Mercy General Hospital — Emergency Department
Patient: Gonzalez, MarcusDOS: 03/14/2026MRN: 0042189
History of present illness
34-year-old restrained driver, rear-ended at moderate speed, with immediate
lumbar pain radiating into the right buttock. No loss of consciousness.
Examination & assessment
Lumbar paraspinal tenderness to palpation, most pronounced at L4–L5; range of
motion limited by pain. Lumbar X-ray obtained.
Impression: acute lumbar strain with tenderness at L4–L5; X-ray negative for
acute fracture.
Discharged with cyclobenzaprine, activity restrictions, and orthopedic referral.
Mercy General Hospital — Emergency Department
Patient: Gonzalez, MarcusDOS: 03/14/2026Page 5 — Disposition
Disposition & determination
Emergency medical condition determined per § 627.736; patient advised of
orthopedic follow-up.
Return precautions reviewed. Referred to Valley Orthopedics for ongoing
evaluation of lumbar radicular symptoms.
Valley Orthopedics — Initial Evaluation
Provider: A. Whitfield, MDDOS: 03/22/2026
Objective
Antalgic gait. Lumbar flexion limited to 40°.
Positive straight-leg-raise on the right at 45°; decreased sensation along
the right L5 dermatome.
Plan
Ordered lumbar MRI without contrast to evaluate for disc involvement.
Valley Imaging Center — Radiology Report
MRI Lumbar Spine, w/o contrastDOS: 03/29/2026
Findings
Vertebral body heights preserved. Disc hydration preserved except at L4–L5,
where there is a posterior disc herniation.
Impression
4 mm posterior disc herniation at L4–L5 with right neural-foraminal
narrowing and nerve-root impingement.
Mild facet arthropathy. No fracture.
Valley Orthopedics — Follow-up
Provider: A. Whitfield, MDDOS: 04/05/2026
Assessment
Lumbar radiculopathy secondary to L4–L5 disc herniation, consistent with the MRI
and exam findings.
Plan
Recommend a course of physical therapy and a lumbar epidural steroid
injection at L4–L5.
Continue activity modification; follow up in four weeks.
Active Recovery Physical Therapy — Evaluation
Therapist: R. Nguyen, DPTDOS: 04/12/2026
Plan of care
Initiated an 18-session course of therapeutic exercise and manual therapy for
lumbar stabilization and radicular symptoms,
two to three visits per week. Baseline pain 6/10 with activity.
Valley Orthopedics — Procedure Note
Provider: A. Whitfield, MDDOS: 05/30/2026
Procedure
Lumbar epidural steroid injection at L4–L5 performed under fluoroscopic
guidance.
Tolerated well; partial symptom relief reported at follow-up.
Active Recovery Physical Therapy — Discharge Summary
Therapist: R. Nguyen, DPTDOS: 06/20/2026
Discharge status
Completed 18 sessions; discharge note documents residual radicular symptoms
with activity
and a recommendation for a home exercise program.
Mercy General Hospital — Itemized Statement
Patient: Gonzalez, MarcusAccount: 0042189-MG
| Date |
Code |
Description |
Charge |
| 03/14/26 |
99284 |
ED visit, level 4 |
$2,480.00 |
| 03/14/26 |
72148 |
MRI lumbar w/o contrast |
$3,200.00 |
| 03/29/26 |
72148 |
MRI lumbar w/o contrast |
$3,200.00 |
| 03/29/26 |
76140 |
Outside imaging over-read |
$470.00 |
Valley Orthopedics — Itemized Statement
Patient: Gonzalez, MarcusAccount: VO-7741
| Date |
Code |
Description |
Charge |
| 03/22/26 |
99204 |
New-patient office visit |
$410.00 |
| 04/05/26 |
99214 |
Office visit, established |
$285.00 |
| 05/30/26 |
62323 |
Lumbar epidural steroid injection |
$4,850.00 |
Active Recovery Physical Therapy — Billing Ledger
Patient: Gonzalez, MarcusAccount: AR-2208
| Dates |
Code |
Description |
Charge |
| 04/12–06/20 |
97110 |
Therapeutic exercise ×18 |
$5,940.00 |
| 04/12–06/20 |
97140 |
Manual therapy ×11 |
$3,025.00 |
Florida Traffic Crash Report — Officer J. Reyes #4471
FLHSMV 90010SCrash: 03/14/2026Riverside Ave & 4th StReport №26-03142
Parties
Party 1 (Gonzalez) was stopped for a red signal in the #2 lane. Party 2, a
Riverside Logistics commercial truck, was traveling in the same lane behind
Party 1.
Summary & cause
Party 2 failed to maintain a safe following distance (§ 316.0895, Fla. Stat.)
and struck the rear of Party 1's stationary vehicle.
Party 1's vehicle sustained rear bumper and trunk damage consistent with a
rear-end impact. No citation was issued to Party 1.
Letter of Protection — Active Recovery Physical Therapy
Patient: Gonzalez, MarcusAccount: AR-2208Executed: 04/10/2026
Letter of protection
The undersigned attorney agrees to protect and hold Active Recovery Physical
Therapy's charges for the above patient, payable from the proceeds of any
settlement or judgment in this matter.
Services are itemized at CPT 97110 (therapeutic exercise) and CPT 97140 (manual
therapy); the patient remains personally responsible if no recovery is obtained.
Acknowledged
/s/ Counsel of record for plaintiff — dated 04/10/2026. Provider account
AR-2208.
Gonzalez Deposition Vol. I — Video Transcript
Deponent: Marcus GonzalezTimestamp: 01:14:08
Examination
Q. Where was your vehicle when the impact occurred?
A. I was completely stopped at the light — I'd been stopped a few seconds
when the truck hit me from behind.
Q. Did your vehicle move at all before the collision? A. No. I was at a dead
stop.