Sample Medico-legal Transcription Report
History of Presenting Condition:
XXXXX informed me that on XXXXX, she was involved in a motor vehicle accident as a driver, wearing her seatbelt. She was driving along when she was hit in the rear by a speeding car. She was hit on the right rear side. This made her car spin around into the opposite direction and facing the opposite direction.
She lost consciousness. However, the police attended the scene and the ambulance officers assisted her out of the car. She was taken to XXXXX Hospital where x-rays were carried out. She had pain in the back of the neck and chest and headache. X-rays of the neck demonstrated no fractures.
She developed pain in the neck and left arm she consulted Dr. XXXXX, who referred her for physiotherapy and hydrotherapy.
She had developed pain in her left arm and left shoulder. However, approximately 10 days later, she also became aware of pain in the mid-lower back
She initially saw Dr. XXXXX, who referred her for x-rays of the neck and chest. This was performed on XXXXX. No fractures were demonstrated.
At the time of the injury, she was employed as a kitchen hand on a part-time basis. She went off work for approximately two weeks. She then return to her pre-injury duties and was working approximately 20 hours per week.
She had pain in her neck, back and left arm (left shoulder and left elbow). She was referred to Dr. XXXXX, who referred her for a bone scan. This was performed on XXXXX. It demonstrated arthritic changes at various sites including facet joint in the lumbar spine. There were changes in the greater tuberosity of the right humerus suggesting abnormality of the rotator cuff. She was also referred for an ultrasound of her left shoulder in XXXXX. It demonstrated tendinopathy of the supraspinatus tendon and bursal bunching at 70 degree abduction. There was common extensor tendinopathy and tendinitis of the left elbow ultrasound and on x-rays, there were changes adjacent to the surface of the left elbow tibial tubercle suggestive of periosteal avulsion.
She continued with physiotherapy and was prescribed tablets
Current Symptoms and Severity:
She is complaining of pain in her neck. The pain is in the back of the neck and radiates down to the left side of the neck. On rotating her neck to the right side, she feels pain on the left side.
She has pain in her left shoulder with restrictions in the range of movement.
She is also experiencing intermittent pain in the left elbow. Sometime it is “very sore”.
She is also complaining of pain in her back and pointed to the middle of her back.
She takes Mobic and tramadol tablets for the pain daily. She also takes Panadol tablets and applies Voltaren gel when necessary.
Relevant Past and Medical History:
She gives a history of work-related left hand injury which occurred approximately 24 to 25 years ago. However, her injury resolved within three to four years.
Approximately three to four years ago, she developed pain in her left elbow. She was administered injections by Dr. XXXXX and her symptoms resolved within two to three months.
She confirmed that her neck and left shoulder was asymptomatic prior to the subject motor vehicle accident of XXXXX.
She denies any other relevant medical, surgical or heredity conditions.
Impact on Activities of Daily Living:
Her walking and standing capacities are generally unaffected. However, with prolonged sitting, she develops pain in the neck and back. The cold weather aggravates her symptoms. Her sleep is disturbed particularly when she lies down on the left shoulder.
Squatting precipitates the pain in the mid-back. Sometimes, coughing precipitates her pain in the neck.
Because of her left shoulder symptoms, she has difficulty washing and combing her hair and she tends to use her right arm and shoulder more often.
Her symptoms make it difficult for her to carryout her general household duties. However, she does some work but with pain and takes frequent rest breaks. It takes so much longer than before. She relies on her daughter to help her with many activities such as washing floors, bathroom and showers. She can make the bed but with difficulties.
She can only do very minimal gardening. She does not do any lawn mowing. Sometimes she is able to hang the washing on the line but often relies on her daughter to do it. She gets good days and bad days. On good days, she can do some work but takes frequent rest breaks.
She can only do light shopping as she is unable to tolerate lifting heavy bags and pushing heavy trolleys.
Cervical spine x-rays dated XXXXX demonstrated encroachment on the right C3-C4 exit foramen due to uncovertebral joint degenerative change.
Chest x-rays dated XXXXX demonstrated no abnormality
Bone scan dated XXXXX demonstrated arthritic changes in the AC joints, glenohumeral joints, feet, hips and knees. The most arthritic facet joint in the lumbar spine is located on the right side at T12-L1. There was increased update in the greater tuberosity of the right humerus suggesting an abnormality of the rotator cuff.
Ultrasound of the left shoulder dated XXXXX demonstrated tendinopathy of the anterior aspect of the supraspinatus tendon. There was bursal bulging at 70 degrees abduction with the arm externally rotated.
Left elbow ultrasound dated XXXXX demonstrated tendinopathy/tendinitis of the common extensor tendons. There was soft tissue thickening over the tibial tubercle with changes consistent with recent avulsion injury.
Left elbow x-rays dated XXXXX demonstrated changes suggestive of lateral epicondylitis and shadow suggestive of periosteal avulsion.
XXXXX presented her stated age. She was walking with a normal gait and was not limping.
She pointed to the back of the neck and the left side of the neck as the site of pain and tenderness. There was mild to moderate tenderness. There was no muscle guarding.
The active forward flexion of the neck was possible to approximately 80% of normal. Extension was reduced to 60% of normal and she slightly tilted her neck to the left side. Lateral flexion and rotation to the left was reduced to approximately 75% of normal. Lateral flexion and rotation to the right was possible to 85% of normal. However, on rotating her neck to the right, she complained of pain on the left side of the neck.
She complained of pain in the anterolateral aspect of the left shoulder and over the left lateral epicondyle of the left elbow.
There was no unilateral muscle wasting in the upper limbs. There were no crepitations in the left shoulder.
