Sample Medical Summary for Attorneys

What is an EvenUp Medical Summary?

A template within the AI Drafts Suite that compiles synced treatment records into a structured summary of care, diagnoses, and impairment findings. Powered by Piai™, it offers line-level detail to support case valuation and strategy. Intended for attorney review, not final use.

May 31, 2025

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1.1. Medical Treatment Summary

09/15/2024 -Miami-Dade Fire Rescue - Paramedic Elliott Ramirez: Paramedic Ramirez responded to a motor vehicle collision in which Mr. Calder, the restrained driver, was rear-ended while stopped at a traffic light. Mr. Calder reported neck and lower back pain, stating "My neck and lower back are really hurting. I felt a sharp pain right after the impact.". The physical assessment revealed pain on palpation of the back of the neck with limited range of motion and tenderness along the mid and lower back. Treatment included applying a cervical collar, securing Mr. Calder to a long backboard with head blocks, establishing an intravenous line in the left arm, and administering Ketorolac for pain management. Mr. Calder was transported to Mercy Hospital Miami with an assessment of cervical and lumbar strain/sprain following the collision.

09/15/2024 -Mercy Hospital Miami - Dr. Eliza Marquez, M.D.: Dr. Marquez evaluated Mr. Calder in the Emergency Department after the motor vehicle collision. Her physical examination revealed tenderness in the back of the neck, limited movement due to pain, and tenderness in the thoracic and lumbar regions. X-rays of the cervical, thoracic, and lumbar spine showed straightening of the normal curves, likely due to muscle spasm, and mild degenerative changes. Dr. Marquez diagnosed Mr. Calder with acute strain/sprain in the cervical, thoracic, and lumbar regions. Her treatment included Cyclobenzaprine and Naprosyn, which improved his symptoms, reducing pain from 5/10 to 3/10. She provided discharge prescriptions of Naproxen,

Cyclobenzaprine, and instructions to continue using a cervical collar as needed. Mr. Calder was referred to Miami Spine & Rehabilitation Center for chiropractic evaluation.

11/01/2024 -Miami Spine & Rehabilitation Center - Dr. Marcus Wilson, D.C.: Dr. Wilson performed an initial chiropractic evaluation of Mr. Calder, who presented with neck, upper back, and lower back pain following the 09/15/2024 collision. Mr. Calder rated his neck pain as 6/10 and his back pain as 5/10 at rest, increasing to 8/10 with movement. The examination revealed moderate to severe tenderness in the neck, mid back, and lower back, along with subluxation at various spinal levels and the right sacroiliac joint. Dr. Wilson diagnosed multiple issues including sprain/strain, segmental dysfunction, and early degenerative changes. He outlined a treatment plan of chiropractic adjustments, soft tissue mobilization, therapeutic exercises, heat and cold therapy, and electrical muscle stimulation for several weeks.

11/02/2024 - 11/05/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported continued neck pain (5-6/10) and back pain (5/10) with slight improvement in his neck. Dr. Wilson provided additional chiropractic adjustments, interferential current therapy, therapeutic exercises, moist heat, and soft tissue mobilization.

11/07/2024 -South Florida Orthopedic Specialists - Dr. Jennifer Patel, M.D.: Dr. Patel evaluated Mr. Calder and diagnosed a rotator cuff tear in his right shoulder. She recommended starting with conservative care and then considering injection therapy if needed.

11/09/2024 -Miami Spine & Rehabilitation Center -Dr. Wilson: Mr. Calder reported improvement in his neck pain to 4/10 but noted new discomfort in his right shoulder when reaching overhead. Examination showed pain during shoulder abduction above 100° and internal rotation, with mild tenderness over the right rotator cuff and a positive Hawkins-Kennedy test. Dr. Wilson assessed the shoulder as having a possible rotator cuff strain/impingement and adjusted his treatment to focus more on the right shoulder.

11/12/2024 - 11/16/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported gradual improvement in neck and back pain (both 4/10) but an increase in right shoulder pain (5-6/10). Examination of his right shoulder revealed limited active range of motion, positive impingement tests, and noticeable tenderness over the supraspinatus tendon and bicipital groove. His treatment continued with chiropractic adjustments, interferential current therapy, therapeutic exercises focusing on the shoulder, and soft tissue mobilization.

11/15/2024 -South Florida Imaging Center - Dr. Patel (ordering): An MRI of the right shoulder was performed. The imaging showed a full-thickness tear of the supraspinatus tendon measuring approximately 1.5 cm with mild retraction, moderate subacromial bursitis, mild acromioclavicular joint arthropathy, a Type II acromion, mild glenohumeral joint effusion, and mild degenerative changes of the glenoid labrum.

11/19/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported that his neck pain had improved to 3/10 and his back pain to 3/10. However, his right shoulder pain persisted at 6/10 with only limited improvement. The examination indicated that shoulder abduction was limited to 110° with pain, positive impingement signs, and pain with resisted external rotation. Dr. Wilson assessed the shoulder as having rotator cuff tendinitis/impingement and referred Mr. Calder to Dr. Patel for further evaluation.

11/23/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported that his neck pain had decreased to 2/10 and his back pain to 2/10. Dr. Wilson continued his chiropractic care once per week for an additional four weeks and recommended coordinating care with an orthopedic specialist for his shoulder.

