PIAB Irish Medicolegal Template 1

Clinician's Specialty: Emergency Medicine Specialist PIAB Medical Assessment Form (Form B) PIAB Application Number 2024/IRE/12345 Examining Doctor's Name Dr. Fiona O'Connell Claimant Name Patrick Murphy Address Apartment 4B, O'Connell Street, Dublin 1, D01 A1B2 Gender Male Date of Birth 15/03/1988 Occupation (including details of any change since the date of accident) Construction Worker (previously site foreman, now light duties only) Currently at work? 1. [X] "Yes" 2. [ ] "No" Right or left hand dominant? 1. [X] "Right" 2. [ ] "Left" Height 178 cm Weight 85 kg BMI (and details of any change since accident date) 26.8 (Increased by 1.5 since accident due to reduced activity) Date of Accident 10/05/2024 Examination Date 01/11/2024 Total Time Elapsed Since Date of Accident (date of accident to examination date) Years: 0 Months: 5 Brief Accident Details The claimant, Mr. Patrick Murphy, was involved in a motor vehicle collision on 10th May 2024. He was the driver of a car that was rear-ended at a moderate speed while stationary at traffic lights. His vehicle sustained significant rear-end damage. He reported immediate onset of neck and back pain. Details of Dominant/Most Significant Injury Sustained (within your expertise) Mr. Murphy sustained a whiplash injury to his cervical spine, manifesting as severe neck pain, stiffness, and headache. Immediately after the accident, he experienced acute pain, radiating into his shoulders. Over the subsequent few days, the pain intensified, particularly with movement, and was accompanied by persistent headaches and difficulty sleeping. He also noted paresthesia in his right upper limb. Details of Other Injuries Sustained He also reported acute lower back pain, exacerbated by prolonged sitting or standing. This pain developed within hours of the accident and was a constant, dull ache, occasionally sharp with sudden movements. Date First Treatment Sought 10/05/2024 From Who Was It Received? Emergency Department, St. James's Hospital Was Claimant Hospitalised? 1. [ ] "Yes" 2. [X] "No" If hospitalised, where? Duration of Inpatient Stay Total Length of Absence from Work Years: 0 Months: 2 From: 11/05/2024 To: 10/07/2024 If Absence is Ongoing, Is It Due to the Accident? No, he has returned to light duties. Was/Is the Claimant's Absence Period Reasonable? 1. [X] "Yes" 2. [ ] "No" Number of GP Visits 5 Number of Specialist/Consultant Visits 2 Identity of Specialist/Consultant(s), if Known Dr. Liam O'Toole (Orthopaedic Consultant), Dr. Sarah Kelly (Physiotherapist) Treatment and Investigations to Date Initial treatment in the Emergency Department included analgesia (ibuprofen and paracetamol) and a soft cervical collar for comfort, used for 3 days. He was advised rest and gradual return to activity. He attended 6 sessions of physiotherapy focusing on mobilising exercises, stretching, and pain management techniques. Medications include Naproxen 500mg twice daily for 4 weeks post-accident, followed by over-the-counter paracetamol as needed. There have been no changes in medication in the last six months as acute phase resolved. Number of Physiotherapy Sessions, if Any 6 X-Ray/MRI Results Cervical spine X-rays performed on 10/05/2024 showed no fractures or dislocations. Lumbar spine X-rays also showed no acute bony pathology. An MRI of the cervical spine performed on 25/05/2024 revealed minor disc desiccation at C5-C6 and C6-C7, consistent with age-related changes, without significant nerve root compression. The findings are not acutely traumatic and it is unlikely that Mr. Murphy would have experienced symptoms regardless of the accident. The symptoms aggravated by the accident are expected to return to a pre-accident state within 9-12 months from the date of the accident. World Health Organisation (WHO) International Classification of Diseases (ICD) S13.4XXA, M54.2 Relevant Medical History Relevant History? 1. [X] "Yes" 2. [ ] "No" Aggravation of Pre-Existing Condition? 1. [ ] "Yes" 2. [X] "No" If Yes, Please Give Nature of Pre-Existing Condition Give Details of Previous (or Subsequent) Accident History, if Any No significant previous accident history. No subsequent accidents. Was Pre-Existing Condition Active/Symptomatic Before the Accident? Not applicable. Present Complaints to Include Effects on Lifestyle/Recreational and Domestic Personal Activities Mr. Murphy continues to experience intermittent neck stiffness and occasional headaches, especially after prolonged periods of computer work or driving. He reports difficulty with overhead tasks and lifting heavy objects. His ability to participate in his weekly football games has been significantly curtailed, leading to frustration and reduced social interaction. Domestic chores requiring bending or reaching, such as vacuuming and gardening, are performed with pain and difficulty. Impact on Employment Currently on light duties, unable to perform previous role as site foreman which involved supervising and occasional manual handling. This has led to a temporary reduction in income and job satisfaction. He is concerned about his long-term capacity to return to full duties. Interference with Quality of Life and Leisure Activities Significant interference