal without significant bulge or herniation (see page 3). Paraspinal soft tissues demonstrate mild edema and inflammatory change, most prominent at L4–L5 and consistent with acute paraspinal muscle strain/spasm (see page 3).

Radiologic Impression

The official radiologic impression enumerates: (1) acute paraspinal muscle strain with edema most prominent at L4–L5 consistent with post‑traumatic change; (2) L4–L5 right paracentral disc protrusion contacting, but not significantly compressing, the right L5 nerve root (which may be post‑traumatic or represent exacerbation of preexisting degenerative change); (3) mild degenerative disc disease at L3–L4 and L4–L5 with facet arthropathy; and (4) no radiographic evidence of spinal fracture or other acute osseous injury (see the formal impression on page 3).

Recommendations Recorded in the Report

The interpreting radiologist recommended conservative management including continuation of physical therapy and anti‑inflammatory medications, consideration of an epidural steroid injection at L4–L5 should symptoms persist or worsen, neurosurgical consultation if neurologic symptoms develop, and repeat MRI in 3–6 months if there is no clinical improvement. The report additionally suggested a functional capacity evaluation to assist with return-to-work planning (see page 4).

Working Diagnoses for Life Care Planning

Based on the radiologic findings and the provided clinical history, the following diagnoses should be incorporated into the life care plan: (A) acute paraspinal muscle strain with focal edema at L4–L5 (post‑traumatic), (B) L4–L5 right paracentral disc protrusion abutting the right L5 nerve root without significant compression, (C) mild multilevel degenerative disc disease (notably L3–L4 and L4–L5) with facet arthropathy, and (D) sequelae of motor vehicle collision including related left hip fracture repair and cervical strain as documented in the intake history (see page 1, page 3).

Prognosis (Clinical Opinion)

The immediate prognosis for resolution of acute paraspinal muscle strain is favorable with adherence to conservative measures (activity modification, structured physical therapy, anti‑inflammatory medication and symptomatic care), as suggested by the radiology report’s recommendation (see page 4). However, the presence of an L4–L5 disc protrusion contacting the right L5 nerve root places the patient at risk for development of radicular symptoms (sciatica) or progressive neurologic deficit; although the report documents no current significant nerve compression, close clinical monitoring is warranted (see page 3).

Anticipated Future Treatment Needs and Follow-up

Short-term management recommendations include continuation and potential escalation of rehabilitative therapy, a trial of non‑steroidal anti‑inflammatory medication and muscle relaxants, and close outpatient follow-up with the referring PM&R physician (see page 4). If symptoms persist or radicular features develop, the following are reasonable next steps: targeted lumbar epidural steroid injection at L4–L5 with image guidance, diagnostic/therapeutic facet injections given facet arthropathy at L4–L5, repeat MRI in 3–6 months to document interval change, and neurosurgical consultation if neurologic deficit or progressive radiculopathy occurs (see page 4).

Rehabilitation, Functional Assessment, and Work Considerations

The report explicitly suggests that a formal functional capacity evaluation may inform return-to-work planning; this should be scheduled in coordination with the treating PM&R physician and physical therapy team to quantify residual impairment and functional limitations attributable to the lumbar pathology and post‑traumatic muscle strain (see page 4).

Limitations and Recommendations for Documentation

This radiology report provides anatomic and pathoanatomic detail but does not substitute for a contemporaneous clinical neurological examination, electromyography (if indicated for radicular pain), or interventional treatment notes. Correlation with outpatient clinic notes, physical therapy documentation, procedural records (e.g., epidural injections), and any subsequent imaging is required to build a comprehensive life care plan and to quantify future care needs and likely frequency of interventions (see the technique and clinical correlation statements in the report: page 2, page 3).

Documentation and Authorship

The findings and recommendations above are derived from the institutional MRI report generated 09/15/2025 and electronically signed by Dr. Lisa Radiology, MD; the file records dictation at 14:30 and electronic signature at 16:20 on 09/15/2025 (see page 4 and page 1). The radiology report is explicitly labeled as a diagnostic radiology interpretation and contains the interpreting physician’s attestation (see page 4).

Conclusions for Inclusion in the Life Care Plan

For life care planning purposes, the following elements should be included: (1) short-term conservative care (PT, medications, activity modification); (2) potential interventional procedures (epidural steroid injections and/or facet injections targeted to L4–L5) if symptoms fail to improve; (3) monitoring by PM&R and possible neurosurgical referral if neurologic signs develop; (4) repeat imaging (MRI) in 3–6 months if clinically indicated; and (5) functional capacity testing to quantify work capabilities and restrictions (see recommendations: page 4, and imaging impressions: page 3).

I have based the above medical history and plan summary solely upon the supplied MRI report and its internal clinical history. Additional treating clinician notes, objective neurologic examinations, procedure records, physical therapy notes, and subsequent imaging would refine prognostic estimates and resource utilization projections.

Document source references (PDF viewer page numbers): MRI report intake, demographics and clinical history (see page 1); MRI technique and initial findings including L1–L2 through L4–L5 descriptions (see page 2); L5–S1, paraspinal edema, impression and clinical correlation (see page 3); and formal recommendations, attestation and signature (see page 4).

Source: Neuropsychological Evaluation Report (neuropsych_eval_1.pdf)

Document description: The source document is a formal Neuropsychological Evaluation Report prepared by Dr. Michelle Mindful, Ph.D., a licensed clinical psychologist with specialization in neuropsychology and chronic pain psychology, completed on 11/15/2025; this evaluation is titled "NEUROPSYCHOLOGICAL EVALUATION REPORT" and clearly identifies the patient as John A. Doe (DOB 01/15/1985) and the reason for referral as cognitive assessment post-trauma (page 1, page 6, page 7).

I. Pertinent demographic and event history

The patient is a 40‑year‑old, right‑handed male, John A. Doe (DOB 01/15/1985), with a bachelor’s degree in accounting who underwent neuropsychological testing on 11/15/2025 after sustaining injuries in a motor vehicle collision that occurred on 07/30/2025 (page 1, page 2). Pre‑morbid functioning is documented as high school and college completion with continuous employment for >15 years in accounting and no prior neurologic disease, learning disability, or substance abuse history (page 2).

II. History of present illness and symptoms

The referral indicates cognitive complaints beginning after the motor vehicle collision of 07/30/2025, with the patient reporting difficulty sustaining attention for >15–20 minutes, frequent forgetfulness for recent events, slowed mental processing described as "fog," word‑finding difficulty, impaired mental arithmetic/numerical processing, and intolerance for prolonged reading or complex multitasking (page 1, page 2).

III. Current medications and factors affecting cognition

The record lists active pain medications that have well‑recognized cognitive side effects: tramadol 50 mg every 6 hours PRN (patient reports taking 3–4 times daily) and gabapentin 600 mg three times daily, as well as tizanidine 4 mg twice daily; these agents are explicitly noted in the report as contributors to sedation, confusion, and memory impairment (page 2, page 3). Additional non‑analgesic medications include lisinopril 15 mg and omeprazole 20 mg; melatonin 3 mg is used PRN for sleep (page 3).

IV. Behavioral observations and exam-like findings

During the testing sessions (total testing time 4.5 hours over two sessions), the patient was cooperative, appeared alert but fatigued with prolonged tasks, requested repetition of instructions, self‑corrected with additional time, and required frequent breaks for pain; the examiner explicitly documents good effort and no evidence of malingering (page 1, page 3).

V. Neuropsychological testing — instruments and pertinent results

The battery included Wechsler Adult Intelligence Scale–IV (WAIS‑IV), Wechsler Memory Scale‑IV (WMS‑IV), Trail Making Test A and B, Stroop Color‑Word, PASAT (2‑second), and standard mood inventories; testing was administered by Dr. Mindful on 11/15/2025 (page 1, page 3).

Intellectual functioning: WAIS‑IV Full Scale IQ = 108 (70th percentile, Average), Verbal Comprehension = 115 (84th percentile, High Average), Perceptual Reasoning = 112 (79th percentile, High Average), Working Memory = 95 (37th percentile, Average), and Processing Speed = 88 (21st percentile, Low Average) — these values are documented in the intellectual functioning table (page 3).

Memory: WMS‑IV Auditory Memory = 92 (30th percentile, Average), WMS‑IV Visual Memory = 98 (45th percentile, Average), WMS‑IV Immediate Memory = 96 (39th percentile, Average), and WMS‑IV Delayed Memory = 89 (23rd percentile, Low Average), demonstrating relative weakness in delayed retrieval (page 3, page 4).

Attention and executive function measures indicate deficits in sustained attention and mental flexibility: Trail Making Test A = 38 seconds (25th percentile, Low Average), Trail Making Test B = 95 seconds (16th percentile, Below Average), Stroop Color‑Word T‑score = 42 (20th percentile, Below Average), and PASAT (2‑second) = 35/60 correct (15th percentile, Below Average) (page 4).

Mood and pain questionnaires: Beck Depression Inventory‑II score = 18 (mild to moderate depression), Beck Anxiety Inventory score = 15 (mild anxiety), and Pain Catastrophizing Scale score = 28 (moderate catastrophizing); the clinical interview documented sleep disturbance with awakenings 3–4 times nightly, social withdrawal, and frustration about cognitive changes (page 4).

VI. Interpretation and diagnostic impressions

The examining psychologist concludes that the pattern of cognitive strengths and weaknesses is most consistent with the combined effects of chronic pain, disrupted sleep, depressive symptoms, and medication side effects rather than a primary neurodegenerative disorder; global intellectual abilities remain in the average range with selective deficits in processing speed, complex working memory, sustained attention, executive flexibility, and delayed memory retrieval (page 5, page 4).

The report explicitly identifies contributing factors: (1) chronic pain as a persistent distractor, (2) medication effects of gabapentin and tramadol causing cognitive slowing, (3) sleep disruption negatively impacting attention and memory, (4) depression/anxiety compounding cognitive inefficiency, and (5) physical deconditioning (page 5).

VII. Functional impact and work‑related implications

Based upon the cognitive profile and the patient’s pre‑injury occupational demands as a staff accountant, the examiner opines that the documented deficits (slowed processing speed, difficulty sustaining attention, impaired mental arithmetic and numerical processing, and executive dysfunction) would significantly interfere with core job functions such as sustained concentration, complex financial calculations, multitasking, and management of multiple deadlines (page 2, page 5).

