Based on your differential and working diagnosis, Dr. Shah and I would like to treat Brian for a concussion and a degenerated disc. We do not have enough test results to determine the exact status of the damaged disc, but from our experience and from looking at the MRI, the damage appears to be minimal at this time.

Dr. Shah and I would now like you to recommend a treatment plan for Brian Johnson. Your goal should be to choose the best options for reducing the symptoms of pain and swelling, promoting healing of the injured parts, and restoring normal movement and functionality.

Ideally, the diagnosis is the correct one, the physician prescribes the appropriate treatment or therapy, the patient follows the instructions, and the patient's condition improves. However, we do not work in an ideal world, and sometimes, we will never know with absolute certainty if our diagnosis was correct. Therefore, we usually plan follow-up consultation with the patient to confirm that the treatment plan is having the intended effect. If our proposed treatment does not effectively address the problem, both the diagnosis and the treatment plan must be reviewed, and further tests can be performed.

Treatment Plan
With your experience critiquing the treatment plan for Jenny Anderson, Dr. Shah and I think you are ready to recommend your own treatment plan for Brian, using the attached treatment plan template (similar to the one you critiqued for Jenny). Decide which elements to incorporate and in what ways, and be thorough in your justification so your opinion is well-informed. Even though Brian's accident was recreational, he may still be sensitive to how soon he can return to activity, so your plan should still account for the patient's potential needs and desires.

I look forward to seeing your plan.

Lee Mendoza, M.D.