MEDICAL REPORT SOLICITOR’S REF AB/12/FGH/679 INSTRUCTIONS FROM
MEDICAL REPORT SOLICITOR’S REF AB/12/FGH/679 INSTRUCTIONS FROM Jones and Jones Solicitors CLIENT’S NAME John Finton ADDRESS 98 Prescot Road, Macclesfield, Cheshire DOB 10 January 1978 DATE OF ACCIDENT 15 February 2010 DATE OF REPORT 15 April 2010 REVIEW OF NOTES None OCCUPATION Welder IDENTIFICATION Passport ACCIDENTAt 2pm on 15 February 2010 Mr Finton was travelling in Macclesfield in a Nissan Almera fitted with seatbelts and headrests. He was the driver. Without warning whilst turning right another vehicle impacted with the rear of his vehicle.
The impact to the other vehicle was to the front.MOVEMENT OF CLIENT ON IMPACTHe suffered a forced flexion extension movement of his neck without rotation.IMMEDIATE SYMPTOMSHe had no immediate symptoms.CHRONOLOGICAL PROGRESSION OF PHYSICAL SYMPTOMSThe next day he developed pain in his neck and across his shoulders. He went to Green Bank Accident and Emergency Department where he was examined, no x-rays were taken and whiplash type injury was diagnosed. He was discharged with advice. The pain was severe for one week interfering with sleep and needing analgesics and then improved.
He has had six sessions of physiotherapy which have proved helpful.CHRONOLOGICAL PROGRESSION OF PSYCHOLOGICAL SYMPTOMSThere have been no serious psychological symptoms associated with the accident.CURRENT SYMPTOMS AND TREATMENTHe has intermittent pain in his left arm.PAST MEDICAL HISTORYHe gives no past medical history of note. No previous history of accidents. No history of stress disorder or depression.
No history of musculoskeletal problems.LOSS CONSEQUENTIAL TO INJURYHe is a Welder and had two weeks off work following the accident. I would regard this as reasonable considering the nature of his injuries and the nature of his occupation. The accident had no other effect on his social or domestic life.EXAMINATIONOn examination he is a man of normal build with a normal gait.Examination of his upper limbs is normal.Examination of his cervical spine shows a full range of movement actively and passively in all directions. There was no muscular tenderness.
Flexion extension of his lumbosacral spine was full. Straight leg raising was full. There was no spinal tenderness.
There were no other marks, scars or bruises and no inappropriate responses.SUMMARY AND CONCLUSIONSAs a result of a road traffic accident on 15 February 2010 Mr Finton sustained a whiplash injury to his cervical spine. The injuries sustained are compatible with the accident. There were no adverse features associated with the accident. Consequent to the accident he had severe pain in his neck and shoulders for one week which then improved.
He is not yet asymptomatic in that he still has some residual intermittent pain in his right arm.Psychologically there has been no consequence of the accident.The accident caused him to have two weeks off work but did not otherwise interfere with his lifestyle.Examination shows that movement of his cervical spine and lumbosacral spine is full and pain free actively and passively in all directions.PROGNOSISIn my opinion on the balance of probability full physical recovery can be anticipated from the effects of the accident at a time within six months of the date of the accident. I base my opinion on the facts that recovery to date has been satisfactory, the range of movement of his cervical spine is full and there were no adverse features associated with the accident.
I have no further recommendation regarding furtherinvestigations, specialist opinions or treatment.The Client is a good historian and his injuries are consistentwith the accident. The injuries will have no long term effect onhis future work prospects.The contents of this report are true to the best of my knowledge.REVIEW OF MEDICAL RECORDSThe report has been compiled without access to his GeneralPractitioner notes.
In my opinion examination of the notes is notrequired as the Client is a good and reliable historian and theinjuries sustained are compatible with the accident described.DeclarationI am a general practitioner and have been a member of the Royal College of General Practitioners since 1968. I have been in general practice since 1964.John Finton was seen by me on 15 April 2010. The instruction was taken from Jones and Jones solicitors for the purpose of the preparation of this medico-legal opinion with regard to an accident on 15 February 2010.The opinion was prepared with the benefit of a clinical interview and clinical examination.I understand my duty is to the Court and this opinion has been compiled with the Duty Rule 35,10(2).
I understand the Expert’s duty is to help the Court on matters within my expertise.I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.I understand that my duty as expert witness is to the Court.
I have complied with that duty. This report includes all matters relevant to the issues on which my expert evidence is given. I have given details in this report of any matters which might affect the validity of this report.