with quality of life. Unable to play football, cycle, or engage in active recreational pursuits. Experiences difficulty sleeping due to discomfort, leading to fatigue. Social activities have decreased due to pain and mood. Impact on Personal Relationships Increased irritability reported by his partner due to chronic pain and frustration. Reduced participation in family outings and activities with his children due to physical limitations. Visual Analogue Scale (VAS) for Pain Score 4/10 Clinical Findings on Examination On examination, cervical spine showed a restricted range of motion, particularly in rotation and lateral flexion (approximately 20% reduced in all planes). Palpation revealed tenderness over the paraspinal muscles in the cervical and upper thoracic regions. No neurological deficits were noted in the upper or lower limbs. Deep tendon reflexes were symmetrical and intact. Muscle power 5/5 bilaterally. No objective sensory loss. No photographs of accident-related scarring are included as no significant scarring present. Clinical Description of Effects of Claimant's Illness/Accident/Disablement 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. [X] "Minor" 3. [ ] "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/General Comments and Latest Prognosis Indicate the degree to which you feel all of the claimant's symptoms/disability have been caused by the accident/event which is the subject of this claim; based on assessment of the injury as described by the claimant, the accident/events accounts for: 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" Please Comment Further The accident has significantly exacerbated underlying age-related degenerative changes in the cervical spine, leading to the current symptomology. While some mild degenerative changes were likely present pre-accident, the acute onset and severity of symptoms directly correlate with the reported mechanism of injury. It is estimated that approximately 50% of the current symptoms and disability are directly attributable to the accident. Are Further Investigations Required in Respect of Any of the Injuries Sustained in the Accident? 1. [ ] "Yes" 2. [X] "No" Details of Further Investigations Required Is the Medical Intervention and Treatment Received Consistent with the Injuries Suffered? 1. [X] "Yes" 2. [ ] "No" If Not Consistent, Please Comment Further If a Claimant Has a Pre-Existing Condition That Is Aggravated by an Injury, Please Detail the Extent to Which the Pre-Existing Injury Has Been Made Worse and the Duration of Any Increased Symptomology While no clearly defined pre-existing condition was aggravated, the accident appears to have made dormant age-related degenerative changes symptomatic. The increased symptomology, particularly neck stiffness and pain, has persisted for 5 months and is expected to continue for another 4-7 months before reaching pre-accident baseline. Estimated Total Time Period from the Date of Accident in Which a Substantial Recovery Took Place Years: 0 Months: 9 If a Substantial Recovery Has Not Already Taken Place, Please Provide the Estimated Total Time Period from the Date of Accident to Substantial Recovery Years: 0 Months: 12 Are Late Complications Expected? 1. [ ] "Yes" 2. [X] "No" If a Substantial Recovery Is Not Expected, Please Detail the Expected Prognosis Including the Likely Effects on Lifestyle/Work Are Further Specialist Reports Recommended? 1. [ ] "Yes" 2. [X] "No" If Further Specialist Reports Are Recommended, Please Specify the Speciality Required Anticipated Future Treatment Required Further physiotherapy sessions (approximately 4-6) are anticipated to aid in full recovery and return to pre-accident activity levels. Cost per session approximately €60-€80, total estimated cost €240-€480. Summary/Additional Information Mr. Murphy presented with classic symptoms of a whiplash injury following a road traffic accident. While initial recovery was positive with return to light duties, persistent symptoms, though reducing, continue to impact his quality of life and work capacity. Prognosis is good for substantial recovery within 12 months, with no expected late complications. It is important to consider the contribution of pre-existing degenerative changes in the overall recovery timeline. Completed By Name Dr. Fiona O'Connell, Emergency Medicine Specialist Signature F. O'Connell Address Emergency Department, St. James's Hospital, James's Street, Dublin 8 Qualifications MB BCh BAO, FRCEM Medical Council Registration Number 012345 Completion Date 01/11/2024 Please Complete This Section Only if a Claimant Has Suffered Neck Pain or Whiplash Associated Disorder (WAD) Findings as at time of examination Examination revealed restricted cervical range of motion, tenderness in the paraspinal muscles, and no neurological deficits. These findings are consistent with a persistent whiplash-associated disorder. The claimant demonstrates a consistent pain behaviour during movements that stress the cervical spine, but no signs of malingering. 