VIII. Diagnoses (impression)

The report documents the following working clinical impressions: cognitive disorder secondary to medical condition/consequences of chronic pain and medications with coexisting depressive and anxiety symptoms; specific neuropsychological deficits include slowed processing speed, attention/executive dysfunction, and reduced delayed memory retrieval — the examiner’s formal diagnostic labels and differential are described in the summary and interpretation section (page 5).

IX. Prognosis

Prognostically, the examiner indicates that cognitive limitations are at least partially reversible/modifiable with targeted interventions — specifically by optimizing analgesic regimen to reduce sedating medications, improving sleep architecture, treating mood symptoms, engaging in cognitive rehabilitation, and physical reconditioning; repeat neuropsychological testing in approximately 6 months is recommended to document recovery trajectory or need for ongoing accommodations (page 6, page 5).

X. Recommended treatment plan, follow‑up, and accommodations

Immediate and near‑term recommendations include: comprehensive medication review with the prescribing clinician to minimize cognitive side effects (noting tramadol and gabapentin specifically), formal sleep study referral to address awakenings 3–4 times nightly, and cognitive behavioral therapy for chronic pain and depression (page 6, page 3).

Neurorehabilitation recommendations enumerated by the examiner include attention training, compensatory strategies, memory enhancement techniques and external aids, processing speed training programs, and executive function skills remediation. Workplace accommodations recommended to facilitate return to work include reduced initial hours (4–6 hours/day), frequent breaks every 30–45 minutes, simplification of tasks, use of calculators and computerized aids for numeric tasks, written instructions and checklists, and a quiet workspace to minimize distraction (page 6).

Follow‑up testing is advised at approximately 6 months post‑evaluation to quantify change and guide modification of rehabilitation or vocational accommodations (page 6).

XI. Consultations, documentation and attestations

The neuropsychological examination was conducted personally by Dr. Michelle Mindful, Ph.D., and the report is signed and dated 11/15/2025 with license number PSY‑999999 (noted as fictional for this test document); the examiner’s specialization in neuropsychology and chronic pain psychology is included in the report (page 6, page 7).

XII. Summary for life care planning considerations

For life care planning, the record documents a clearly articulated causal exposure (motor vehicle collision 07/30/2025) temporally preceding the onset of persistent pain, sleep disruption, depressive symptoms, and objectively measured cognitive deficits on standardized testing conducted 11/15/2025; these findings support the need for ongoing multidisciplinary management including medication optimization, targeted cognitive rehabilitation, psychological treatment, sleep medicine evaluation, and workplace accommodations in the short to intermediate term (page 1, page 5, page 6).

Specifically, life care considerations should account for: periodic physician consultations for pain medication management and potential substitution of non‑sedating alternatives (given tramadol 50 mg and gabapentin 600 mg TID are documented contributors), provision of formal cognitive rehabilitation services (attention, processing speed, memory and executive function remediation), psychotherapy for mood and pain catastrophizing (BDI‑II = 18; PCS = 28), a sleep medicine evaluation, vocational rehabilitation and modified duty or part‑time work capacity (recommendation of 4–6 hours/day with frequent breaks), and follow‑up neuropsychological reassessment in ~6 months to quantify recovery and ongoing accommodation needs (page 3, page 4, page 6).

Report prepared from the cited neuropsychological evaluation document and reflects the findings and recommendations contained therein (Dr. Michelle Mindful, Ph.D., Neuropsychological Evaluation, 11/15/2025). Source document pages cited above correspond to the sequential PDF viewer page numbers of the source file: pages 1–7 (page 1, page 2, page 3, page 4, page 5, page 6, page 7).

Medical History — Orthopedic Consultation Summary

Source document: Orthopedic Surgery Consultation (General Teaching Hospital)

Nature of source: Emergency Department orthopedic surgery consultation completed and electronically signed by Dr. Robert Boneman, MD, documenting evaluation of a traumatic left intertrochanteric femur fracture after a motor vehicle collision; consultation dated 07/30/2025 (see source). For primary source images, refer to the document pages provided below: page 1, page 2, page 3, page 4.

Patient identifiers: The consulting record identifies the patient as John A. Doe, date of birth 01/15/1985 (age 40 years at time of consult), male, MRN 1234567890; these demographic data are documented on the consultation cover page (page 1). The consultation was requested by the Emergency Department and was performed by Dr. Robert Boneman, MD on 07/30/2025 with a recorded time of 18:15 (page 1).

History of Present Illness and Mechanism

History of present illness: The patient is described as a 40-year-old male involved in a motor vehicle collision on the date of consultation; specifically the patient reports being struck on the driver's side, wearing a seatbelt, with airbag deployment and no loss of consciousness, and onset of severe left hip pain and inability to bear weight on the left lower extremity (documented in the HPI) (page 1). The record documents additional complaints of neck and back pain but no prior hip problems and baseline full ambulatory status prior to the event (page 1).

Pertinent Past Medical, Surgical, Social and Family History

Past medical history: The consultation documents a history of hypertension that is reported as controlled, as well as a prior appendectomy in 2010; current outpatient medication includes lisinopril 10 mg daily and no known drug allergies (NKDA). Social history indicates occasional alcohol use and non-smoking status; family history notable for paternal osteoarthritis (all items recorded on the PMH section) (page 2).

Physical Examination

Examination findings relevant to the orthopaedic injury: On exam the patient was noted to be alert and cooperative but in moderate distress due to pain. The left lower extremity was short and externally rotated, with marked tenderness over the greater trochanter and groin and severely limited passive range of motion due to pain; no open wounds were identified (page 2). Neurovascular status of the limb was documented as intact with palpable dorsalis pedis and posterior tibial pulses and preserved motor (toe wiggle, dorsiflexion/plantarflexion) and light touch sensation (page 2).

Imaging and Radiographic Interpretation

Radiographic assessment: Emergency department anterior-posterior and lateral radiographs of the left hip demonstrate a displaced intertrochanteric fracture of the proximal femur, with the fracture line extending from just below the greater trochanter obliquely across to the lesser trochanter region; there is approximately 15 mm of shortening and lateral displacement of the distal fragment, without extension into the femoral neck as noted in the report (page 2). The fracture is classified in the note as an AO/OTA 31-A2.2, an unstable intertrochanteric fracture pattern (page 2). Additional imaging reviewed included chest and cervical spine radiographs which were reported as without acute abnormality (page 2).

Assessment and Working Diagnoses

Primary diagnosis: The consultant rendered the primary diagnosis as a displaced, unstable left intertrochanteric femur fracture, coded as S72.141A in the record (page 3). The clinical assessment integrates the mechanism, exam, and radiographic findings to conclude an unstable trochanteric pattern in a young, previously ambulatory adult (page 1).

Plan, Surgical Recommendations and Immediate Preoperative Management

Surgical recommendation: Given the displaced and unstable nature of the intertrochanteric fracture in an otherwise healthy, relatively young patient, the attending recommended operative fixation with open reduction and internal fixation using a cephalomedullary nail (CMN) to provide stable fixation and permit early mobilization; this is documented in the surgical plan section (page 3).

Immediate preoperative orders and logistics: The record documents preoperative recommendations that include NPO status in anticipation of surgery the following morning, continuation of IV analgesia as needed, mechanical DVT prophylaxis with sequential compression devices, initiation of pre-operative medical clearance, and that informed consent for surgery was obtained and documented (items enumerated in the Immediate Management section) (page 3).

Operative scheduling: The operative time was scheduled in the record as 08:00 on 07/31/2025 (the day after the consultation), and the plan anticipated early postoperative mobilization and initiation of physical therapy on postoperative day 1 with expected hospital length of stay of two to three days barring complications (page 3).

Surgical Consent and Risk Discussion

Informed consent: The chart documents that the risks, benefits, and alternatives were discussed with the patient and documented, including infection, hemorrhage, nerve injury, nonunion, malunion, hardware failure, the potential need for revision surgery, and anesthesia-related risks; the record indicates patient understanding and agreement to proceed (page 3).

Attestation, Signature and Document Validity

Attestation: The attending orthopedic surgeon, Dr. Robert Boneman, MD, attested to having personally examined the patient and reviewed the medical record and imaging studies; the consultation is electronically signed with date/time 07/30/2025, 18:15 and is recorded on the attestation page of the document (page 4). The consult forms contain explicit labels that this is a fictitious testing document; however, the clinical content is recorded in standard consult format and is used here solely as the source for the medico-legal life care planning exercise (page 1, page 4).

Prognosis and Anticipated Course

Short-term prognosis: Given the fracture pattern (AO/OTA 31-A2.2, unstable intertrochanteric fracture) and the plan for cephalomedullary nailing in a previously healthy 40-year-old, the anticipated short-term course is operative fixation with early mobilization and physical therapy beginning on postoperative day 1, with an expected 2–3 day initial hospitalization if uncomplicated (page 3).

Medium- and long-term prognosis: In this age group and with modern intramedullary fixation, the prognosis for fracture union is generally favorable, but the unstable fracture pattern confers increased risk for mechanical complications (e.g., varus collapse, limb shortening, screw cut-out) and potential need for revision ORIF or arthroplasty if fixation fails or nonunion/malunion occurs. These risks were explicitly discussed with the patient as part of consent (page 3).

Anticipated Future Treatments, Rehabilitation and Recommendations for Life Care Planning

Surgical and perioperative needs: Anticipated needs include operative fixation with a cephalomedullary nail (documented recommendation), operating room time and associated perioperative anesthesia and medical clearance, inpatient postoperative care including pain control, DVT prophylaxis, wound care, and infection surveillance (all items are referenced in the Immediate Management and Surgical Plan sections) (page 3).

Rehabilitation: Physical therapy beginning on postoperative day 1 with progressive weight-bearing as tolerated with a walker is anticipated in the inpatient setting, transitioning to outpatient physical therapy focused on gait training, strengthening, range of motion, and progressive return to activities; these expectations are explicitly stated in the Expected Course section of the consult (page 3).

Contingent and potential future interventions: Given the unstable intertrochanteric pattern and the documented 15 mm shortening with lateral displacement, the life care plan should include contingency provisions for complications such as hardware failure, nonunion, malunion, or post-traumatic osteoarthritis that may necessitate prolonged rehabilitation, revision surgery, or conversion to femoral arthroplasty in the medium to long term; these potential complications were enumerated in the consent and risk discussion (page 3).

