Personal Injury Case Study #1
Category: Legal Nurse
Author: Georgina Bell
Posted: Friday - August 6, 2021
Patient Status: Bailey Allen is a 30 year old female who is married and works as a CNA. She reports smoking marijuana/cannabis daily and drinking alcohol occasionally. Mrs. Allen has a past medical history of hypertension, anxiety, and eczema. Her past surgical history is a tonsillectomy.
Accident Details: Mrs. Allen was found sitting on a sidewalk by the fire department. Witnesses said she self-extricated after a 2 vehicle traffic collision. She was reportedly traveling at a moderate rate of speed when she was hit head on by another vehicle. She was restrained and airbags deployed, however there was no passenger space intrusion. At the scene, she had an obvious deformity of her right wrist and abrasions to the same. She was transported to a local Emergency Room for further evaluation and care.
Assessment: Upon arrival to the Emergency Room, Mrs. Allen complained of a laceration to the innerweb space between thumb and forefinger which required sutures, abrasion to left wrist, left abdominal wall abrasion, bruise to left hip, and right wrist fracture. Tramadol was prescribed and she was discharged. Five days after the MVA, Mrs. Allen presented to Dr. Jones for an Orthopedic consultation. A short cast was placed on her right wrist and Naproxen was prescribed.
Treatment Course: 1 month following the MVA, Mrs. Allen presented to Dr. Shaffer for Chiropractic evaluation and treatment. A course of conservative chiropractic manipulation/adjustment and soft tissue physiotherapy treatments was recommended, as well as a referral to pain management.
2 months post-MVA, Mrs. Allen presented to Dr. Fred for an Orthopedic consultation. Her chief complaints were right wrist and lower back pain. After a confirmatory X-ray, the cast on her right wrist was removed, a wrist brace was placed, and an MRI of the Lumbar spine was recommended for further evaluation.
2.5 months after the MVA, Mrs. Allen presented to Dr. Goli for a Pain Management consultation. Her chief complaints were pain in the lower back, upper back, neck, and right wrist. MRIs of the cervical and lumbar spine were ordered and prescriptions for an anti-inflammatory gel and a muscle relaxer were issued. The Cervical MRI revealed median disc protrusion impressing upon the midline anterior cord at C2-C3, C3-C4, and C4-C5 as well as disc prominence and facet arthropathy causing decreased right foraminal patency of 3-4mm at C4-5 and C5-6. The Lumbar MRI revealed a 6-7mm broad prominent disc protrusion into the right greater than left lateral recess compressing the S1 root against the medial facet joint at L5-S1. A course of physical therapy was prescribed for twice a week for four weeks to include traction of the cervical spine. Acupuncture of the cervical and lumbar spine was also recommended for 1-3 sessions per week for 4 weeks.
Due to a continuation of symptoms after 1 month of physical therapy trigger point injections [TPI] were administered to the left upper thoracic area 4 months following the MVA. TPI were repeated 1 month later.
A Neurological consultation was performed by Dr. Kieran 4 months after the MVA due to ongoing complaints of headaches, memory problems, ringing in ears, loss of balance, anxiety, fatigue, sleep difficulty and occasional dizziness. Recommendations for an electroencephalogram and 3T MRI of the brain were given. Both diagnostic tests were unremarkable.
4.5 months post-MVA she was able to achieve full range of motion without pain after completion of physical therapy and was released from care for her right wrist. Mrs. Allen was released to return to work with no restrictions.
6 months following the MVA, Mrs. Allen returned to Dr. Goli for a follow-up evaluation. At this time, he recommended proceeding with L5-S1 intra-articular facet injections and a right-sided L5-S1 transforaminal epidural injection with platelet rich plasma or PRP due to continued lumbar spine symptoms. 1 month later the procedure was completed. Upon 6 week follow-up, she reported a complete resolution of her lumbar pain.
What might be the most likely cause of the abdominal wall abrasion and bruise to Mrs. Allen’s left hip? These injuries are most likely caused by Mrs. Allen’s seatbelt. In the medical world, this is referred to as “seatbelt sign”.
What providers would you recommend following up with regarding ongoing treatment? Follow-up is recommended for the following:
Dr. Fred: Consider requesting medical records from the date of last visit, Lumbar spine MRI report, and any other provider referrals.
Dr. Goli: Consider requesting medical records for visits after 6 week post-op follow-up visit and any other provider referrals.
Dr. Kieran: Consider requesting medical records from the date of last visit.
Acupuncture Provider: Consider inquiring if Mrs. Allen followed up with an acupuncture provider as recommended by Dr. Goli. If so, consider requesting all medical records from the provider.
What information would you look for in future follow-up visits? Changes in Mrs. Allen’s health status, changes in medications, changes in treatment recommendations, referrals to new providers, providers not mentioned in previous records, and previous injuries or past medical history not mentioned in previous records.
What information would you look for in medical records previous to the MVA? Previous injuries, past medical and surgical history, worker’s compensation injuries, and additional providers for whom you do not have records for.
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