Gonzalez_Medical_Records.pdf · 186 pages · DOB Apr 12, 1979
Ms. Gonzalez was taken to the ER after a rear-end collision on March 3 with neck and low-back pain. Cervical MRI on March 20 showed a C5-6 disc protrusion. She treated with an orthopedist and physical therapy through June, received a cervical epidural injection in July, and at her last visit in September reported pain of 4/10 with ongoing restriction in neck rotation.
Treatment dates
Aug 14, 2023 – Sep 15, 2026
Providers
5
Billed (as shown in records)
$48,215.40
| Date | Provider | What happened | Page |
|---|---|---|---|
| Aug 14, 2023 | Sherman Oaks Chiropractic · Dr. R. Patel, DC | VisitNeck stiffness after slipping at work; adjusted and released. No follow-up.Dx: Cervicalgia (M54.2)Billed $120.00 | 14 |
| Mar 3, 2026 | Valley Presbyterian Hospital · Dr. S. Moreno | ERArrived by ambulance after rear-end collision. Neck pain 8/10, low-back pain 6/10. CT cervical spine negative for fracture. Discharged with cyclobenzaprine and ibuprofen.Dx: Strain of neck muscle (S16.1XXA); Low back strain (S39.012A)Billed $6,840.00 | 22 |
| Mar 10, 2026 | Kim Orthopedics · Dr. Alan Kim | VisitPersistent neck pain radiating to left shoulder, 7/10. Reduced rotation (45° left). Ordered cervical MRI and referred to PT.Dx: Cervical radiculopathy (M54.12)Billed $450.00 | 33 |
| Mar 20, 2026 | Encino Imaging Center | ImagingCervical MRI: broad-based C5-6 disc protrusion with mild left foraminal narrowing.Dx: Cervical disc displacement C5-6 (M50.222)Billed $2,850.00 | 41 |
| Mar 24, 2026 | Westside Physical Therapy · J. Ortiz, DPT | TherapyPT evaluation; plan of 2x/week for 12 weeks. Pain 7/10.Billed $380.00 | 97 |
| Jun 12, 2026 | Westside Physical Therapy · J. Ortiz, DPT | TherapyDischarged from PT after 22 visits. Pain 5/10; rotation improved to 60° left.Billed $8,360.00 | 131 |
| Jul 21, 2026 | Pacific Pain Management · Dr. L. Chen | ProcedureLeft C5-6 interlaminar epidural steroid injection under fluoroscopy.Dx: Cervical radiculopathy (M54.12)Billed $4,200.00 | 152 |
| Sep 15, 2026 | Kim Orthopedics · Dr. Alan Kim | VisitPain 4/10 after injection; neck rotation still limited. Discussed surgical consult if symptoms persist.Dx: Cervical disc displacement C5-6 (M50.222)Billed $450.00 | 178 |
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