Follow-up and Documentation Recommendations

Recommended follow-up: Postoperative clinical and radiographic follow-up is required to confirm fracture reduction and progression to union, with typical postoperative clinic visits at 2 weeks for wound check, 6 weeks, 3 months, and as indicated thereafter. The initial consultation documents scheduling of definitive operative fixation on 07/31/2025 at 08:00; the life care plan should require documentation of the operative report, anesthesia record, inpatient notes, and subsequent outpatient orthopedic and physical therapy notes to fully define long-term impairment and need for durable medical equipment or home health services (page 3, page 4).

Summary and Expert Opinion

In summary, this emergency orthopedic consultation documents a displaced, unstable left intertrochanteric femur fracture (AO/OTA 31-A2.2) in a previously ambulatory 40-year-old male after a motor vehicle collision, with physical findings of limb shortening and external rotation, neurovascularly intact distal limb, and radiographs demonstrating 15 mm shortening and lateral displacement; the attending recommended operative stabilization with a cephalomedullary nail and planned surgery for 07/31/2025 with initiation of early postoperative mobilization and therapy (page 1, page 2, page 3).

For purposes of life care planning, the above-documented consultation provides the baseline clinical, radiographic, and operative intent information. Definitive estimation of long-term care needs, durable medical equipment, home modification, long-term physical therapy, chronic pain management, and potential future surgical procedures requires review of the operative report, immediate postoperative inpatient course, and serial follow-up clinic and imaging records; those subsequent documents should be linked to this consultation record for continuity of care and accurate life care cost projections (page 3, page 4).

Document citation: General Teaching Hospital — Department of Orthopedic Surgery, Orthopedic Surgery Consultation for John A. Doe; consultation dated 07/30/2025, electronically signed by Dr. Robert Boneman, MD (see original source): page 1, page 2, page 3, page 4.

Medical History and Examination — Life Care Plan Addendum

Source: Pain Management Consultation Report (full source)

Nature of source document: Pain Management Consultation report authored by Dr. Patricia Painfree, MD (Pain Management & Anesthesiology), consisting of a comprehensive outpatient consultation dated 09/20/2025 (consultation documented on page 1 of the PDF) and associated plan and follow-up documentation (pages 1–5). See original report: page 1.

I. Summary of Presenting History

The patient, John A. Doe (DOB 01/15/1985), presented to the General Teaching Hospital Pain Management Center for a consultation documented on 09/20/2025 (consultation date and attending physician listed on page 1). The history reports a motor vehicle accident (MVA) that occurred on 07/30/2025 with subsequent surgical repair of a left intertrochanteric hip fracture on 07/31/2025; these dates and the mechanism are recorded in the HPI (see page 1 and page 2).

II. Pain Complaints and Functional Impact

At the time of consultation (09/20/2025), the patient reported persistent multi-site pain 8 weeks after the MVA and surgical intervention (duration and reason for consult documented on page 1 and page 2), specifically left hip, cervical (neck), and lumbar spine symptoms. Pain descriptors and intensity are recorded as: hip deep-aching 3–4/10 at rest and 6–7/10 with activity; neck baseline 4/10 and movement-provoked 7/10; lumbar baseline 6/10 and activity-provoked 8–9/10 (numeric ratings and descriptors on page 2). Average daily pain was 6/10 with worst daily pain up to 9/10 (documented on page 2).

The pain significantly impacted sleep, with the patient reporting awakening 3–4 times nightly due to pain, mood disturbance with a PHQ‑9 score of 12 (moderate depressive symptoms), and marked functional limitations including inability to sit at a computer >30 minutes and inability to return to work (sleep, mood, and functional impact recorded on page 2).

III. Prior and Current Treatments

Prior to the consultation the patient had trialed pharmacologic and rehabilitative measures including tramadol, ibuprofen, cyclobenzaprine, acetaminophen, and ongoing physical therapy with minimal improvement reported over the preceding month (medication and prior treatments listed on page 1 and page 3). The current medication list at consultation documented tramadol 50 mg q6h PRN (taking 3–4 times per day), ibuprofen 600 mg TID with food, cyclobenzaprine 10 mg at bedtime, and acetaminophen 1000 mg twice daily; lisinopril 10 mg daily for hypertension is also listed (current medications and dosing on page 3). Prior opioid exposure was limited to intra/post‑operative morphine; no chronic opioid therapy prior to the accident is documented (prior opioid history on page 3).

IV. Review of Systems and Objective Examination

Review of systems was notable for intermittent right thumb/index finger numbness consistent with a C6 radiculopathy and fatigue secondary to sleep disturbance; other systems were largely noncontributory (ROS documented on page 3).

Vital signs at the consultation were recorded as blood pressure 145/90 mmHg, heart rate 88 beats per minute, temperature 98.6°F, and weight 185 lbs (vital signs documented on page 3). Gait was slightly antalgic with use of a cane for distances >100 feet (gait and assistive device on page 3).

Focused musculoskeletal and neurologic examination revealed limited cervical range of motion with paraspinal tenderness and a negative Spurling’s test; lumbar examination demonstrated visible paraspinal muscle spasm, limited flexion, and a positive straight leg raise at 60° on the right (cervical and lumbar exam findings on page 3). Left hip exam noted a well‑healed incision, flexion limited to 90°, and tenderness over the greater trochanter (hip findings on page 4). Motor testing demonstrated 5/5 strength throughout except for left hip flexors and extensors which were 4/5; sensory deficit in the right C6 distribution was documented (strength and sensation on page 4).

V. Diagnostic Impressions and Clinical Diagnoses

The consulting physician recorded the following primary diagnoses: (1) chronic post‑traumatic multi‑site pain syndrome, (2) post‑surgical hip pain with functional limitation, (3) post‑traumatic cervical strain with C6 radiculopathy, (4) post‑traumatic lumbar strain with L4‑L5 disc protrusion, and (5) pain‑associated sleep disturbance and mood changes. These diagnostic statements and their hierarchy are explicitly listed in the assessment section of the consultation (diagnoses on page 4).

VI. Interventional and Medication Management Plan

The plan included interventional procedures directed at the lumbar spine and hip: a lumbar epidural steroid injection at L4–L5 was scheduled for 09/25/2025 (procedure scheduling documented on page 4), with consideration of a cervical epidural injection if neck symptoms persist, and consideration of a greater trochanteric bursa injection for persistent hip pain (interventional plan documented on page 4).

Medication adjustments were carefully delineated: continuation of tramadol 50 mg q6h PRN with reassessment after procedures, initiation of gabapentin 300 mg TID with titration to 600 mg TID over two weeks for neuropathic pain, continuation of ibuprofen with gastroprotection via omeprazole 20 mg daily, replacement of cyclobenzaprine with tizanidine 4 mg BID for muscle relaxation, and a short prednisone taper at 20 mg daily for five days for acute inflammation (medication management and dosing on page 4).

VII. Non‑pharmacologic Interventions, Follow‑up, and Rehabilitation Plan

The multidisciplinary plan emphasized continued and targeted rehabilitation: continuation of physical therapy with a focus on functional restoration, addition of occupational therapy for work conditioning, referral to psychology for pain coping strategies and mood support, and consideration of a TENS unit trial (non‑pharmacologic interventions on page 4).

Follow‑up scheduling included return in two weeks after the epidural injection, a functional capacity evaluation (FCE) in 4–6 weeks, a target goal to wean off daily opioids within 8 weeks, and a return‑to‑work evaluation in 6–8 weeks (follow‑up timeline and goals on page 5). Sleep hygiene counseling and patient education (including expected magnitude of improvement and instructions for gabapentin) were also documented (education and counseling on page 5).

VIII. Prognosis

The prognosis as implied by the consulting document is guarded but potentially favorable with multimodal care. The report sets a realistic target of approximately 50% pain reduction and delineates staged interventions (interventional procedures, neuropathic medication titration, structured rehabilitation, and behavioral health support) as the path to functional restoration (prognostic expectations and goals on page 5).

The presence of ongoing neuropathic features (burning back pain, positive SLR, and documented C6 sensory deficit), moderate depressive symptoms (PHQ‑9 = 12), and significant sleep disruption are negative prognostic factors that increase the likelihood of protracted recovery and need for sustained multidisciplinary care (PHQ‑9 and symptom burden on page 2; neurologic findings on page 4).

IX. Anticipated Future Medical Needs Relevant to a Life Care Plan

Based on the consultation, anticipated ongoing and future services likely to be required include: targeted interventional pain procedures (e.g., lumbar epidural steroid injections at L4–L5 with potential repeat administration, possible cervical epidural if symptoms persist, and greater trochanteric bursa injection for refractory hip pain) as documented in the interventional plan (procedural plan on page 4).

Pharmacologic management anticipated in the short‑ to medium‑term includes gabapentin titration to a neuropathic analgesic dose (up to 600 mg TID), continuation of non‑opioid analgesics with gastroprotection (ibuprofen + omeprazole), short course steroids for flares, and close monitoring of tramadol use with an explicit goal of opioid wean within 8 weeks (medication plan and wean goal on page 4 and page 5).

Rehabilitation needs include continued outpatient physical therapy emphasizing progressive loading and functional restoration, occupational therapy for work conditioning and activities of daily living, formal FCE to inform return‑to‑work restrictions, and referral to behavioral health for cognitive‑behavioral interventions targeting pain coping and mood (rehabilitation and referral plan on page 4 and page 5).

Additional supportive measures likely to be required include assistive devices for ambulation as needed (cane use for >100 ft documented), possible durable medical equipment for mobility during early recovery, home exercise programs, sleep hygiene interventions, and potential longer‑term specialty care if neuropathic or radicular symptoms persist (cane use documented on page 3; sleep counseling on page 5).

X. Summary and Recommendations for Life Care Plan Documentation

In summary, the Pain Management Consultation (Dr. Patricia Painfree, MD; consultation dated 09/20/2025) documents an 8‑week post‑MVA clinical course with multi‑site musculoskeletal and neuropathic pain, objective exam findings of reduced hip range and strength, cervical and lumbar findings consistent with radiculopathy and disc protrusion, substantive sleep disturbance, and psychosocial impact (consultation and HPI on page 1, symptom quantification and PHQ‑9 on page 2, exam and assessment on page 3 and page 4).

For inclusion in a formal life care plan, the following should be itemized and costed with timelines and frequency consistent with the treating clinician’s plan: scheduled and potential repeat interventional procedures (lumbar epidural at L4–L5, possible cervical epidural, trochanteric bursa injection), gabapentin therapy with monitoring and titration, short‑term corticosteroid for flares, non‑opioid analgesics with gastroprotection, targeted PT and OT sessions, behavioral health visits, TENS/DME trial, FCE and return‑to‑work evaluation, and follow‑up visits at the intervals specified (procedural schedule and follow‑up on page 4 and page 5).