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" Indicate the Whiplash Associated Disorder (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" If the Claimant's WAD Grade Has Changed During the Course of Their Recovery, Please Comment on These Changes Initially, the claimant presented with symptoms suggestive of WAD Grade I, primarily neck pain and stiffness without objective physical signs. Within 48 hours, due to increased stiffness and markedly decreased range of motion, this progressed to WAD Grade II. This grade has remained stable during his recovery process to date. Neck Disability Index (NDI) Score 32 % Neck Disability Index (NDI) Claimant Name Patrick Murphy PIAB Reference 2024/IRE/12345 Date Completed 01/11/2024 This questionnaire has been designed to provide information as to how your neck pain has affected your ability to manage in everyday life. Please mark in each and every section (1–10) only one box that applies to you. We realise you may consider that two or more statements in any one section relate to you, but please mark just the box in each section that most closely describes your problem. Section 1: Pain Intensity 1. [ ] "I have no pain at the moment" 2. [ ] "The pain is very mild at the moment" 3. [X] "The pain is moderate at the moment" 4. [ ] "The pain is fairly severe at the moment" 5. [ ] "The pain is very severe at the moment" 6. [ ] "The pain is the worst imaginable at the moment" Section 2: Personal Care (washing, dressing, etc.) 1. [ ] "I can look after myself normally without causing extra pain" 2. [X] "I can look after myself normally but it causes extra pain" 3. [ ] "It is painful to look after myself and I am slow and careful" 4. [ ] "I need some help but can manage most of my personal care" 5. [ ] "I need help every day in most aspects of self-care" 6. [ ] "I do not get dressed, I wash with difficulty and stay in bed" Section 3: Lifting 1. [ ] "I can lift heavy weights without extra pain" 2. [ ] "I can lift heavy weights but it gives extra pain" 3. [ ] "Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table" 4. [X] "Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned" 5. [ ] "I can only lift very light weights" 6. [ ] "I cannot lift or carry anything" Section 4: Reading 1. [ ] "I can read as much as I want to with no pain in my neck" 2. [X] "I can read as much as I want to with slight pain in my neck" 3. [ ] "I can read as much as I want to with moderate pain in my neck" 4. [ ] "I cannot read as much as I want to because of moderate pain in my neck" 5. [ ] "I can hardly read at all because of severe pain in my neck" 6. [ ] "I cannot read at all" Section 5: Headaches 1. [ ] "I have no headaches at all" 2. [X] "I have slight headaches, which occur infrequently" 3. [ ] "I have moderate headaches, which come infrequently" 4. [ ] "I have moderate headaches, which come frequently" 5. [ ] "I have severe headaches, which come frequently" 6. [ ] "I have headaches almost all the time" Section 6: Concentration 1. [X] "I can concentrate fully when I want to with no difficulty" 2. [ ] "I can concentrate fully when I want to with slight difficulty" 3. [ ] "I have a fair degree of difficulty in concentrating when I want to" 4. [ ] "I have a lot of difficulty in concentrating when I want to" 5. [ ] "I have a great deal of difficulty in concentrating when I want to" 6. [ ] "I cannot concentrate at all" Section 7: Work 1. [ ] "I can do as much work as I want to" 2. [X] "I can only do my usual work, but no more" 3. [ ] "I can do most of my usual work, but no more" 4. [ ] "I cannot do my usual work" 5. [ ] "I can hardly do any work at all" 6. [ ] "I cannot do any work at all" Section 8: Driving 1. [ ] "I can drive my car without any neck pain" 2. [X] "I can drive my car as long as I want with slight pain in my neck" 3. [ ] "I can drive my car as long as I want with moderate pain in my neck" 4. [ ] "I cannot drive my car as long as I want because of moderate pain in my neck" 5. [ ] "I can hardly drive at all because of severe pain in my neck" 6. [ ] "I cannot drive my car at all" Section 9: Sleeping 1. [ ] "I have no trouble sleeping" 2. [X] "My sleep is slightly disturbed (less than 1 hr sleepless)" 3. [ ] "My sleep is mildly disturbed (1–2 hrs sleepless)" 4. [ ] "My sleep is moderately disturbed (2–3 hrs sleepless)" 5. [ ] "My sleep is greatly disturbed (3–5 hrs sleepless)" 6. [ ] "My sleep is completely disturbed (5–7 hrs sleepless)" Section 10: Recreation 1. [ ] "I am able to engage in all my recreation activities with no neck pain at all" 2. [ ] "I am able to engage in all my recreation activities, with some pain in my neck" 3. [X] "I am able to engage in most, but not all, of my usual recreation activities because of pain in my neck" 4. [ ] "I am able to engage in a few of my usual recreation activities because of pain in my neck" 5. [ ] "I can hardly do any recreation activities because of pain in my neck" 6. [ ] "I cannot do any recreation activities at all" Claimant Signature: Patrick Murphy Date: 01/11/2024 Visual Analogue Scale (VAS) for Pain Claimant Name Patrick Murphy PIAB Reference 2024/IRE/12345 Date of Assessment 01/11/2024 The VAS for pain consists of a 10cm line with two end-points representing 'no pain' and 'pain as bad as it could possibly be'. Claimants are asked to rate their pain by placing a mark on the line corresponding to their current level of pain. 4/10 Claimant Signature: Patrick Murphy Date: 01/11/2024