Sarah Mitchell

ID: MFC-2024-0089

Active Patient Insurance Verified

Encounter Date

Jan 15, 2026 • 10:30 AM

Provider

Dr. James Chen

Visit Type

Certification Renewal

Status

In Progress

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AI Clinical Insights

Detected Symptoms

Chronic pain Sleep disturbance

Suggested ICD Codes

M54.5

Low back pain

G47.9

Sleep disorder, unspecified

Cannabis Treatment Suggestions

CBD:THC 1:1 Ratio

• Evening dose recommended
• Start low, titrate slowly
• Monitor for 2 weeks

Compliance Alert

Patient eligible for certification renewal in 10 days

Encounter Progress

Check In

10:25 AM • Completed

Vitals

10:28 AM • Completed

Consultation

In Progress • 10:30 AM

Dr. Chen reviewing symptoms

Prescription

Pending

Certification

Pending

Complete

Pending

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Encounter Summary Draft

AI-generated based on conversation • Last updated: 10:35 AM

Chief Complaint: Patient presents for certification renewal for medical cannabis use, reporting continued symptoms of chronic lower back pain and sleep disturbances.

History of Present Illness: 
Patient reports chronic lower back pain persisting for approximately 6 months (onset: July 2025). Pain is described as dull and aching, rated 6-7/10 on the pain scale, worsening with prolonged sitting and physical activity. Patient also reports sleep disturbance characterized by difficulty falling asleep and frequent nighttime awakenings, occurring 4-5 nights per week.

Previous cannabis treatment with CBD:THC 1:1 ratio has provided moderate relief. Patient reports 40% improvement in pain levels and 50% improvement in sleep quality since initiating treatment 12 months ago.

Review of Systems:
Constitutional: No fever, no weight changes
Musculoskeletal: Chronic lower back pain as described
Sleep: Insomnia, frequent awakenings
Psychiatric: Denies anxiety/depression (managed well with current treatment)

Assessment:
1. Chronic low back pain - M54.5
2. Sleep disorder, unspecified - G47.9
3. Medical cannabis certification renewal indicated

Plan:
- Continue CBD:THC 1:1 ratio, evening dosing
- Maintain current dosage: 10mg THC / 10mg CBD nightly
- Re-evaluate in 3 months or sooner if symptoms worsen
- Physical therapy referral for back strengthening exercises
- Sleep hygiene counseling provided
- Certification renewed for 12 months

Encounter History

Date	Provider	Visit Type	Status	Notes
Jan 15, 2026	Dr. James Chen	Certification Renewal	In Progress	Renewal for chronic pain management...
Oct 12, 2025	Dr. Sarah Williams	Initial Consultation	Completed	Initial evaluation for MMJ certification...
Sep 28, 2025	Nurse Practitioner	Follow Up	Completed	Routine follow-up, dosage adjustment...
Aug 15, 2025	Dr. James Chen	Urgent Care	Completed	Acute pain flare-up management...

Showing 4 of 12 encounters