XI. Attestation

The consulting note is electronically signed by Dr. Patricia Painfree, MD on 09/20/2025 and contains the clinician’s attestation that the patient was personally examined and that the assessment and plan represent the clinician’s recommendations (physician attestation and signature on page 5 and consultation header on page 1).

Document reference: General Teaching Hospital — Pain Management Consultation (PDF pages 1–5). Complete source: https://records.kaplanlifecareplan.com/files/Fake/unzipped9/pain_management_1.pdf.

Source Document: Richard Skeptical, M.D. — Expert Medical Opinion on Causation (pmr_expert_con_1.pdf)

The following medical history and synthesis are prepared from the referenced expert report, a defense‑retained causation opinion authored by Richard Skeptical, M.D., Board‑Certified in Physical Medicine & Rehabilitation (opinion dated 01/20/2026) (see source identifying data on page 1 and the expert certification on page 10). This document is titled an “EXPERT MEDICAL OPINION ON CAUSATION” and is explicitly identified as a fictitious testing document in its header (page 1).

Case Identifying History and Source Description

The patient is identified as John A. Doe, DOB 01/15/1985, who is reported to have sustained injuries in a motor vehicle collision on 07/30/2025; these demographic and incident data are recorded in the expert report header (page 1). The expert opinion provided is dated 01/20/2026 and was prepared for the defense (opinion and retaining party documented on page 1 and again in the certification section on page 10).

Records Reviewed and Nature of the Source Material

The author reports a comprehensive review of a complete medical record (noted as >525 pages) that includes emergency department records, operative reports, rehabilitation and physical therapy records, pain management documentation, neurologic evaluations, imaging studies with independent radiological review, neuropsychological testing, functional capacity evaluation, and vocational assessments; the scope of review is explicitly enumerated in the materials reviewed section (page 2). The report also documents review of objective evidence such as surveillance footage, independent medical examinations, accident reconstruction, and vehicle damage assessments (page 2 and page 3).

Mechanism of Injury — Accident Reconstruction and Biomechanics

The report contains a critical biomechanical analysis concluding the collision was of moderate rather than high energy; described vehicle damage patterns and reconstruction data are used to estimate peak accelerations of approximately 8–10 G and a delta‑V of approximately 12–15 mph, with preservation of the occupant compartment and no B‑pillar intrusion (page 3). These engineering assessments are cited by the author to argue that forces were insufficient to produce the extensive injury pattern attributed to the accident by plaintiff experts (page 3).

Summary of Presenting Clinical Course and Reported Symptoms

According to the report, the patient experienced onset of symptoms after the collision; however, the author asserts the trajectory of symptoms is inconsistent with typical post‑traumatic recovery, noting that purported symptoms have remained static or worsened over >24 weeks rather than showing expected improvement within 12–16 weeks for common soft tissue injuries (page 4 and page 9). The report further documents persistent pain complaints despite apparently successful surgical management of a hip fracture (reported as healed), limited and transient benefit from pain interventions, and minimal objective improvement with extensive physical therapy (page 5 and page 9).

Pertinent Objective Findings: Imaging, Electrodiagnostics, and Surgical Course

Imaging review documented multilevel degenerative disc disease with disc height loss at L3‑L4 and L4‑L5, facet arthropathy and vertebral endplate changes consistent with chronic degenerative processes rather than acute traumatic disc disruption (lumbar MRI findings described on page 4). The report additionally notes “mild EMG findings” that are characterized as not sufficiently concordant with severe functional deficits (page 5). The hip fracture was surgically managed; the author states the fracture has healed without complication and that radiographic/surgical outcomes should not explain ongoing severe functional limitation (page 5 and page 9).

Functional Assessments and Surveillance Evidence

The author places emphasis on objective audiovisual surveillance evidence, describing observed activities inconsistent with the claimant’s reported limitations: continuous sitting for >90 minutes at a sporting event (contradicting reported 45‑minute tolerance), repeated lifting of 25–30 lb objects (exceeding a claimed 15‑lb limit), prolonged standing/yard work >90 minutes, ladder climbing and overhead reaching, and an essentially normal gait without consistent use of assistive device (page 5 and page 6). The report asserts behavioral inconsistency (cane used primarily in medical settings) and concludes the surveillance materially undermines the claimant’s subjective disability assertions (page 6).

Consultations, Rehabilitation, and Response to Treatment

The report documents multiple domains of care having been rendered: emergency treatment, operative management of the hip fracture, multiple rehabilitation and physical therapy episodes, and interventional pain management procedures; the author reports that extensive physical therapy produced minimal objective gains and that pain interventions provided only temporary relief, which the author interprets as inconsistent with ongoing significant organic pathology (page 2 and page 5).

Diagnostic Impressions and Forensic Differential Diagnosis

The author’s diagnostic synthesis attributes the claimant’s ongoing clinical state primarily to pre‑existing degenerative spinal disease, deconditioning, psychological overlay with potential symptom magnification, and secondary gain related to litigation, while recognizing that the hip fracture itself was accident‑related but has healed and thus should not account for persistent severe limitation (page 4, page 5, and page 9). The author also explicitly lists alternative causation theories—including pre‑existing asymptomatic disease, deconditioning syndrome, secondary gain, and psychological overlay—and places these high in the differential (page 8 and page 9).

Prognosis

Utilizing current literature, the author states that minor soft tissue injuries would be expected to resolve within 12–16 weeks and that cervical strain usually recovers in approximately 3 months in most patients; the report cites literature‑based expectations (e.g., 85% recovery for cervical strain within 3 months, 90% good functional recovery by 6 months after hip fracture) to support an overall favorable prognosis for recovery when deconditioning/psychological factors are addressed (page 8 and page 9). The author ultimately opines that the accident caused only minor soft tissue injury and that the claimant should achieve substantial symptomatic and functional recovery with appropriate rehabilitation (page 9 and page 10).

Recommended Future Treatment and Life Care Implications

The author’s explicit recommendations for immediate management include discontinuation of passive modalities (continued injections and ongoing passive PT), institution of an aggressive reconditioning program, psychological evaluation to address symptom magnification, and return‑to‑work planning with minimal accommodations; these recommendations are intended to remediate deconditioning and psychological overlay and are itemized in the recommendations section (page 10). The author further recommends minimal future medical care limited largely to routine annual follow‑up for the surgically repaired hip and standard age‑appropriate care, and estimates future medical costs in the range of $5,000–$10,000 over the lifetime (page 10).

Work Capacity and Functional Prognostication

The expert opines that the claimant is capable of a full‑time return to pre‑accident employment with no permanent restrictions required and that a gradual supervised return may be useful primarily to reverse deconditioning; the author sets an anticipated timeframe for functional recovery of 6–8 weeks following appropriate rehabilitation interventions (page 10).

Forensic Considerations and Reported Limitations of Opposing Opinions

The report contains a critical appraisal of the plaintiff’s retained expert (identified as Dr. Causation in the report), listing methodological concerns such as overreliance on subjective complaint, misinterpretation of imaging, biomechanical overestimation, and failure to address surveillance evidence; the author concludes the opposing opinion reflects advocacy rather than balanced medical analysis (page 7). These forensic critiques are used to support the defense‑oriented causation conclusion contained in this file (page 7).

Synthesis for Life Care Planning Purposes

For purposes of preparing a life care plan, the report posits a low future medical resource demand related to the accident: routine hip surveillance, primary care preventive measures, and an emphasis on rehabilitative services (intensive reconditioning and psychological intervention) rather than continuing specialty interventional procedures. The document explicitly quantifies lifetime future medical cost estimates at $5,000–$10,000, a figure that would inform projected future medical expenditures if the report’s causation and prognosis conclusions are accepted (page 10).

Limitations of the Source and Final Expert Certification

The report is presented as an expert opinion by Richard Skeptical, M.D., and the author signs a certification attesting to holding opinions to a reasonable degree of medical certainty dated 01/20/2026; the report is, however, clearly marked as a fictitious testing document for software validation in multiple locations, which must be considered when weighing the literal applicability of the document to actual clinical decision‑making (page 1 and page 10).

Concluding Statement

In summary, this expert record attributes the claimant’s ongoing functional status predominantly to pre‑existing degenerative spinal disease, deconditioning, and psychological/secondary gain factors, with the motor vehicle collision of 07/30/2025 characterized as producing only minor soft tissue injury and an acutely managed hip fracture that has since healed; these principal conclusions and their supporting documentary citations are contained throughout the report (key identifiers and dates on page 1, record review and evidence types on page 2, biomechanical analysis on page 3, imaging discussion on page 4, surveillance and functional contradictions on page 5 and page 6, literature‑based recovery expectations on page 8, and final recommendations and cost estimates on page 10).

Document reference: Richard Skeptical, M.D., Expert Medical Opinion on Causation (defense‑retained), dated 01/20/2026; full source file available here: pmr_expert_con_1.pdf (see page 1 and see page 10).

Source Document: DAVID CAUSATION, M.D. — Expert Medical Opinion on Causation (Full PDF)

This medical history and summary is derived from the Expert Medical Opinion on Causation authored by David Causation, M.D., a Board‑Certified Physical Medicine & Rehabilitation physician, dated 01/15/2026 and contained within the supplied PDF source (primary source document) (see page 1). The document is expressly titled an expert causation opinion and lists the retained party as plaintiff’s counsel (page 1).

Summary of Source Content and Nature of Document

The source is an expert medico-legal causation report by Dr. David Causation summarizing a comprehensive review of medical records (over 525 pages according to the report), independent medical examinations, diagnostic studies, and ancillary expert reports; the author provides an opinion that the subject’s current medical conditions were directly and proximately caused by a motor vehicle collision that occurred on 07/30/2025 (page 1), and that this opinion is offered to a reasonable degree of medical certainty (page 9).

Identifying and Administrative Details

Patient identifiers provided in the report include the name John A. Doe and date of birth 01/15/1985 (fictional data for testing), and the date of injury is recorded as 07/30/2025 (page 1), with the expert opinion dated 01/15/2026 (page 1).

