TORT ASSESSMENT

Psychiatry Assessment Prepared by Dr. Eleanor Vance, MD (insert the full name and credentials of the clinician completing the report. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Date of the Assessment: 01/11/2024 (insert the full date the assessment was conducted. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Date of the Report: 01/11/2024 (insert the date the report was completed. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Date of last modification: 01/11/2024 (insert the most recent modification date. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Regarding: John Smith (insert the full legal name of the patient. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Date of Birth: 15/03/1980 (insert in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Date of Loss: 10/09/2024 (insert the index date of the incident or injury, if applicable. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) TABLE OF CONTENTS 1) HISTORY OF INJURIES 2) TREATMENTS AND PROGRESS 3) MEDICAL AND SURGICAL HISTORY 4) MENTAL HEALTH HISTORY 5) SOCIAL HISTORY 6) WORK AND EDUCATION HISTORY 7) ACTIVITIES OF DAILY LIVING 8) CURRENT SYMPTOMS 9) PAIN-RELATED AND MENTAL HEALTH SCREENING 10) PHYSICAL EXAMINATION 11) RESPONSES TO QUESTIONS HISTORY OF INJURIES Mr. Smith was involved in a motor vehicle accident on 10/09/2024. He was the driver of a car that was struck from behind at a traffic light. The accident occurred in good weather conditions. He reported immediate neck pain and headache at the scene. He was assessed by paramedics and transported to the local emergency room. X-rays were taken and were unremarkable. He was discharged home with instructions for rest and pain management. (include patient demographics, accident details, time, location, weather, role in the incident, actions taken before/during/after, symptoms at the scene, emergency care, investigations, hospital course and discharge. Write in full paragraph form. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) TREATMENTS AND PROGRESS Following discharge from the emergency room, Mr. Smith followed up with his primary care physician. He was prescribed ibuprofen for pain. He attended physical therapy twice a week for the past six weeks, focusing on cervical range of motion exercises and postural correction. He reports some improvement in neck pain, but headaches persist. He was referred to the pain clinic for further evaluation. (include follow-up appointments, symptom progression, family physician input, prescriptions, diagnostics, rehabilitation, treatment responses, referrals, declined care, and healthcare utilisation. Write in full paragraphs or bullet points as appropriate. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) MEDICAL AND SURGICAL HISTORY PRE-ACCIDENT * No prior history of accidents. * Occasional headaches, managed with over-the-counter medication. * No chronic conditions. * No surgeries. * No known drug allergies. (summarise previous accidents, chronic conditions, surgeries, medications, drug allergies, pain history and healthcare access. Bullet points or short paragraphs. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) POST-ACCIDENT * Cervical strain. * Post-concussive syndrome. * Referred to pain clinic. * Prescription for ibuprofen. (list any new diagnoses, treatments, surgeries, medications, recommendations declined, investigations completed, symptom fluctuations. Use bullet points. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) MENTAL HEALTH HISTORY PRE-ACCIDENT No prior history of mental health conditions or treatment. (describe any pre-existing diagnoses, treatments, counselling, stressors, and support systems. Use paragraph format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) POST-ACCIDENT Patient reports increased anxiety and difficulty sleeping since the accident. He denies any suicidal ideation. (summarise mood changes, withdrawal, anxiety, cognition, sleep disturbances, nightmares, flashbacks, and driving anxiety. Paragraph format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) SOCIAL HISTORY PRE-ACCIDENT * Married, living with wife and two children. * Employed as a software engineer. * Active in community sports. (include birthplace, childhood, immigration status, marital/relationship status, children, living situation, family relationships, education and substance use. Bullet or short paragraph format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) POST-ACCIDENT * Reports increased irritability with family. * Reduced participation in social activities. (describe changes to relationship status, living arrangements, family dynamics, substance use, caregiving roles and social activities. Bullet format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) WORK AND EDUCATION HISTORY PRE-ACCIDENT Employed full-time as a software engineer. (include job title, employer, work schedule, duties, school attendance, and any secondary employment. Bullet or paragraph format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) POST-ACCIDENT Has been on sick leave since the accident. (summarise return-to-work, time off, modified duties, job performance, and school or secondary job adjustments. Paragraph format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) ACTIVITIES OF DAILY LIVING (ADL) PRE-ACCIDENT Independent in all ADLs. (describe ability to complete tasks such as bathing, grooming, dressing, toileting, feeding, and mobility. Use bullet points. