Sample Medico-legal report

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					J Smith (29/05/55)

15897

12 Cedric Road, Weston, Bath, BANES, BA1 3PA Tel: 01225 312522 Mobile: 07818085216 therapists@physioimpulse.co.uk www.physioimpulse.co.uk

MEDICO-LEGAL REPORT
(Sample)
Prepared By

Stuart Galise BSc.(Hons) MCSP HPC
Chartered Physiotherapist and Expert Witness Our Ref: Your Ref: Name: Date of birth: Address: SGMLR80104JS 15897 Mr John Smith 29/05/55 The Cottage North Street The Village BS16 9HE Salesman 10/06/03 Kingswood Natural Health Centre BS15 1AF 7/01/2004 8/01/2004 White, Smith and Jones 10.00am

Occupation: Date of Accident: Location of examination: Date and time of examination: Date of report: Prepared for:

Medico-Legal Report by

Stuart Galise BSc.(Hons) MCSP HPC

J Smith (29/05/55)

15897

A. INTRODUCTION: i) I have been instructed to provide a Medico-Legal report upon the Claimant by White, Smith and Jones I understand my duty to the Courts and I have complied with that duty. MY QUALIFICATIONS: I am a Chartered Physiotherapist and my qualifications are more specifically set out in Appendix 1. iii) MY INSTRUCTION: I have been instructed to produce a Medico-Legal report upon the Claimant dealing specifically with: • • • • • • iv) The Claimant's pre-accident medical condition (G). The injuries the Claimant has suffered in the accident (Hi). My opinion as to whether the injuries complained of are related to the relevant accident (Hi). How the Claimant's injuries will affect their ability to work (C). My opinion as to the most appropriate reasonable treatment regime together with my view as to the cost of supplying this (H iii). My view on the reliability of the claimant as a witness (H iv).

ii)

LIST OF ALL DOCUMENTS PERUSED BY ME: 1. 2. 3. Witness Statement. GP notes. Hospital Notes

B.

HISTORY OF INJURY

i) The Claimant informed me that the accident occurred as follows:Mr Smith told me that whilst traveling to work on the morning of the 10th of June 2003 at approximately 7.45am when he was stationary at traffic lights his car a VW Golf was struck from behind. He was wearing a seatbelt at the time and was thrown forwards and then backwards and has a clear recollection of what happened. There was no loss of consciousness and no visible sign of external injury. He was shaken but not immediately aware of any injury. He was able to exit from the car, exchange details and give details to the police and subsequently able to continue his journey to work. Mr Smith did not receive any medical treatment at the scene and was able to continue his journey to work.

Medico-Legal Report by

Stuart Galise BSc.(Hons) MCSP HPC

J Smith (29/05/55)

15897

ii) Progression of symptoms and subsequent treatment:Over the next 24 hours he became aware of a gradual onset of pain and stiffness in his neck. He does not recall any seatbelt marks. He tells me there was significant damage to the rear end of his car in the region of £1,000 to repair. He had difficulty in raising his head off the pillow. His neck felt stiff and it was difficult to shave without discomfort the next morning. He has also been experiencing mild headaches lasting for one or two hours since the accident particularly when driving. He visited his GP the next day 11th June 2003 and was advised to wear a soft collar and to take pain relieving medication prescribed by the GP. He visited his GP on two further occasions 25.6.03 and 7.7 03. He tells me he wore the collar for one week and took painkillers for four weeks. C. i) EFFECTS ON EMPLOYMENT Mr Smith is a traveling salesman with a local company selling greetings cards, traveling about 700 miles a week. Mr. Smith continues to work and has not had any time off since the accident. His restricted cervical spine movements result in difficulty in reversing the car. This activity is undertaken on a frequent basis. Mr Smith’s prospects in the open job market are unchanged. EFFECTS ON HOBBIES AND PASTIMES Mr Smith had previously enjoyed playing golf once a week and undertook regular walks with his family. Since the accident he has been unable to play a full round of golf, but is able to continue walking 6-7 miles at the weekends. The mild headaches have resulted in a reduced level of social activity. PRESENT CONDITION Mr Smith describes still suffering from intermittent stiffness over the top of his left shoulder to the base of his neck (points to his left trapezius muscle). As aforementioned he is aware of his symptoms when reversing his car and at other times when he needs to rotate his head fully to the left. If this is undertaken quickly he experiences brief pain. Mr Smith also describes experiencing pain when lying on his left side in bed. He does however sleep on his right side and his sleep is not disturbed. He does not presently feel the need to take analgesia (painkillers) at any time.

ii) D. i)

ii) E. i) ii)

iii) iv)

Medico-Legal Report by

Stuart Galise BSc.(Hons) MCSP HPC

J Smith (29/05/55)

15897

F.