History of Present Illness (HPI) and Pre‑accident Baseline

According to the expert’s review, the patient was entirely asymptomatic prior to the collision and had minimal medical issues: no prior back pain, no prior neck complaints, no hip problems, no chronic pain, no psychiatric diagnoses, and no relevant substance abuse history; the report specifically characterizes the patient as a healthy, high‑functioning 40‑year‑old with active recreational activities and full employment prior to the event (page 3). The expert lists only controlled essential hypertension and a remote appendectomy in 2010 as pertinent pre‑existing medical items (page 3).

Accident Mechanism and Biomechanics

The collision is described as a left‑side lateral impact to the subject’s vehicle at approximately 35–40 mph resulting in substantial lateral acceleration and multi‑vector loading of the occupant; an accident reconstructionist provided quantitative estimates including peak lateral acceleration of approximately 12–15 G and a delta‑V of approximately 18–22 mph, with the principal direction of force left lateral (page 4). The expert correlates these forces mechanistically with the injury pattern observed in this case (page 4).

Initial Clinical Presentation and Records Reviewed

Dr. Causation reports that he reviewed a comprehensive set of medical records (over 525 pages), including complete emergency department records from the date of injury 07/30/2025, orthopedic operative reports, comprehensive rehabilitation medicine notes, physical therapy documentation, pain management consults and injections, neurological evaluations with EMG/NCS, and all diagnostic imaging (X‑ray, MRI, CT) among other items (page 2).

Pertinent Diagnostic Studies and Objective Findings

The report documents objective findings across multiple modalities: imaging and clinical correlation demonstrate a left intertrochanteric femoral fracture (status post surgical repair noted in the record), MRI evidence of an L4–L5 disc protrusion, and electrodiagnostic confirmation of a C6 radiculopathy; the expert specifically cites EMG/NCS abnormalities consistent with C6 nerve root injury (page 7, page 2).

Interventions, Consultations, and Follow‑up Visits

The expert’s materials review includes operative orthopedic reports documenting surgical fixation of the left intertrochanteric fracture and subsequent orthopedic follow‑up, multiple physical therapy episodes (approximately 16 weeks documented), pain management consultations including injection procedures, and ongoing rehabilitation medicine and mental health treatment records; these records are enumerated in the materials reviewed section (page 2).

Current Diagnoses Attributed to the Collision

On the basis of the record review, the expert attributes the following primary diagnoses to the motor vehicle collision: (1) post‑traumatic left hip dysfunction secondary to a left intertrochanteric fracture status post surgical repair with developing post‑traumatic arthritic change; (2) post‑traumatic cervical radiculopathy due to C6 nerve root injury as documented by EMG/NCS; and (3) post‑traumatic lumbar disc syndrome with an L4–L5 disc protrusion demonstrated on MRI (page 7). Secondary diagnoses include chronic multi‑site pain (central sensitization), post‑traumatic stress disorder and depression related to the event, and objective cognitive dysfunction reported on neuropsychological testing (page 7).

Temporal Relationship and Causation Rationale

Dr. Causation emphasizes a tight temporal relationship between the collision of 07/30/2025 and the immediate onset of symptoms, with no antecedent history of the described problems; he further states that the observed injury pattern is biomechanically consistent with the left lateral impact forces and that no reasonable alternative etiology is present in the pre‑accident medical history (pages 4–5).

Responses to Competing Opinions and Functional Evidence

The author critiques defense‑oriented IME opinions (specifically Dr. Helen Optimistic) on the basis of perceived inadequate examination duration and selective evidence review, and he interprets surveillance evidence as inconsistent with sustained work‑level function; these counterarguments are outlined in the report (page 6).

Prognosis and Anticipated Clinical Course

The expert assigns a guarded long‑term prognosis: chronic pain syndrome is described as likely permanent, post‑traumatic arthritis is expected to progress, psychological sequelae may require long‑term management, and the subject’s work capacity is likely to remain significantly limited relative to pre‑injury function; these prognostic conclusions are explicitly stated in the report (page 8).

Recommended Future Medical Care and Life Care Elements

Dr. Causation outlines long‑term care needs anticipated as a direct consequence of the collision: ongoing orthopedic surveillance for post‑traumatic arthritis, continued pain management interventions (including medication management and potential interventional procedures), consideration of future surgical interventions (including potential hip arthroplasty and possible spinal fusion), ongoing physical therapy/rehabilitation, psychological counseling for PTSD and depression, and neurological follow‑up for the C6 radiculopathy; these planned care items are enumerated in the report (page 8).

Estimated Medical Costs (As Reported by the Expert)

The report provides estimated ranges for future medical expenditures: immediate future care (five years) is projected at approximately $150,000–$200,000, and lifetime medical costs are estimated in the range of $500,000–$750,000; these figures are intended to encompass medications, therapy, procedures, and potential surgeries (page 8).

Final Causation Opinion and Certification

Dr. Causation concludes, under penalty of perjury and to a reasonable degree of medical certainty, that all of the subject’s present medical conditions are directly and proximately caused by the motor vehicle collision of 07/30/2025, that there were no significant pre‑existing conditions contributing to the current disability, and that lifelong medical care will be required; the formal certification and signature block appear in the document (page 9).

Limitations of Source Material and Forensic Considerations

The primary document is an expert opinion and not a primary contemporaneous hospital chart; although it reports review of extensive records (>525 pages) and cites objective test results, the opinion necessarily synthesizes third‑party records rather than reporting original bedside findings. For independent life care planning, each element recommended should be cross‑referenced to the original contemporaneous operative, imaging, and electrodiagnostic reports contained in the underlying medical record set enumerated by the expert (page 2).

Conclusions for Life Care Planning

Based on the expert’s synthesis, the life care planner should incorporate the following core elements into the life care plan: (1) ongoing orthopedic follow‑up and imaging surveillance for post‑traumatic hip arthritis with potential progression to total hip arthroplasty; (2) multidisciplinary chronic pain management including pharmacotherapy, interventional procedures, and periodic functional re‑evaluation; (3) continued spinal care for symptomatic L4–L5 disc disease with consideration of progressive conservative management and surgical options if clinically indicated; (4) psychological and neuropsychological services for PTSD, depression, and cognitive dysfunction; and (5) vocational rehabilitation and durable medical equipment or home modification needs as indicated by objective functional assessments — all recommendations are consistent with the expert’s stated future care needs (page 8).

References to Source Pages

Primary report pages referenced in this summary: page 1 (administrative and case identification, including DOB and injury date), page 2 (materials reviewed—records inventory), page 3 (pre‑accident medical history), page 4 (accident mechanism and biomechanics), page 5 (temporal relationship and mechanism consistency), page 6 (analysis of defense IME and surveillance), page 7 (current diagnoses and objective findings), page 8 (future care and prognosis, cost estimates), and page 9 (final causation opinion and expert certification) (page 1, page 2, page 3, page 4, page 5, page 6, page 7, page 8, page 9).

Prepared by: Physician Life Care Planner — based upon and citing the expert report of David Causation, M.D. (Expert Medical Opinion on Causation) dated 01/15/2026 (page 9), and the record inventory referenced therein (page 2).

Source Document: Comprehensive Psychological Evaluation — Behavioral Health Associates (psych_eval_1.pdf)

Medical History: Psychological Evaluation — John A. Doe

This medical history is prepared from a single-source comprehensive psychological evaluation prepared by Dr. Emily Mental, Psy.D., completed 12/20/2025, titled "COMPREHENSIVE PSYCHOLOGICAL EVALUATION" (document header and signature), which is available in full as the source file (see source document page 1 and attestation on page 8). (pdf page 1) (pdf page 8).

Identifying Information and Source Description

The evaluation document identifies the patient as John A. Doe (fictional), date of birth 01/15/1985 (age 40 at evaluation), male, married; the evaluation was completed on 12/20/2025 and was performed by Dr. Emily Mental, Psy.D., at Behavioral Health Associates, Comprehensive Psychological Services. (pdf page 1) The report header and signature block (attestation) corroborate the date of completion and clinician identification. (pdf page 8).

Referral, Reason for Evaluation, and Index Event

The evaluation was performed at the request of the referring physician (Dr. Patricia Painfree, MD) for post‑trauma psychological assessment following a motor vehicle accident that occurred on 07/30/2025, with the express referral questions including current mental health status, impact of chronic pain on psychological functioning, presence of trauma-related conditions, and capacity for return to work. (pdf page 1) (pdf page 1 — referral questions).

History of Present Illness

The patient reports significant psychological distress that began after the motor vehicle collision on 07/30/2025; he endorses persistent depressed mood, anxiety, sleep disturbance, irritability, and social withdrawal, and specifically describes feeling "like a different person" since the accident. (pdf page 1) (pdf page 2 — presenting problems).

The evaluation documents vivid recollection of the impact and immediate aftermath of the index trauma with some avoidance of driving (particularly highway travel), nightmares about the accident (1–2 times/week), intrusive memories, hypervigilance, and anticipatory anxiety about pain exacerbations; these trauma-related symptoms are explicitly referenced as part of the mental status and diagnostic impressions. (pdf page 2 — trauma history) (pdf page 4 — sleep/nightmares).

Relevant Past Psychiatric, Medical, and Social History

The record states no prior mental health treatment, no prior psychiatric medications, no history of substance abuse treatment, and no psychiatric hospitalizations; family history is notable for maternal anxiety treated with medication. (pdf page 2 — psychiatric and family history).

Socially, Mr. Doe is married (12 years) with two children (ages 8 and 6), previously active in community sports and with close coworker relationships prior to the accident; since the accident he reports social withdrawal and reduced participation in recreational activities. (pdf page 3 — social history).

Mental Status Examination and Observations

Mental status examination documented in the source indicates an appropriately dressed but tired and somewhat disheveled male with minimal eye contact, cooperative but uncomfortable behavior, monotone speech, dysthymic and restricted affect, mood described as "depressed and frustrated", linear and goal-directed thought processes, preoccupation with pain and disability, passive death wishes without active suicidal ideation, and cognition alert and oriented ×3 with mild recent memory impairment. (pdf page 4 — mental status exam).

Pertinent Psychological Testing and Objective Findings

Formal psychometric testing was administered and documented. On self-report measures the patient scored Beck Depression Inventory–II = 28 (moderate depression), Beck Anxiety Inventory = 22 (moderate anxiety), PTSD Checklist for DSM‑5 (PCL‑5) = 35 (meets threshold for probable PTSD), Pain Catastrophizing Scale = 34 (high catastrophizing), Pain Disability Index = 42 (severe disability), Chronic Pain Acceptance Questionnaire = 28 (low acceptance), and SF‑36 Mental Component = 32 (significant impairment). (pdf page 4 — psychometrics table).