Examination of the left shoulder revealed normal outline and contour. The following active range of motion was obtained with the goniometer:
Abduction, 140 degrees on the left and 160 degrees on the right;
Flexion, 145 degrees on the left and 180 degrees on the right;
Extension, 50 degrees bilaterally;
Abduction, 40 degrees bilaterally;
External rotation, 80 degrees on the left and 90 degrees on the right;
Internal rotation, 65 degrees on the left and 80 degrees on the right.
The range of movement of the left elbow was normal in all directions. However, there was tenderness over the lateral epicondyle and over the olecranon.
There was mild weakness of hand grip of the left hand, which precipitated pain in the left elbow.
She pointed to the middle back as the site of pain and tenderness. There was mild to moderate tenderness but no muscle guarding. The active forward flexion of the spine was possible approximately 80% of normal. Extension was also possible to 80% of normal. Lateral flexion and rotation to the sides was also possible to 80% of normal. She was able to squat but complained of pain in the lower back. She was able to lie down on the couch. The straight leg raising test was possible to 80 degrees bilaterally. There was no unilateral muscle wasting in the lower limbs. Her lower limb reflexes were present and equal. There was no sensorineural dysfunction of the lower limb.
XXXXX suffered soft tissue injuries and chronic musculoligamentous strain of the neck and back (cervicothoracic and thoracolumbar spine).
She has symptoms consistent with tendinitis of the left shoulder and epicondylitis of the left elbow with imaging evidence of a small avulsion in the left elbow.
Her injury occurred in XXXXX. She remained symptomatic. Her neck and left shoulder and back were asymptomatic prior to the subject motor vehicle accident of XXXXX. However, she had some pain in her left elbow as described above. But she also confirmed that her elbow became asymptomatic prior to the subject motor vehicle accident of XXXXX.
She stated that at the time of the accident, she was holding the steering wheel tightly and that the impact precipitated the pain in the left shoulder and left arm.
Her injuries are consistent with the stated cause. The above motor vehicle accident has been a substantial contributing factor in the development of her current disabilities.
It is difficult, however, to relate her current elbow symptoms to the subject motor vehicle accident as there has been no evidence of direct trauma to her left elbow. The supplied contemporaneous documentation, which includes XXXXX Hospital clinical records and the ambulance report as well as the medical certificate from Dr. XXXXX dated XXXXX does not indicate a direct trauma to the left elbow but rather left arm pain.
She is currently on no active treatment.
Capacity for Work:
Educational and Occupational History:
XXXXX was born in XXXXX and completed eight years of primary school in XXXXX. She then did one year of economics.
She came to XXXXX in XXXXX. Her first employment was in XXXXX when she worked at a factory as a factory worker/process worker
In XXXXX, she worked with XXXXX as a process worker for about a year and then work at a laundry as a laundry assistant for approximately one year.
She then worked at a window/window frames company for approximately one year, installing glass.
In approximately XXXXX, she worked with XXXXX as a process worker for approximately five years until she was made redundant.
She then worked with an agency and was located at XXXXX factory as a process worker until XXXXX when she commence employment with XXXXX as a kitchen hand on a part-time basis.
She tells me she worked approximately 18 to 20 per week and was working between three and five hours per day. This was mostly on Friday, Saturday and Sunday.
The nature of her work requires her to assist the chef. She tells me this is light work and there are no heavy lifting or manual handling activities involved. She helps with the cooking but also washes and dries dishes and pots. She sometimes has to lift bags of chips which she says weigh between 3 and 5 kg.
Fitness for Work and Restrictions:
XXXXX is unsuitable for work requiring the following activities:
Repetitive bending and twisting of the spine;
Heavy manual handling activities;
Repetitive neck rotation;
Sustained flexion or extension of the neck
Repetitive overhead work
Heavy or repetitive use of her left arm
In her current employment, she tells me, she works on a part-time basis and within the above restrictions. Although sometime she feels the pain particularly towards the end of the day and if she had to work longer hours but she manages well as she does not lift any heavy weight or do any repetitive work.
However, should she wish to change employment, she will need to obtain work above restrictions. She is likely to have difficulties working long hours as she will be predisposed to exacerbation of her symptoms. She is, therefore, fit to continue in her current employment, which she tells me is within the above restrictions.
XXXXX has limited fluency in English and is unlikely to be able to work in an office setup not only because of her lack of skills and qualifications but also because of her inability to tolerate the sustained flexion of the neck and static loading on her neck and back and the repetitive use of the computer because of her left elbow and shoulder injuries.
The multitude of her physical restrictions and because of the need of taking painkilling medications and her limited fluency in English will make it difficult for her to obtain suitable employment in the open labour market. She is therefore fit for permanently modified duties within the above restrictions. Her earning capacity is impaired.
Treatment and Rehabilitation:
This is unaltered since my previous report.
DRE2 due to non-uniform loss of range of motion.
The whole person impairment in relation to her left shoulder is assessed as per the range of motion method. This is as per Figure 38, 41 and 44 on pages 43 to 45. Her impairment is assessed at 7% upper extremity impairment (-1% impairment, present in the right uninjured side) equals 6% upper extremity impairment, which is equivalent to 4% WPI.
There is no assessable impairment in relation to her left elbow since her impairment is primarily pain-related impairment.
Please see above. Apportionment is not indicated.
Total Whole Person Impairment:
Her total whole person impairment is assessed by combining the above various equivalent to 5% combined with 4% equals 9% WPI.
Medico-legal Transcription Report
Copyright © 2016 by "Divine Mercy Transcription"
All Rights reserved