SOCIAL HISTORY

Mr Smith is married with two teenage children who are both at school. He is a right handed 49 year old who works full time. G. PRE-ACCIDENT PAST MEDICAL HISTORY

From the medical records that I have reviewed I would describe the Claimant's relevant medical history as follows:i) ii) iii) H. Good general health. Mr Smith has not visited his GP for some years and then only for minor ailments such as throat infections etc. He has never suffered from neck pain before and has never been involved in a road traffic accident. He has not been prescribed medication or had any previous X-rays. MY EXAMINATION: (Appendix 2 contains a glossary of terms used)

I examined the Claimant and I record my findings as follows:i) Cervical spine: Neck held in slight flexion in sitting and standing, increased excursion of left first rib on deep inspiration. Tender over cervical and upper thoracic regions to T4, reduced compliance in right and left upper trapezius muscles. No noticeable swelling. Left first rib painfully restricted on testing. Left facets of C4-T1 painfully restricted in extension on assessment of segmental mobility (movement of individual vertebrae). Flexion reduced by 25%, extension reduced by 25%. Right rotation reduced by 50%, left rotation reduced by 50%. Right side flexion reduced by 50%, left side flexion reduced by 50%. Retraction was limited by 25%. Pain was the limiting factor in all movements. SLR: within normal range left & right Slump: pain in upper thoracic region ULTTs: within normal range left & right Vertebrobasilar artery tests normal Upper cervical ligament tests normal

Observation: Posture

Palpation:

Motion palpation:

Movement:

Special tests:

Medico-Legal Report by

Stuart Galise BSc.(Hons) MCSP HPC

J Smith (29/05/55)

15897

Neurological: ` ii) Thoracic spine: iii) Lumbar spine: iv) Upper limbs: v) Lower limbs: H.

Sensation: normal Power: normal Reflexes: normal Vibration: normal Flexion limited by 25% in upper thoracic spine. Extension limited by 10% in upper thoracic spine.

Nothing abnormal discovered Nothing abnormal discovered Nothing abnormal discovered

OPINION & PROGNOSIS

A summary of my opinion upon the injuries, how they relate to the relevant accident and prognosis upon Mr Smith who was injured in a road traffic accident on the 10th day of June 2003 are as follows:I) INJURIES SUMMARY Mr Smith has an acute sprain of the cervical spine and displays tight cervical spine musculature with associated loss of range of movement. The mechanism of the injury would suggest that this gentleman had an acute extension and then flexion sprain to the cervical spine. This is often called a Whiplash Associated Disorder (WAD). In my opinion the injuries summarised above were related to the accident that occurred on the 10th day of June 2003 because: Mr Smith did not have a history of neck pain before the accident. ii) PROGNOSIS 1. Had the Claimant not been injured in the relevant accident, his condition on the balance on probability would have been pain free neck with full movement. 2. As a result of the injuries recorded above, the Claimant can expect to experience intermittent pain in the cervical and upper thoracic regions for a number of weeks with restricted mobility. He may also have occasional headaches. 3. Consensus of opinion is that at four months after injury there is significant time for improvement, which will continue to improve to a point 12-18 months from injury (references 1-8). 4. If physical treatment is undertaken the prognosis will be better than that predicted above. 5. There is no affect on the life expectancy of the claimant. 6. The claimants prospects on the open job market are unaffected.

Medico-Legal Report by

Stuart Galise BSc.(Hons) MCSP HPC

J Smith (29/05/55)

15897

iii) RECOMMENDED TREATMENT The Claimant's injuries in my opinion can be best managed by the following treatment regime: 1. The patient should receive physiotherapy for an initial period of 6 sessions at around £ 35 per session, a total of £210. At the end of this period, the Claimant should be re-assessed. This is an estimate based on a successful response to treatment. There are many factors influencing the outcome and thus the cost of treatment. If the patient is to receive this treatment early, the prognosis will again be better than that predicted above.

2.

iv) FURTHER REPORT If the Claimant's condition does not show significant signs of improvement six months from the date of this report and treatment has been undertaken, I would strongly advise a further Medico-Legal report to determine the final prognosis. v) VIEW OF CLAIMANT AS A RELIABLE WITNESS

All information requested was freely volunteered and there were no discrepancies between the clients recall and the records supplied. I am satisfied that the client’s reports are reliable and their account of events is genuine. I. STATEMENT OF TRUTH:

I understand that my duty is to the Courts, both in preparing reports and in giving oral evidence. I have set out in my report what I understand from those instructing me to be the questions in respect of which my opinion as an expert are required. I confirm that insofar as the facts stated in my report are within my own knowledge I have made clear which they are and I believe them to be true, and that the opinions I have expressed represent my true and complete professional opinion I will notify those instructing me if for any reason I subsequently consider that the report requires any correction or qualification.

Signature
Stuart Galise BSc.(Hons) MCSP HPC

Date

Medico-Legal Report by

Stuart Galise BSc.(Hons) MCSP HPC

J Smith (29/05/55)

15897

J.

REFERENCES 1. Gargan MF, Bannister GC. Long-term prognosis of soft tissue injuries of the neck. J Bone Joint Surg 72-B:901-903 (1990). 2. Hildingsson C, Toolanen G. Outcome after soft tissue injury of the cervical spine: a prospective study of 93 car accident victims. Acta Orth Scand 61:357-9 (1990). 3. Hohl M. Soft-tissue injuries of the neck in automobile accidents. J Bone Joint Surg 56-A:1675-82 (1974). 4. Jonsson H, Cesarini K, Sahlstedt B, Raushing W. Findings and outcomes in whiplash-type distorsions. Spine 19:2733-43 (1994). 5. Lovell ME, Galasko CSB. Whiplash disorders-a review. Injury 33:97-101(2002). 6. Maimaris C, Barnes MR, Allen MJ. Whiplash injuries of the neck: a retrospective study. Injury 19(5):393-6 (1988). 7. Norris SH, Watt I. The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg 65-B:608-611 (1983). 8. Parmar H, Raymakers R. Neck injuries from rear impact road traffic accidents: prognosis in persons seeking compensation. Injury 24:75-8 (1993).

Appendix 1: Curriculum Vitae Appendix 2 : Glossary of terms (Available on request, accompany all reports)

Medico-Legal Report by

Stuart Galise BSc.(Hons) MCSP HPC