The MMPI‑2‑RF profile is described as valid with elevations in Depression (T = 75), Anxiety (T = 68), and Somatic Complaints (T = 72) and no evidence of symptom exaggeration or malingering; the profile is interpreted as consistent with genuine psychological distress and significant concerns related to chronic pain and medical symptom reporting. (pdf page 5 — MMPI‑2‑RF results).

Functional Impact

Occupationally, Mr. Doe is reported as unable to return to work as a staff accountant due to concentration difficulties (unable to focus on complex tasks for more than 15–20 minutes), heightened anxiety about performance, and financial stressors that exacerbate mood symptoms. (pdf page 5 — occupational functioning).

Socially and in activities of daily living he demonstrates significant withdrawal, decreased motivation for self‑care, increased reliance on his spouse for daily tasks, cessation of recreational sports participation, and observable strain in family relationships with children noting changes in his affect. (pdf page 5 — social/ADL impact).

Diagnostic Impressions

The evaluating clinician assigned the following primary DSM‑5‑TR diagnoses: Major Depressive Disorder, single episode, moderate (296.22); Generalized Anxiety Disorder (300.02); Post‑Traumatic Stress Disorder (309.81); and Psychological Factors Affecting Other Medical Conditions (316) related to chronic pain and catastrophizing. (pdf page 6 — diagnostic impressions).

The report explicitly links the onset of mood and anxiety symptoms to the motor vehicle collision of 07/30/2025 and documents criteria met for Major Depressive Disorder (6 of 9 criteria cited), probable PTSD based on re‑experiencing, avoidance, negative alterations in cognition/mood, and hyperarousal, and generalized anxiety with excessive, difficult‑to‑control worry present since the incident. (pdf page 6 — diagnostic rationale) (pdf page 1 — index trauma date).

Treatment Recommendations and Follow‑Up

Immediate recommendations include initiation of weekly individual psychotherapy using cognitive behavioral therapy tailored to chronic pain and trauma, referral for psychiatric medication evaluation for antidepressant therapy, structured sleep hygiene interventions, and enrollment in a specialized pain psychology program. (pdf page 7 — immediate interventions).

Specialized modality recommendations include EMDR for trauma memory processing, Acceptance and Commitment Therapy (ACT) to improve pain acceptance and psychological flexibility, Mindfulness‑Based Stress Reduction (8‑week program), and couples counseling to address familial strain; group support (chronic pain and depression support groups) is also recommended. (pdf page 7 — specialized and group interventions).

Return‑to‑work guidance provided in the report indicates Mr. Doe is not psychologically ready to resume occupational duties at the time of evaluation, with a recommended course of 3–6 months of psychological treatment prior to work trial, gradual re‑entry with workplace accommodations (reduced hours and complexity), and ongoing psychological follow‑up during the transition. (pdf page 7 — return to work considerations).

Prognosis

The clinician characterized short‑term prognosis (3–6 months) as fair to good with appropriate psychological interventions, noting expected improvements in mood, anxiety and sleep; PTSD symptoms may require longer course of therapy. (pdf page 8 — short‑term prognosis).

Long‑term prognosis (6–24 months) is described as good given strong pre‑morbid functioning, family support, and treatment motivation, but the report cautions that chronic pain and financial stressors may maintain or exacerbate depressive symptoms and that ongoing pain management and psychological care will likely be needed. (pdf page 8 — long‑term prognosis).

Summary Statement and Implications for Life Care Planning

In summary, the contemporaneous psychological evaluation dated 12/20/2025 documents moderate major depressive disorder, generalized anxiety disorder, probable PTSD, and psychological factors adversely affecting medical conditions in the setting of post‑traumatic chronic pain following a motor vehicle collision on 07/30/2025; objective psychometric scores (BDI‑II = 28, BAI = 22, PCL‑5 = 35, Pain Disability Index = 42, PCS = 34, CP Acceptance = 28, SF‑36 Mental = 32) and MMPI‑2‑RF elevations corroborate clinically significant affective, anxiety, trauma, and somatic symptom burden. (pdf page 1 — eval date/DOB/index trauma) (pdf page 4 — psychometric scores) (pdf page 5 — MMPI‑2‑RF).

For life care planning purposes, the evaluation supports the need for short‑ and long‑term psychological services (CBT, trauma‑focused therapy such as EMDR, ACT, mindfulness groups), psychiatric medication management as indicated, enrollment in pain psychology or multidisciplinary pain rehabilitation programs, family or couples therapy, and workplace accommodations with a graduated return to work; these services should be included in the plan and provisioned over the recommended 3–24 month horizon with ongoing re‑evaluation. (pdf page 7 — recommendations) (pdf page 8 — prognosis).

Clinician Attestation and Document Integrity

The evaluation is signed and attested by Dr. Emily Mental, Psy.D., License #: PSY‑777777 (fictional), dated 12/20/2025; the document header denotes Behavioral Health Associates, Comprehensive Psychological Services. The record contains a clear statement that the materials are fictitious for software testing in this dataset, but for purposes of this history the contents of the evaluation have been abstracted verbatim from the source pages referenced here. (pdf page 8 — attestation) (pdf page 9 — end of document).

This medical history is prepared to inform life‑care planning and medico‑legal opinion and is based solely upon the referenced comprehensive psychological evaluation (psych_eval_1.pdf). Any recommendations for additional medical or psychiatric records, medication lists, or objective medical testing should be obtained to supplement this psychiatric summary where necessary. (pdf page 1 — source).

Prepared by: Physician Life Care Planner — Medical history abstraction from source evaluation. Source document: Comprehensive Psychological Evaluation (psych_eval_1.pdf).

Source: Physical Therapy Initial Evaluation (John A. Doe) — Kaplan Lifecare Records

Document type and nature: This report is the Physical Therapy Initial Evaluation for John A. Doe, created by Rehabilitation Services — Physical Therapy at a General Teaching Hospital. The specific document title is "PHYSICAL THERAPY INITIAL EVALUATION" and the evaluation is dated 08/18/2025 on PDF page 1. The record is explicitly labeled as a software testing/fictitious data document in the header and footer (page 1, page 5).

Demographic and Administrative Data

Patient identifiers on the evaluation include the name John A. Doe (noted as fictional), date of birth 01/15/1985 (age recorded as 40 years), sex male, and MRN 1234567890; these demographics are documented on PDF page 1.

Referral, Orders, and Stated Diagnoses

The patient was referred by Dr. Amanda Rehab, MD (PM&R), with a referral date of 08/15/2025; the written diagnosis on the referral and initial evaluation is "S/P left hip ORIF, cervical strain, lumbar strain" and the therapy order specifies evaluation and treat x 6–8 weeks with precautions of weight-bearing as tolerated (WBAT) on the left lower extremity (page 1).

Index Event and Operative History

The history indicates a motor vehicle collision occurring on 07/30/2025 with subsequent operative fixation for a left intertrochanteric hip fracture performed on 07/31/2025, described in the subjective history as "3 weeks status post left intertrochanteric hip fracture with ORIF" (page 1).

Subjective Complaints and Functional Goals

At the time of the evaluation the patient reported ongoing left hip pain and stiffness with resting pain documented as 4–5/10 and activity-related pain 7/10 (page 1). Additional subjective complaints included neck stiffness and pain (4/10 constant) and lower back pain (6/10, worse with sitting). The patient reported an inability to return to prior activities and specified functional goals of ambulating without an assistive device, returning to work as an accountant, resuming playing tennis, and independence with activities of daily living (page 1).

Objective Examination — Range of Motion and Spinal Mobility

Objective range-of-motion (ROM) measurements documented on the evaluation include left hip flexion 85° versus right 115° (normal 0–120°), left hip extension −5° versus right 15° (normal 0–20°), left hip abduction 25° versus right 45° (normal 0–45°); cervical rotation recorded as 60° bilaterally (normal 0–80°) and cervical flexion 35° (normal 0–50°). Lumbar flexion was recorded as fingertips 15 cm from the floor (limited) rather than fingertips to floor; these values are recorded on PDF page 2.

Objective Examination — Strength Testing

Manual muscle testing (MMT) is documented using a 0–5 scale. Left hip and thigh musculature demonstrated weakness compared with the right: hip flexors left 4/5 (right 5/5), hip extensors left 3+/5 (right 5/5), hip abductors left 3/5 (right 5/5), quadriceps left 4−/5 (right 5/5), and hamstrings left 4/5 (right 5/5). These findings are recorded in the strength table on PDF page 2.

Functional Assessment and Gait Analysis

The functional assessment documents that the patient is independent with bed–chair transfers but requires minimal assistance for car transfers; ambulation was limited to approximately 100 feet with a walker prior to fatigue, and the gait is antalgic with decreased weight-bearing on the left, shortened left stance phase and a Trendelenburg pattern. Gait speed was measured at 0.4 m/s (characterized in the note as severely impaired; normal >1.2 m/s). Stairs were not assessed because the patient was not ready. These functional details are listed on PDF page 3.

Special Tests, Incision Status, and Neurologic Exam

Selected special tests and wound inspection are recorded as follows: a positive Thomas test on the left consistent with hip flexor tightness; straight leg raise tests were negative bilaterally; lumbar extension was limited. Neurologic screening reported intact sensation and symmetric deep tendon reflexes graded 2+ bilaterally. The surgical incision was described as well-healed without signs of infection and only minimal swelling. These items are documented on PDF page 3.

Physical Therapy Assessment and Clinical Impression

The treating therapist assigned a primary PT diagnosis of "impaired physical function secondary to left hip fracture status post ORIF with associated cervical and lumbar strain." The listed impairments included decreased ROM of the left hip and spine, decreased strength of the left hip and thigh musculature, impaired gait with an antalgic pattern, functional limitations with mobility and ADLs, and pain limiting participation. The therapist recorded a prognosis of "good" given the patient’s age and motivation and noted appropriate healing post-surgery (PDF page 3).