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) POST-ACCIDENT Reports difficulty sleeping and reduced ability to concentrate. (note any reductions in independence, supports required, new routines or limitations. Bullet format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) HOUSEHOLD AND CAREGIVING RESPONSIBILITIES PRE-ACCIDENT Shared household chores with wife. (list household chores, caregiving roles, including information on household members needing assistance. Bullet points. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) POST-ACCIDENT Wife has taken on more household responsibilities. (include changes in chores, meal prep, caregiving limitations, and dependency on others. Bullet format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) OTHER EXTENDED ACTIVITIES OF DAILY LIVING (EADL) PRE-ACCIDENT Active in community sports and social events. (include hobbies, recreational activities, social events, driving short/long distances. Bullet format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) POST-ACCIDENT Reduced participation in sports and social activities. (summarise reduction in or avoidance of activities, physical/psychological limitations, and driving status. Bullet format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) CURRENT SYMPTOMS * Neck pain: located in the posterior neck, described as a dull ache, rated 4/10, aggravated by prolonged sitting, relieved by rest. * Headaches: located in the frontal region, described as a pressure, rated 5/10, associated with nausea, triggered by stress, relieved by rest and ibuprofen. * Anxiety: feeling of worry and unease, rated 3/10, triggered by thoughts of the accident, relieved by distraction. (for each symptom, describe location, severity, quality, radiation, associated symptoms, triggers, and relieving factors. Use structured bullets or detailed paragraph. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) PAIN-RELATED AND MENTAL HEALTH SCREENING Patient completed the PHQ-9 and GAD-7 questionnaires. PHQ-9 score was 8, indicating mild depression. GAD-7 score was 7, indicating mild anxiety. (include formal tools used, patient self-report, severity, impact on function, and clinician interpretation. Paragraph format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) PHYSICAL EXAMINATION BIOMETRICS Height: 180 cm (insert measured height. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Weight: 80 kg (insert measured weight. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Dominant hand: right (insert 'left' or 'right'. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) - Gait Assessment: Normal gait. - General Appearance: Appears stated age, well-groomed. - CNS Examination: Cranial nerves II-XII intact. - Head and Neck Examination: Tenderness to palpation in the cervical paraspinal muscles. Reduced cervical range of motion. - Shoulder Examination: Full range of motion, no pain. - Lumbar Spine Examination: No tenderness to palpation. - Hip Examination: Full range of motion, no pain. - Neurological Examination: Reflexes 2+ bilaterally in upper and lower extremities. Sensory intact to light touch. (summarise findings in the following systems using structured sentences. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) PAIN-DIAGRAM Patient marked the posterior neck and frontal head as areas of pain. (describe areas marked by the patient and any significant distribution patterns. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) CLINICAL SUMMARY Mr. Smith presents with ongoing neck pain, headaches, and symptoms of anxiety following a motor vehicle accident. Examination reveals cervical muscle tenderness and reduced range of motion. Psychological screening indicates mild depression and anxiety. (summarise mechanism of injury, injuries sustained, current diagnoses, contributing factors and clinical rationale. Paragraph format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) TREATMENT RECOMMENDATIONS * Continue physical therapy. * Follow up with pain clinic. * Consider referral to a psychologist for cognitive behavioral therapy. * Continue ibuprofen as needed for pain. (list specific treatment recommendations by symptom domain including provider, intervention type, frequency and rationale. Bullet format. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) RESPONSES TO QUESTIONS 1. What is the prognosis for my neck pain? (state the question asked by the patient. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) With continued physical therapy and pain management, the prognosis is good. (insert clinician’s detailed response. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) 2. Will I be able to return to work? (state the question asked by the patient. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) Yes, with appropriate treatment and management of symptoms, a return to work is anticipated. (insert clinician’s detailed response. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) 3. (state the question asked by the patient. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) (insert clinician’s detailed response. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) 4. (state the question asked by the patient Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) (insert clinician’s detailed response. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) 5. (state the question asked by the patient. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) (insert clinician’s detailed response. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) 6. (state the question asked by the patient. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) (insert clinician’s detailed response. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state that the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section out entirely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)