Personal Injury Medical Report on Joan Smith DOB 24.12.74 Reference by Dr. A.R.Feltbower MB BChir DRCOG AFOM General Medical Practitioner Westminster Road Medical Services Ltd 41 Westminster Road Coventry. CV1 3GB Tel : 02476 223565 Fax :02476 230053 Email: Tony.Feltbower@nhs.net at the request of Brain and Brace, Solicitors consisting of 14 pages Date of accident 05.04.02 Date of Examination - 06.05.03 PIreport - 1 - Report of Dr A R Feltbower
Contents Section Page number 1. Introduction summary of instructions and claim 3 2. Summary of my conclusions and recommendations 4 3. Investigation of facts 5 4. My examination 8 5. My Opinion 10 6. Statements of compliance and truth 11 Appendices 1. My experience and qualifications 12 2. Documents I have examined in producing this report 13 3. References 14 PIreport - 2 - Report of Dr A R Feltbower
1. The writer 1.1 I am Dr Tony R Feltbower, a full-time General Medical Practitioner. Full details of my qualifications and experience are in appendix 1. These entitle me to give an expert opinion. Summary of the claim 1.2 My instructions are to prepare a GP medical report of the physical and psychological injuries sustained by Joan Smith as a result of having been involved in a road traffic accident that occurred on 05.04.02 1.3 She was seen and examined on 06.05.03 1.4 It has been 13 months since the accident. PIreport - 3 - Report of Dr A R Feltbower
Summary of my conclusions, Prognosis and recommendations 1.5 As a result of having been involved in a road traffic accident on 05.04.02, Joan Smith incurred neck, left knee and psychological injuries and symptoms from which she has made partial recoveries. 1.6 I recommend physical therapy to assist rehabilitation. 1.7 It is likely to be a further 3-6 months before full recovery from her physical symptoms back to her pre-accident condition, and a further 3-6 months for full recovery from the psychological symptoms back to her pre-accident condition. PIreport - 4 - Report of Dr A R Feltbower
2. Investigation of facts as stated to me by Joan Smith Personal History. 2.1 Joan Smith is married. She lives with her in-laws. 2.2 She is a full time Student and also has a part-time job as a Telephonist. 2.3 She is not an active sportsperson, but enjoys attending a gym. 2.4 She is right handed. Past Medical History 2.5. She tells me that 2 years prior to the accident she injured her knee and was on a waiting list for an arthroscopy. She denies any past history of back or neck symptoms. She was not taking any relevant medication. History of Accident 2.6 On 05.04.02 at 3 p.m. she states that she was a front seat passenger of a motor vehicle. She was stationary. She was involved in a collision with a car that drove into her rear end jolting her vehicle forcibly forwards. She tells me she was wearing her seat belt and there are normal headrests for the front seats. As a result of this she sustained the following injuries. 2.7 A sudden hyperextension / hyperflexion injury to the cervical spine 2.8 A jarring, jolting force to the left knee. PIreport - 5 - Report of Dr A R Feltbower
2.9 She was emotionally shaken and distraught in a general sense which lasted for 2 3 days. She denied experiencing any physical features of stress. 2.10 Neither the police nor an ambulance attended at the scene. 2.11 Approximately 15 minutes later she was driven home. Injuries. 2.12 Physically she experienced pain down the back of her neck, across her shoulders & down between her shoulder blades soon after the accident. These symptoms began to improve after 3 weeks. 2.13 She also noticed that she developed a general occipital headache which has been fairly constant since then. 2.14 In addition she experienced some increased symptoms of pain and stiffness in her left knee. 2.15 Emotionally she felt shaken and distraught generally for 2 3 days associated with disturbed sleep. She became anxious when in a car which has interfered with her learning to drive. 2.16 She attended an Accident and Emergency department 2.17 She saw her own GP. PIreport - 6 - Report of Dr A R Feltbower
2.18 She took anti-inflammatory painkillers and had some massage treatment to her neck. Present Condition 2.19 She tells me that she has made partial recoveries. 2.20 In relation to her neck, she continues to wake up most mornings with stiffness. She also develops pain in the back of her neck if she is lifting or carrying anything heavy. 2.21 In relation to her knee, she had an arthroscopy approximately 3 4 months ago and she is waiting for follow-up assessment. She continues to experience some pain and tenderness around the joint but this is related to the arthroscopy which was required from the previous injury. 2.22 She continues to experience some anxiety when in a car. Employment 2.23 Joan Smith did not need to take any time away from work. 2.24 As it is anticipated she will make a full recovery back to her pre-accident state, her prospects in the open job market are not likely to be reduced. Hobbies/Sport/Lifestyle 2.25 A few weeks after the accident, she returned to the gym but has not been back since she had her arthroscopy. PIreport - 7 - Report of Dr A R Feltbower
