Medical Legal Report regarding Jorge Fernandez



4657725000CMCC Campus clinic6100 Leslie St, North York, ON M2H 3J1(416) 482-2340cmcc.ca/clinics Medical Legal Report regarding Jorge FernandezPrepared by: Megan Yim, B.A., MSc., D.C. (2019)Jorge Fernandez, Claim # 103478921D.O.B. 08/22/1969Initial visit: Aug 29, 2017Address: 1639 St Clair Ave. WOccupation: Building Superintendent Date of Report: 03/26/2018Date of Assessment: 08/29/2017Location of Assessment: CMCC campus clinicDate of accident: 08/22/2017Prepared for: TD InsuranceDescription of incident: Motor vehicle accident, Mr. Fernandez was driving and was rear ended on the 401 highway going 100 km/hr. The car spin around several times and hit the median. Patients relevant medical and social history: Mr. Fernandez reported good health with no medical conditions prior to the accident. He has been taking diazepam for 3 years for anxiety. He is married and has a 15 year old daughter. His job is quite physical and he is motivated to return to work. Intro: This report is concerning Jorge Fernandez’s motor vehicle accident that occurred on the 22 of September 2017. It has been prepared for TD Insurance at their request. Qualifications:I am a Chiropractic intern trained for 3 years at Canadian Memorial Chiropractic College, prior education includes a Bachelor of Arts with a major in Psychology received at Vancouver Island University and a Master of Science received at the University of Victoria. Summary: Mr. Fernandez presented with constant dull right sided neck pain and a constant burning sensation running from the shoulder, upper arm and forearm stopping at the wrist. He has found nothing that relieves the pain and it is a 7/10 level of pain at all times. Details of the accident:At 9am on September 22, 2017 Mr. Fernandez was traveling West on the 401 Collector at 100km/hr in a Toyota Rav4 2009. He was then rear ended by a 1995 Ford Taurus attempting to change lanes. Mr Fernandez’s car subsequently spun around ~3 times before it struck the median. Mr Fernandez was wearing his seat belt but was jolted side to side and back into the seat. He woke up in hospital with pain and “funny” vision with no memory from the time of the crash to waking up in hospital. The car suffered extensive damage. Mr. Fernandez was told that he had sustained a concussion but was sent home after a four of hours of being monitored. He was given tramadol (a muscle relaxant) at the hospital. Mr. Fernandez has been unable to work due to the dull ache in his neck and burning sensation in his arm present since the accident. History: Mr. Fernandez, a 48 year old building superintendent, presented with constant right sided dull neck pain and constant burning in his right shoulder, down the outside of his upper arm and forearm down to the wrist. The neck pain is described as “really really bad” and it is rated at a 7/10 on the visual analog scale of pain intensity. The pain has been constant since is motor vehicle accident one week ago. The tramadol given at the hospital relieves the pain a little bit but nothing else has been found to help. The pain is bad at all times with nothing in particular aggravating it more. When Mr. Fernandez first woke up in hospital he reported that his vision was “off” and this feeling remained for a few days after the accident but is now back to normal. No other physical symptoms were noted by the patient.Physical:Upon examination Mr. Fernandez’ vitals were within normal limits (BP: 124/78, HR: 70). In neutral posture he had a slight right and anterior rotation of the head and neck and reported that deviating from this position caused him pain. All ranges of motion (active, resisted) were restricted and painful to the right neck, except extension, rotation and lateral flexion to the left which were just painful but not restricted. Neurological testing revealed no deficit in reflexes or motor response however there was diminished crude touch sensation in dermatomes C5 and C6 on the right. Jackson and Spurling tests were both positive for radicular symptoms on the right, Valsalva’s maneuver was negative. Shoulder abduction and EAST test were delayed and painful but negative. Traction provided relief. Palpation revealed tender and hypertonic upper trapezius, levator scapula, scalenes, splenius capitus, suboccitals and sternocleidomastoid on the right. Mr. Fernandez was also quite sore during cervical segmental rotation and flexion on the right side.Diagnosis: Based on the history, physical exam findings and imaging I have diagnosed Mr. Fernandez with a Grade III Neck associated disorder with myofascial pain specifically scalenes and C6 radiculopathy. Differentials include a neck associated disorder grade II with associated costoclavicular/ pectoralis syndrome and a cervical spine disc herniation at C5/6. Plan of management: Mr. Fernandez has already undergone the first treatment which included multimodal care specifically soft tissue work to the hypertonic musculature, segmental rotation and lateral flexion mobilizations of the cervical spine, thoracic spine manipulation and supervised graded neck strengthening exercises along with a series of neck stretches to be performed at home daily. On the second treatment he will be reassessed and cervical spine joint manipulations will be added to the treatment protocol. This treatment is recommended 2x/week for 6 weeks. Progress will be assessed at every visit with orthopedic tests and palpation as well as every 2 weeks using the visual analog scale and neck disability index. The main goals are cessation of pain and radicular symptoms as well as return to work and sport.Prognosis:Mr. Fernandez’s short term prognosis is good. He is very likely to find relief from his pain and radicular symptoms within 6 weeks and will likely return to work and sport within that time. Positive prognostic factors include his good health history, strong social support system and motivation to return to work and sport. His long term prognosis I fair due to the degenerative processes known to occur after an injury such as this. It is possible that due to the accident Mr. Fernandez will be more prone to developing degenerative disorders such as degenerative joint disease, degenerative disc disease and stenosis. Financial record:Initial assessment, Sept 22, 2017: $149Treatment, Sept 22 2017: $50Treatment, Sept 25, 2017: $50Total: $249Signature: ___________________________________ Date:_________________________________Megan Yim, MSc, DCPlease be advised that my standard fee is $150/page being 4 pages the price is $600. Please make it payable to Megan Yim. ................
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