Plan of Care, Goals, and Treatment Strategy

The plan of care specifies treatment frequency of 3 times per week for 6–8 weeks with an estimated total of 18–24 visits (PDF page 4). Short-term goals (2–3 weeks) are to increase left hip flexion to 100°, increase left hip strength to 4+/5 for major muscle groups, ambulate 300 feet with a walker independently, and decrease activity pain to 3/10. Long-term goals (6–8 weeks) include return of hip ROM within 10° of the contralateral side, restoration of 5/5 strength in left hip musculature, independent unlimited ambulation without an assistive device, return to work without restrictions, and resumption of recreational activities as appropriate. The documented treatment modalities include therapeutic exercise for strength and ROM, gait training with progressive weight-bearing, manual therapy, functional ADL and work conditioning, pain management modalities as appropriate, and patient education with a home exercise program (page 4).

Therapist Attestation and Administrative Details

The evaluation is signed and attested by Sarah Therapy, PT, DPT, with a documented evaluation time and date of 08/18/2025 at 09:00. The PT license number shown is PT-11111 (noted as fictional in the testing document). These administrative data are contained in the therapist attestation block on PDF page 4.

Prognosis and Anticipated Future Care

The treating therapist provided a favorable prognosis ("good") based on the patient’s young age and motivation, and documented appropriate post-operative healing. The written plan anticipates progressive rehabilitation over 6–8 weeks with serial objective reassessment of ROM, strength, gait speed, and pain scores (page 3; page 4). Given the functional deficits documented (e.g., gait speed 0.4 m/s, ambulation 100 ft with walker), expected near-term needs include intensive outpatient physical therapy (estimated 18–24 visits) focused on progressive loading of the left hip, gait re-training, targeted hip abductor and extensor strengthening, and a home exercise program to maintain ROM and progress function (page 3; page 4).

Recommendations for Coordination of Care and Contingencies

From a life care planning perspective, the initial PT record supports the immediate need for structured outpatient therapy (3×/week × 6–8 weeks; estimated 18–24 visits) and progressive functional evaluation. Contingency plans should include prompt orthopedic follow-up if there is delayed wound healing, increasing pain, unexplained neurologic change, or plateau in functional gains; the incision was described as well healed at the time of PT (page 3), but continued surveillance is standard after ORIF. Additional needs potentially required if recovery is slower than expected include extended outpatient PT, home health PT for a limited interval, and consideration of assistive devices or durable medical equipment while gait remains impaired (gait speed 0.4 m/s) (page 3; page 4).

Limitations of the Source Document

This physical therapy initial evaluation is a single-provider outpatient rehabilitation record and does not include contemporaneous orthopedic operative notes, inpatient hospitalization notes, imaging reports, or detailed medication records; those documents were not present in the provided PDF. The PT record itself is explicitly designated for software testing with fictitious identifiers in the header/footer, which should be considered when weighing legal or forensic admissibility (page 1; page 5).

Concise Clinical Summary

In summary, the subject presented three weeks following a left intertrochanteric femur fracture treated with ORIF (MVA 07/30/2025; surgery 07/31/2025) with persistent pain (left hip 4–5/10 at rest, 7/10 with activity), objective left-sided hip ROM restriction (e.g., flexion 85°), asymmetric weakness of hip musculature (e.g., abductors 3/5, extensors 3+/5), and markedly limited ambulation (100 ft with walker; gait speed 0.4 m/s). The initial rehabilitation plan is for structured outpatient physical therapy 3×/week for 6–8 weeks with defined short-term and long-term goals and an estimated 18–24 visits; the therapist’s overall prognosis is documented as good (page 1; page 2; page 3; page 4).

Prepared from: Rehabilitation Services — Physical Therapy, "PHYSICAL THERAPY INITIAL EVALUATION" (document dated 08/18/2025; PDF pages 1–5). Source file: pt_evaluation_1.pdf (end of document noted on page 5).

Source of Document: Eagle Eye Investigations — Surveillance Investigation Report (PDF)

The primary source for the history and observations summarized in this medical-history body is a private investigator surveillance report entitled "SURVEILLANCE INVESTIGATION REPORT" prepared by Eagle Eye Investigations on behalf of defense counsel. The surveillance report documents observations of the subject, "John A. Doe," over the period 12/01/2025–12/07/2025 and is certified by the investigator on 12/08/2025; see the report cover and certification pages for identification and dates (page 1, page 8).

I. Summary of Source and Nature of Information

The document under review is an investigative surveillance report (private investigation) prepared by Eagle Eye Investigations and completed on 12/08/2025 (investigator certification), which summarizes video, photographic, and observational data obtained during covert public-area surveillance of a claimant identified as John A. Doe during the interval 12/01/2025 through 12/07/2025 (page 1, page 8).

The surveillance was undertaken in the context of pending personal-injury litigation arising from a motor vehicle collision reportedly occurring on 07/30/2025 (case background reported by the investigator), and the stated assignment was to document daily activities and physical capabilities to compare against claimed limitations contained in medical records and in litigation submissions (page 1, page 2).

II. Reported Medical History and Claimed Functional Limitations

The surveillance report enumerates the claimant's reported limitations as summarized from medical records and claim submissions: sitting tolerance limited to 45 minutes, walking tolerance limited to 200 feet, lifting capacity limited to 15 pounds, requirement for frequent position changes, reported use of a cane for ambulation, inability to perform activities of daily living independently, and chronic pain rated 6–8/10 affecting activities. These reported limitations are explicitly listed in the report for comparison with observed function (page 2).

III. Surveillance Observations Relevant to Examination/Functional Capacity

The investigator documents 32 hours of surveillance over six days and presents time-stamped video and photographic evidence of the subject performing multiple tasks. The surveillance log lists activities with specific times and locations, including departure from residence and retrieval of mail, grocery shopping with lifting of a 24-pack of water, attendance at a medical office where a cane was observed upon ingress/egress, inspection and lifting of lumber at a home improvement store, attendance at a son's soccer game with prolonged sitting and bleacher climbing, yard work including raking and handling full leaf bags, and washing a vehicle and cleaning gutters from an 8-foot ladder (page 3, page 4, page 6).

Photographic exhibits are catalogued within the report and dated: a photograph of the subject lifting a 24-pack of water at a grocery store (12/01/2025, 15:22), examination of lumber at Home Depot (12/03/2025, 11:15), yard work in the backyard (12/05/2025, 16:45), and ladder climbing to clean gutters (12/07/2025, 09:30). The report indicates total video footage of 4 hours, 15 minutes with HD recordings and GPS time-stamps (page 4).

IV. Correlation Between Observations and Reported Medical Findings

The investigator's physical capability analysis explicitly contrasts observed activity with the claimant's reported limitations: sitting tolerance observed at greater than 90 continuous minutes at a sporting event (contrasting with claimed 45 minutes), walking and standing endurance during prolonged shopping excursions, lifting of items approximating or exceeding 20–30 pounds (24-pack of water, filled leaf bags), and selective use of a cane only during entry/exit of a medical facility. These contrasts are itemized as contradictions within the surveillance report (page 5, page 6).

The surveillance report additionally documents behavioral observations such as apparent modification of behavior in and around medical facilities and more normal gait and function in non‑medical settings; these behavioral patterns are raised as potentially relevant to the assessment of credibility of subjective symptom reporting (page 7).

V. Pertinent Absences in the Source Document (Limitations of the Evidence)

The surveillance report is not a medical record and contains no formal clinical examination findings by physicians, no documented diagnostic imaging (e.g., radiographs, CT, MRI), no objective neurologic testing, and no standardized functional testing (e.g., range-of-motion measurements, timed walk tests, or formal functional capacity evaluation (FCE)). The report itself notes that its purpose is surveillance and recommends medical expert review of the video evidence but provides no medical diagnoses confirmed by imaging or clinician assessment (page 5, page 7).

VI. Summary Medical Impression and Working Diagnoses

Based solely upon the surveillance data contained in the report (i.e., observation of functional activities), the following working impressions are offered with the caveat that they are hypotheses requiring corroboration by clinical examination and objective testing: 1) reported chronic musculoskeletal pain (claim) without confirmatory diagnostic data in this source document; 2) functional capacity that appears at times to permit moderate endurance activities and lifting above 15 lb based on observed tasks; 3) inconsistent or situational assistive-device use (cane) that may reflect intermittent symptomatic exacerbation, behavioral modification, or non‑medical factors. These impressions derive from the investigator's contradictory findings summarized in the report (page 2, page 5).

VII. Prognosis (Based on Available Evidence)

Prognostic statements cannot be definitively made from surveillance alone. The observed participation in sustained activities (prolonged sitting, ambulation throughout large retail stores, lifting and handling of heavy objects, yard work, ladder climbing) suggests that, at minimum, the claimant retains substantial functional reserve inconsistent with severe global disability as self‑reported in the absence of corroborating medical documentation. However, intermittent use of a cane at medical facilities suggests periods of symptom exacerbation or situational behaviors that require clinical correlation. Thus, the provisional prognosis is guarded-to-favorable for functional recovery or maintenance of moderate activities unless contrary objective medical findings (e.g., structural neurologic or spinal pathology) are demonstrated by clinical evaluation and imaging (page 3, page 6).

VIII. Recommended Diagnostic Work-Up and Consultations

To convert surveillance-based observations into clinically actionable conclusions, I recommend the following evaluations and studies, each to be correlated with the claimant's existing medical records and the investigator's media: 1) comprehensive orthopedic and neurologic clinical examination with standardized pain and functional assessments; 2) diagnostic imaging (lumbar and cervical spine MRI ± radiographs) if not already performed or if clinical signs indicate; 3) validated objective functional testing such as a supervised Functional Capacity Evaluation (FCE) and a 6‑minute walk test; 4) pain specialist consultation for assessment of chronic pain management strategies; 5) physical therapy evaluation with objective ROM and strength testing; and 6) vocational assessment if work restrictions remain disputed. These recommendations are concordant with the investigator's suggestion to have medical experts review the video evidence and to consider vocational surveillance (page 7, page 4).

IX. Anticipated Future Treatment, Rehabilitation and Life Care Considerations

Pending the outcome of diagnostic testing and specialist consultation, a conservative-to-interventional treatment plan may be indicated. Potential components of a comprehensive life care plan include: structured physical therapy focusing on graded conditioning and core stabilization; outpatient pain management (pharmacologic optimization, consideration of interventional procedures such as epidural steroid injection or facet procedures if indicated by imaging and clinical correlation); durable medical equipment only if objectively required (e.g., cane or brace) with clear documentation of necessity; home- and vehicle‑modification assessment only if objective impairment persists; and vocational rehabilitation if work capacity is reduced. These recommendations align with the investigator's call for medical expert review of preserved evidentiary media and for continued surveillance to clarify function during clinical encounters (page 7, page 4).