11/25/2024 -Miami Pain Specialists - Dr. Carlos Rivera, M.D.: Dr. Rivera evaluated Mr. Calder, who presented with right shoulder pain following the collision. After reviewing the MRI that showed a full-thickness supraspinatus tear, Dr. Rivera diagnosed a right shoulder rotator cuff tear, impingement syndrome, subacromial bursitis, glenohumeral joint effusion, and pain related to the collision. He treated Mr. Calder with a subacromial corticosteroid injection using a mixture of Kenalog and lidocaine.

11/26/2024 - 11/30/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported that his neck and back pain had further improved to between 2/10 and 1/10, but his right shoulder pain remained at 5-6/10. He received additional treatments including chiropractic adjustments, interferential current therapy, therapeutic exercises, and soft tissue mobilization.

12/03/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported minimal neck pain (1/10) and back pain (1/10) with his right shoulder pain at 4/10 after a steroid injection from Dr. Rivera. His treatment included targeted chiropractic adjustments to C5 and L5, interferential current therapy, therapeutic exercises, soft tissue mobilization, and a modified exercise program to improve shoulder mobility.

12/10/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported no neck pain (0/10) and only intermittent low back pain (1/10). His right shoulder pain remained at 4/10 but his range of motion had improved following the injection. Treatment included a chiropractic adjustment to L5, interferential current therapy, advanced therapeutic exercises, and soft tissue mobilization.

12/13/2024 -Miami Pain Specialists - Dr. Rivera, M.D.: Mr. Calder returned for a follow-up and reported that his shoulder pain had improved for about a week after the first corticosteroid injection but then returned. He stated that his pain had decreased from 6/10 to 2/10 for 7-10 days after the injection, but over the past week it progressively increased to 5/10 at rest and 7/10 with activity. Dr. Rivera administered a second corticosteroid injection to the right shoulder and discussed surgical options, including arthroscopic rotator cuff repair if conservative management failed.

12/17/2024 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported no neck pain (0/10) and occasional low back discomfort (1/10) when sitting for prolonged periods. His right shoulder pain improved to 3/10 following the second injection. Dr. Wilson reduced the treatment plan to maintenance adjustments, therapeutic exercises, and recommended a home exercise program with ergonomic practices. Treatment frequency was reduced to every other week.

12/30/2024 -Miami Pain Specialists - Dr. Rivera, M.D.: Mr. Calder returned for follow-up with concerns about long-term solutions for his shoulder. He reported significant improvement in pain since the second injection, rating his pain as 2/10 at rest and 4/10 with activity. Examination showed significant improvement in his range of motion. Dr. Rivera administered a third and final corticosteroid injection to the right shoulder and discussed surgical intervention. He recommended arthroscopic rotator cuff repair based on the MRI findings and scheduled a surgical consultation with Dr. Patel for February 2025.

01/07/2025 -Miami Spine & Rehabilitation Center - Dr. Wilson: Mr. Calder reported that his neck symptoms had resolved and his low back discomfort was minimal. His right shoulder function improved, although he still experienced pain at 2/10 with certain movements. Dr. Wilson provided a maintenance adjustment, a final home exercise program, and discharged Mr. Calder from active care for his spinal conditions while supporting his decision regarding shoulder treatment.

01/07/2025 -South Florida Orthopedic Specialists - Dr. Patel, M.D.: Dr. Patel conducted a new patient office visit with a comprehensive evaluation and obtained X-rays (2 views) of the right shoulder.

01/28/2025 -South Florida Orthopedic Specialists -Dr. Patel: Dr. Patel conducted an established patient office visit with a detailed evaluation and provided therapeutic exercise instruction.

01/28/2025 -Miami Pain Specialists - Dr. Rivera, M.D.: Dr. Rivera evaluated Mr. Calder during a follow-up regarding next steps for his shoulder. Mr. Calder reported continued improvement after the third injection, rating his pain as 1-2/10 at rest and 3-4/10 with strenuous activity. He indicated that he had consulted with Dr. Patel about surgical intervention and was leaning toward arthroscopic rotator cuff repair. Dr. Rivera strongly recommended arthroscopic rotator cuff repair as the definitive treatment based on the MRI findings and clinical presentation. He outlined a postsurgical pain management plan and advised coordinating with Dr. Patel for scheduling the surgery. Dr. Rivera certified that the shoulder injury was directly related to the 09/15/2024 collision and that the recommended surgery was medically necessary.

02/05/2025 -Miami Spine & Rehabilitation Center - Dr. Wilson: Dr. Wilson conducted a final evaluation of Mr. Calder, who reported resolution of his neck and low back symptoms with only minor discomfort after prolonged activities. Mr. Calder noted that his right shoulder, though improved, still had limitations with pain rated at 2/10. He confirmed his decision to proceed with arthroscopic surgery scheduled for 02/20/2025 with Dr. Patel. Dr. Wilson assessed that the cervical, thoracic, and lumbar conditions had resolved while the right shoulder tear had improved with conservative management but required surgery. He recommended monthly maintenance visits for three months and provided a home exercise program for spinal maintenance. The prognosis was favorable for the spine and guarded for the shoulder pending surgical outcome.

02/20/2025 (Scheduled) -South Florida Orthopedic Specialists - Dr. Patel, M.D.: Arthroscopic surgery for the right shoulder was scheduled.

Exhibit List