PIAB Irish Medicolegal Template 2

IDENTIFICATION Patient Name: Sarah Jane O'Connell PIAB Reference / Application Number: PIAB/2023/123456 Examining Doctor: Dr. Fiona Kelly Date of Birth: 15/03/1988 Gender: Female Address: 14 Maple Drive, Dublin 4, D04 A1B2 Occupation (include changes since accident): Primary school teacher, currently unable to perform duties requiring prolonged standing or lifting due to back pain. Currently at Work: 1. [ ] "Yes" 2. [X] "No" Dominant Hand: 1. [X] "Right" 2. [ ] "Left" Height: 168 cm Weight: 72 kg BMI (and change since accident): 25.5 kg/m^2 (increased from 24.0 kg/m^2 due to reduced activity levels). INCIDENT Date of Accident: 01/05/2024 Examination Date: 01/11/2024 Total Time Elapsed Since Accident: 0 years 6 months Brief Accident Details: Ms. O'Connell was involved in a rear-end road traffic collision while stationary at a red light. She reports feeling a sudden jolt and her head snapped back and forth. She experienced immediate neck and lower back pain, accompanied by a dull ache in her right shoulder. She was able to exit her vehicle but required assistance from a bystander. DOMINANT / MOST SIGNIFICANT INJURY Details of Dominant/Most Significant Injury (include history immediately after accident and subsequent days): Acute cervical strain and lumbar strain. Immediately after the accident, Ms. O'Connell reported significant stiffness and pain in her neck, exacerbated by movement. She also noted a constant, aching pain in her lower back, rating it 7/10 at its worst. Over the subsequent days, her neck pain radiated into her right trapezius and shoulder, limiting overhead movements. Lumbar pain worsened with prolonged sitting and standing, making it difficult to carry out daily tasks. OTHER INJURIES Details of Other Injuries Sustained (history immediate and subsequent few days): - Right shoulder contusion: Developed bruising and mild tenderness over the right acromion process, resolving within 2 weeks. - Headaches: Occasional tension-type headaches, particularly in the occipital region, improving with over-the-counter analgesia. INITIAL CARE & HOSPITALISATION Date First Treatment Sought: 01/05/2024 From Whom: Paramedics at the scene of the accident, followed by A&E doctor at St. James's Hospital. Was Claimant Hospitalised: 1. [ ] "Yes" 2. [X] "No" If Yes — Where: St. James's Hospital Duration of Inpatient Stay: Not applicable Total Length of Absence from Work: From 02/05/2024 to ongoing If Ongoing, Is Absence Due to the Accident: 1. [X] "Yes" 2. [ ] "No" Was the Absence Reasonable: 1. [X] "Yes" 2. [ ] "No" Number of GP Visits: 8 Number of Specialist/Consultant Visits: 3 Specialist(s) Identity (if known): - Dr. Liam Byrne, Orthopaedic Surgeon - Dr. Aoife Casey, Physiotherapist TREATMENT & INVESTIGATIONS TO DATE Medications (name, dose, start/stop/change since accident): - Paracetamol 1g QDS PRN (started 01/05/2024, ongoing) - Ibuprofen 400mg TDS PRN (started 01/05/2024, stopped 01/07/2024 due to gastric irritation) - Diclofenac 50mg BD PRN (started 01/07/2024, ongoing) Physiotherapy Sessions: 10 sessions. Patient reported initial improvement in neck and shoulder range of motion, but lower back pain remains persistent despite exercises and manual therapy. Imaging and Test Results (X-ray/MRI/CT/bloods): - Cervical Spine X-ray (01/05/2024): No fractures or dislocations. Minor degenerative changes noted, consistent with age. - Lumbar Spine MRI (15/05/2024): Mild disc bulge at L4/L5 with no nerve root impingement. No significant traumatic findings. Imaging suggests some age-related wear and tear, which has been symptomatically activated by the accident. Other Treatments (injections, surgery, psychological therapy): - None to date. RELEVANT MEDICAL HISTORY Relevant History: 1. [X] "Yes" 2. [ ] "No" If Yes — Describe: Ms. O'Connell has a history of occasional lower back stiffness, typically resolved with rest and mild exercise. She had no significant neck or shoulder pain prior to the accident. Aggravation of Pre-Existing Condition: 1. [X] "Yes" 2. [ ] "No" If Yes — Nature of Pre-Existing Condition: Mild, intermittent lower back stiffness, attributed to sedentary work habits. Was Pre-Existing Condition Active/Symptomatic Before the Accident: 1. [X] "Yes" 2. [ ] "No" 3. [ ] "Unknown" Previous (or Subsequent) Accidents (dates and brief details): - Fall in 2018: Minor ankle sprain, fully recovered. PRESENTING COMPLAINTS & EFFECTS Presenting Complaints (symptoms, severity, temporal pattern): Ms. O'Connell continues to experience daily neck pain, rated 4/10 at rest and up to 6/10 with movement. Lumbar pain is constant, rated 5/10 at rest, worsening to 7/10 after prolonged sitting or standing. Both pains are typically worse in the evenings. She also reports intermittent right shoulder discomfort with reaching overhead. Impact on Lifestyle / Recreational / Domestic Activities: She struggles with household chores such as vacuuming and lifting groceries. Recreational activities like cycling and hiking, which she previously enjoyed, are now significantly restricted due to pain. She is unable to play with her young children as actively as before. Impact