X. Medicolegal Considerations and Recommendations for Expert Opinions

For a medico-legal expert opinion, it is essential to: 1) obtain and review complete medical records (pre- and post-accident), objective diagnostic studies, and therapy notes; 2) review the surveillance media (video and photos) in conjunction with clinical examination to determine contemporaneous functional status and effort; 3) perform standardized objective testing (FCE) under controlled conditions; and 4) document any discrepancies between observed community function and self-reported limitations, specifying whether observed activity is inconsistent with claimed restrictions and to what degree these observations affect causation and permanency opinions. The surveillance report itself recommends preservation and review of video evidence and notes chain-of-custody availability (page 4, page 8).

XI. Conclusion

The Eagle Eye Investigations surveillance report documents multiple objective observations of the claimant performing activities that appear to exceed the functional limitations reported in the claimant's records and allegations. These observations include prolonged sitting (>90 minutes), ambulation and standing endurance within large retail environments, lifting and carrying of objects in the range of 20–30 pounds, yard work with repeated bending and carrying of heavy bags, and ladder climbing with overhead reaching (page 3, page 6, page 4).

These surveillance-based findings are important data for life-care planning and causation/permanency assessment; however, they are not a substitute for direct clinical evaluation, objective diagnostic testing, and validated functional testing. I recommend the treating clinicians and retained experts integrate the surveillance evidence with the claimant’s full medical records, complete objective testing, and a direct clinical examination prior to making definitive medical-legal conclusions (page 7, page 8).

Report prepared by a physician life care planner for integration into a larger expert report. Primary source: Eagle Eye Investigations Surveillance Investigation Report (see source link at top) certified 12/08/2025 (page 8).

Source Document: Vocational Rehabilitation Assessment — Career Solutions Rehabilitation

Medical History and Current Functional Status — John A. Doe

The following medical history body is derived from a single-source vocational rehabilitation assessment identified as a "Vocational Rehabilitation Assessment" prepared by Robert Career, M.S., CRC and dated 12/10/2025. The source document is a comprehensive vocational rehabilitation and career assessment provided by Career Solutions Rehabilitation (document header and client identifying information) (page 1) and signed by the vocational counselor (page 8).

Summary of history and mechanism of injury

The claimant, John A. Doe, DOB 01/15/1985 (age 40 at time of assessment) sustained multiple injuries in a motor vehicle collision while commuting to work on 07/30/2025; this information is documented in the client information and referral sections of the vocational assessment (page 1, page 1). The assessment was performed as a comprehensive vocational evaluation for return-to-work planning, with the assessment date recorded as 12/10/2025 (page 1, page 8).

Pertinent past medical and vocational background

Pre-injury, Mr. Doe was employed as a Staff Accountant at Fictional Accounting Services, LLC (January 2020–July 2025) earning approximately $55,000 annually; prior work history and earnings are documented in the vocational history and earnings analysis sections (page 3, page 3). Educational history documents a B.S. in Accounting (State University, 2007) and related professional certifications and continuing education pertinent to his occupation (page 2).

Injury summary and documented diagnoses

The assessment explicitly lists the injury diagnoses as: left intertrochanteric hip fracture (surgically repaired), cervical strain with C6 radiculopathy, lumbar strain with L4–L5 disc protrusion, chronic pain syndrome, secondary depression and anxiety, and cognitive difficulties related to pain and medications (page 2). The report further documents that the claimant was approximately 20+ weeks post-injury at the time of assessment and remained under ongoing medical treatment without return to work (page 2).

Examination and current functional findings (as reported)

The vocational assessment provides specific functional capacity observations derived from record review and functional capacity evaluation data, including physical and cognitive limitations. Physical limitations include a maximum continuous sitting tolerance of 45 minutes, standing tolerance of 20 minutes, ambulation limited to 200 feet without rest, lifting restricted to 15 pounds occasionally, severe limitations in bending/stooping, and driving limited to 30-minute distances (page 4, page 5). Cognitive limitations documented include markedly slowed processing speed, difficulty with sustained concentration (15–20 minutes), memory retrieval problems, reduced mental flexibility and multitasking ability, and medication-related cognitive fog (page 5).

Diagnostic studies and record limitations

The vocational report summarizes diagnoses consistent with imaging-based conditions (e.g., intertrochanteric fracture, L4–L5 disc protrusion) but does not reproduce primary imaging films, operative reports, or specific laboratory data within the assessment; the assessment therefore functions as a synthesis of available medical documentation and functional testing rather than a repository of original diagnostic images or detailed physician progress notes (page 2, page 4). For a comprehensive life care plan, the absence of original operative reports, radiology reports, and treating physician notes within this document should be noted and these primary records should be requested to corroborate the vocational findings (page 2).

Consultations, follow-up, and ongoing care as recommended

The assessment documents ongoing multidisciplinary medical care and recommends continued medical stabilization and active rehabilitation phases. The recommended clinical components include ongoing medical treatment and pain management, cognitive rehabilitation therapy, psychological counseling for adjustment and mood disorders, and sleep disorder treatment during the first 1–3 months of rehabilitation (page 7). Subsequent phases include graduated work conditioning, computer skills refresher training, accommodation technology training, trial work periods, and on-site job coaching as needed for months 4–12 (page 7).

Functional vocational prognosis

The vocational opinion states that current functional limitations preclude full return to the pre-injury Staff Accountant duties without significant accommodations, but that partial return to sedentary work (20–25 hours/week initially) is feasible with accommodations; potential exists for progression to part-time or full-time sedentary work with successful rehabilitation and accommodations (page 5, page 6). The report further notes potential for improvement but emphasizes persistent barriers including inability to sit for extended periods, cognitive deficits affecting complex financial tasks, and reduced processing speed that may limit productivity and earning capacity (page 5, page 6).

Current diagnoses to be incorporated into the life care plan

The following diagnoses from the vocational assessment should be explicitly included in the life care plan: left intertrochanteric hip fracture (post-operative status), cervical strain with C6 radiculopathy, lumbar strain with L4–L5 disc protrusion, chronic pain syndrome, secondary major depressive disorder/anxiety symptoms, and cognitive impairment related to pain and medication effects (page 2, page 5).

Recommended future medical, rehabilitative, and vocational services (life care needs)

The vocational assessment provides a structured rehabilitation plan and itemizes services that are directly translatable into life care plan components. Immediate and near-term needs include continued pain management and medical follow-up, multidisciplinary cognitive rehabilitation (estimated $5,000–8,000), psychological counseling for depression/anxiety, and evaluation/management for sleep disturbance (page 7). Mid-term needs include work conditioning and graded work simulation ($3,000–5,000), technology/accommodation training, and trial work periods; long-term needs may include workplace ergonomic modifications (sit/stand workstation and ergonomic equipment estimated $2,000–3,000), job coaching ($2,000–4,000), and ongoing vocational follow-up (page 6, page 7).

Estimated rehabilitation costs and economic considerations

The vocational source provides itemized estimated costs for recommended services, with total estimated rehabilitation costs ranging from $12,000–20,000 when combining cognitive rehabilitation ($5,000–8,000), work conditioning ($3,000–5,000), accommodations ($2,000–3,000), and job coaching ($2,000–4,000) (page 7). The vocational analysis also quantifies anticipated current and long-term lost earnings, estimating immediate annual losses of $15,000–25,000 and potential long-term loss of $200,000–300,000 over the claimant's remaining work life based on pre-injury earnings and projected retirement at age 65 (page 7, page 3).

Accommodation and vocational reintegration recommendations

Recommended workplace accommodations documented in the assessment include reduced work schedule (initial 4–6 hours/day), sit/stand workstation, frequent scheduled breaks every 30–45 minutes, modified and reduced-complexity duties initially, flexible scheduling for medical appointments, written and electronic task reminders, and a quiet work environment; these accommodations are integral to planning for assistive equipment, workstation modification costs, and job coaching in the life care plan (page 6, page 4).

Limitations of the source and recommendations for further documentation

The vocational assessment is a single-source, vocationally focused synthesis and does not include full primary treating physician progress notes, operative reports, formal neuropsychological testing results, or imaging studies within the document; the life care plan should therefore incorporate direct review of orthopedic operative reports (hip), neurosurgical or spine imaging and reports (L4–L5), electromyography/nerve conduction studies related to C6 radiculopathy if performed, and formal neuropsychological or cognitive testing to quantify cognitive deficits for treatment planning and prognostication (page 2, page 5).

Formal opinion regarding prognosis and projected needs

Based upon the information contained in the vocational assessment, Mr. Doe has persistent, functionally limiting physical and cognitive morbidity related to the 07/30/2025 motor vehicle collision and remains unable to perform his pre-injury Staff Accountant duties without significant accommodation and rehabilitation interventions; this conclusion is supported by the assessment's documentation of current limitations and the vocational counselor's opinion (page 2, page 5, page 8). The prognosis is guarded but potentially favorable for partial vocational reintegration with adherence to multidisciplinary rehabilitation over a 3–12 month time frame as outlined in the three-phase plan (page 7).

Specific items to include in a chronic care life care plan (recommended)

Based on the vocational assessment, the life care plan should include: (1) ongoing primary care and specialist follow-up (orthopedics/hip, spine, pain management, neurology), (2) multidisciplinary pain management and medication review to minimize cognitive side effects, (3) formal cognitive rehabilitation and neuropsychological assessment, (4) psychological counseling for depression/anxiety, (5) work conditioning and graded return-to-work programs, (6) ergonomic workstation modifications and assistive equipment, (7) job coaching and vocational retraining as required, and (8) periodic vocational follow-up and reassessment of work capacity and accommodation efficacy. Estimated cost ranges for the core rehabilitation services are provided in the vocational source and should be used as preliminary budgeting in the life care plan ($12,000–20,000 aggregated estimate for initial rehabilitation services) (page 7, page 6).

Certifying source and contact

The vocational assessment was prepared and certified by Robert Career, M.S., CRC, with certification statement and date 12/10/2025 on the final page of the report; the counselor documents 12 years of vocational rehabilitation experience and a CRC license number within the report (page 8, page 1).

Prepared for inclusion in the life care plan by a physician life care planner based upon the vocational rehabilitation assessment cited above. For validation and to refine cost and frequency estimates, obtain the claimant's primary medical records, operative reports, diagnostic imaging reports, EMG/NCS reports, and any formal neuropsychological testing results referenced but not included in the vocational assessment (page 2, page 7).