3. Physical Examination 3.1 She is a pleasant lady. She is 5' 6" tall and 9 st in weight. She walks without discomfort. She is able to undress and dress easily, and climb on and off the examination couch without difficulty. 3.2 Her face is normal, there being a free play of expressions and normal skin sensation throughout. Examination of the skull is normal. She swallows normally. 3.3 The chest is clear and the heart sounds normal. Hands are steady, pulse 70 per minute and the blood pressure 95/60 mm Hg. 3.4 The cervical spine is normal in development, contour, function and musculature. There is general tenderness in the middle of the cervical spine and across the top of the trapezius muscle on the both sides. There is a normal range of movements free from inhibition apart from some tightness felt on lateral flexion to both sides. There is no neurological deficit relating to this area of the spine. 3.5 There is no deficiency in the joints of the shoulders, elbows, wrists or hands. 3.6 Examination of the left knee reveals general tenderness of the patella and along the joint lines. There are healing scars from the arthroscopy. PIreport - 8 - Report of Dr A R Feltbower
4. My Opinion 4.1. The injuries and symptoms described by Joan Smith are consistent with her descriptions of the accident and treatments she received. 4.2. There is no evidence to suggest that she has sustained any bony damage likely to cause any future long term arthritic changes in the cervical, thoracic or lumbar sacral spine nor any neurological trauma which would lead to future loss of function. 4.3. I understand that there is a body of medical evidence with respect to the prognosis of road traffic accident patients. This suggests that recovery of such cases varies from one case to another, from 1-2 weeks up to 18-24 months. 4.4 Her time away from sporting and lifestyle activities was reasonable for a few weeks. 4.5 I recommend she should commence physical therapy treatment in order to assist her rehabilitation, in my experience I find that 6-12 sessions is usually sufficient. 4.6 Taking into account the injuries sustained, the present symptoms experienced and my findings on examination, it is likely to be a further 3-6 months before there is full recovery from the injuries back to her preaccident state. 4.7 Medical research has shown that if the injuries do not resume completely within 2 years of the accident, there is a 28% chance of intrusive pain after 2 years, and a 12% chance of the pain being severe. (ref 1,2). If the client should not recover in this time period, a further specialist opinion should be sought. 4.8 In addition she will continue to experience times of anxiety when in a car, for a further period of 3-6 months. 4.9 In relation to the left knee, her current symptoms are unlikely to be related PIreport - 9 - Report of Dr A R Feltbower
to the accident. However, it might be appropriate for an Orthopaedic opinion. PIreport - 10 - Report of Dr A R Feltbower
5. Statements of compliance and truth I understand that my duty as an expert witness is to the Court. I have complied with that duty. This report includes all relevant matters to the issues on which my expert evidence is given. I have given details in this report of any matters that might affect the validity of this report. I have addressed this report to the Court. 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. Signed Dr AR Feltbower PIreport - 11 - Report of Dr A R Feltbower
Appendix 1 Qualifications MB BChir LRCP MRCS 1978 Diploma of the Royal College of Obstetrics and Gynaecology 1982 Associate of the Faculty of Occupational Medicine 1991 Cardiff University Expert Witness Certificate 2003 Post-registration Experience GP Clinical Assistant in Accident/Emergency 1984-88 GP Clinical Assistant in Rheumatology 1988-91 GP Clinical Assistant in Gynaecology 1983-96 Present Positions Full-time GP Principle in a Training Practice since 1982 Member Coventry Local Medical Committee Member of Professional Executive Committee of Coventry Primary Care Trust Employment Medical Advisory Service Appointed Doctor under 'Asbestos', 'Lead at Work' and 'Ionising Radiation Regulations' for a number of local companies. Occupational Health Medical Officer for Local Authorities 1997-2005 and many other local companies since 1992 Clinical Complaints Adviser to the Medical Defence Union AVMA registered Registered with UK Register of Expert Witnesses Recognised by the Law Society as a Single Joint Expert I have provided over 5000 personal injury reports and over 350 clinical negligence on behalf of claimants and defendants (60-40 split) since 1994. PIreport - 12 - Report of Dr A R Feltbower
Appendix 2 Medical records I have received some copies of GP records from 1997 to 12.06.02, including copy of attendance at an Accident and Emergency Department on 05.04.02. The records appear incomplete, as there are no Hospital records relating to a knee problem. I believe the Accident & Emergency record is also incomplete as there is only one page for this. I recommend a review of up to date medical records and upon receipt of these, I will provide a supplementary report. PIreport - 13 - Report of Dr A R Feltbower
References a. Long term prognosis of soft tissue injuries of the neck J Bone Joint Surg 1990, 72 B901-3. b. Deans et al 1987 Neck Sprain a major cause of disability following car accidents. Injury 1987 18 : 10-2 c. MacNab Acceleration injuries of the cervical spine J Bone Joint Surg Am 1964, 46-A1797-9 and Norris & Watt the prognosis of neck injuries resulting from rear end vehicle collisions J Bone Joint Surg 1983, 65-B608-111983 and Deans et al 1987. d. Soft tissue injuries of the neck Clin.Orthop 1975, 109 : 42-9 e. The prognosis of Neck Injuries resulting from Rear End Vehicle Collisions, J Bone Joint Surg 1983, 65-B : 608-11. PIreport - 14 - Report of Dr A R Feltbower