on Employment (tasks affected, hours, modifications): As a primary school teacher, tasks involving prolonged standing, bending to assist children, and lifting teaching materials are severely affected. She is currently on sick leave and unable to return to her previous role without significant modifications, such as reduced hours or an assistant. Interference with Quality of Life and Leisure Activities: The constant pain and physical limitations have led to a noticeable decline in her quality of life. She reports increased frustration and irritability, and has withdrawn from social engagements that involve physical activity. Sleep is often disturbed due to discomfort. Impact on Personal Relationships: Her inability to participate in family activities and increased irritability have placed a strain on her relationship with her spouse and children. PAIN & FUNCTIONAL SCORES Visual Analogue Scale (current pain): 6/10 Neck Disability Index (NDI) Score (if neck injury): 45 % CLINICAL EXAMINATION & FINDINGS Vital Signs at Exam (if relevant): BP 120/80 mmHg, HR 78 bpm, Temp 36.8°C. General Appearance: Patient is comfortable at rest but exhibits an antalgic posture when standing from a seated position, favouring her lower back. She appears well-nourished and alert. Local Examination (per region): Head / Neck: Mild tenderness to palpation over the cervical paraspinal muscles, particularly C5-C7. Reduced active range of motion: flexion to 40°, extension to 35°, lateral rotation right 60°, left 55°. No neurological deficits in upper limbs. Thorax / Chest: Normal respiratory effort, no tenderness or deformities. Lumbar / Back: Diffuse tenderness to palpation over the lumbosacral region, primarily L4-S1. Reduced active range of motion: flexion to 50°, extension to 15°, lateral flexion right 20°, left 20°. Straight leg raise negative bilaterally to 70°. Upper Limb: Full strength in biceps, triceps, deltoids, and wrist extensors (5/5 bilaterally). Intact sensation to light touch. Reflexes 2+ bilaterally. Lower Limb: Full strength in hip flexors, knee extensors, and ankle dorsiflexors (5/5 bilaterally). Intact sensation to light touch. Reflexes 2+ bilaterally. Gait is slightly guarded with shortened stride. Range of Motion — Documented: - Cervical Flexion: 40° (Normal: 60°) - Cervical Extension: 35° (Normal: 75°) - Lumbar Flexion: 50° (Normal: 90°) - Lumbar Extension: 15° (Normal: 30°) Neurological Examination: No focal neurological deficits detected in either upper or lower limbs. No signs of radiculopathy or myelopathy. Special Tests Performed and Results: - Spurling's Test: Negative bilaterally. - Faber Test: Negative bilaterally. Photographs of Scarring (if relevant): Not applicable. FUNCTIONAL IMPACT RATING Clinical description of effects on ability — mark the most appropriate level for each domain: Normal / Minor / Moderate / Serious / Severe Mental Health 1. [ ] "Normal" 2. [X] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Learning/Intelligence 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Consciousness/Seizure 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Balance/Co-ordination 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Vision 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Hearing 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Speech 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Continence 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Reaching 1. [ ] "Normal" 2. [X] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Manual Dexterity 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Carrying/Lifting 1. [ ] "Normal" 2. [ ] "Minor" 3. [X] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Bending/Stooping 1. [ ] "Normal" 2. [ ] "Minor" 3. [X] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Sitting 1. [ ] "Normal" 2. [X] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Standing 1. [ ] "Normal" 2. [X] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Climbing Stairs 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" Walking 1. [X] "Normal" 2. [ ] "Minor" 3. [ ] "Moderate" 4. [ ] "Serious" 5. [ ] "Severe" OPINION, CAUSATION & PROGNOSIS Opinion / General Comments and Latest Prognosis: Ms. O'Connell sustained a soft tissue injury to her cervical and lumbar spine, and a right shoulder contusion as a result of the road traffic collision on 01/05/2024. While the shoulder contusion has resolved, she continues to experience persistent neck and lower back pain, which has significantly impacted her occupational and daily activities. Her pre-existing, asymptomatic lower back stiffness appears to have been activated and aggravated by the accident. Despite consistent physiotherapy, her progress has been limited in the last two months. Prognosis for complete resolution of symptoms is guarded given the chronicity and persistent functional limitations. She is likely to experience ongoing mild to moderate intermittent pain. Degree to Which Claimant's Symptoms/Disability Are Caused by the Accident: 1. [ ] "None of the symptoms/disability" 2. [ ] "A small proportion (≤25%) of the symptoms/disability" 3. [X] "A moderate proportion (~50%) of the symptoms/disability" 4. [ ] "Most (≥75%) of the symptoms/disability" 5. [ ] "All of the symptoms/disability" The accident directly caused the acute onset of her neck and lumbar pain. While she had a prior history of mild lumbar stiffness, the current level of pain and disability is a direct consequence of the traumatic event. It is reasonable to attribute approximately 50% of her current symptoms to the aggravation of her pre-existing condition and the new injuries sustained. Are Further Investigations Required: 1. [X] "Yes" 2. [ ] "No" Details of Further Investigations Required: - Referral to Pain Management Clinic for consideration of interventional pain procedures or more advanced pharmacological management, given the chronicity of symptoms. Is the Medical Intervention Received Consistent with the Injuries: 1. [X] "Yes" 2. [ ] "No" If Not Consistent, Comment: If Pre-Existing Condition Aggravated — Extent and Duration of Increased Symptomology: The pre-existing mild lumbar stiffness, previously managed with occasional rest, has been aggravated to a point where it now causes daily moderate pain and significant functional limitation, persisting for 6 months since the accident. Estimated Period to Substantial Recovery (from date of accident): 1 year 6 months If Not Yet Recovered — Estimated Time to Substantial Recovery: 1 year Are Late Complications Expected: 1. [X] "Yes" 2. [ ] "No" If Yes — Describe: Chronic pain syndrome, increased risk of early degenerative changes in the lumbar spine, and potential for psychological distress (e.g., anxiety, depression) due to ongoing pain and functional limitation. If Substantial Recovery Not Expected — Detail Expected Prognosis Including Likely Effects on Lifestyle/Work: Substantial recovery is not expected. Ms. O'Connell is likely to experience persistent, intermittent moderate neck and lumbar pain. This will continue to impact her ability to perform tasks requiring prolonged standing, bending, and lifting. She may require permanent modifications to her teaching role or a career change. Her recreational and domestic activities will remain significantly limited, affecting her overall quality of life and potentially straining personal relationships. FURTHER SPECIALIST REPORTS & FUTURE TREATMENT Are Further Specialist Reports Recommended: 1. [X] "Yes" 2. [ ] "No" If Yes — Speciality Required: Pain Medicine, Occupational Health. Anticipated Future Treatment Required (including approximate future treatment costs if applicable): Further physiotherapy/rehabilitation (estimated €1500), potential pain management injections (€500-€1000 per injection series), psychological therapy for pain coping strategies (estimated €1000), and ergonomic assessment for workplace modifications (estimated €300). SUMMARY / ADDITIONAL INFORMATION Ms. Sarah O'Connell, a 36-year-old primary school teacher, sustained acute cervical and lumbar strain, and a right shoulder contusion in a road traffic accident on 01/05/2024. While her shoulder injury resolved, she continues to suffer from persistent neck and lower back pain, rated 6/10 and 7/10 respectively at their worst. This pain significantly limits her ability to perform occupational duties, household tasks, and recreational activities, leading to a minor impact on mental health and a moderate impact on carrying/lifting and bending/stooping. Her mild pre-existing lumbar stiffness has been aggravated by the accident, contributing approximately 50% to her current symptoms. Prognosis for complete recovery is guarded, with an estimated further 1 year to substantial recovery from the current date, and a risk of chronic pain and early degenerative changes. Further investigations with Pain Medicine and Occupational Health are recommended, along with continued rehabilitation and potential psychological support. COMPLETION & SIGNATURE Completed By: Dr. Fiona Kelly Qualifications: MB BCh BAO, MRCEM, FRCPI Medical Council Registration Number: 12345 Address (Clinician): Department of Emergency Medicine, St. James's Hospital, Dublin 8 Completion Date: 01/11/2024 Signature: Fiona Kelly PIAB WAD SECTION (Only complete when neck pain or whiplash is applicable) Assessment of Cervical Range of Motion: 1. [ ] "Normal" 2. [X] "Abnormal" Palpation for Consistent Tenderness: 1. [X] "Present" 2. [ ] "Absent" Neurological Signs: 1. [ ] "Present" 2. [X] "Absent" WAD Grade: 1. [ ] "WAD 0 — No neck pain, stiffness or any physical signs are noticed" 2. [ ] "WAD I — Complaints of neck pain, stiffness, but no physical signs" 3. [X] "WAD II — Neck complaints and decreased range of motion and local tenderness in the neck" 4. [ ] "WAD III — Neck complaints and neurological signs" 5. [ ] "WAD IV — Neck complaints and fracture, dislocation or injury to the spinal cord" Neck Disability Index (NDI) Score: 45 % Ms. O'Connell's WAD grade has remained at II since her initial presentation, indicating persistent neck complaints with objectively decreased range of motion and local tenderness. The NDI questionnaire completed by the claimant highlights significant disability in personal care, reading, work, driving, recreation, and sleep.