William Craig

Introduction

Dr. William Craig M.D., F.R.C. P. (C) Physical Medicine and Rehabilitation 306 Sasamat Lane North Vancouver, BC V7G 2S4 Phone 604 928-6231 ________________________________________________ (Date) RE: [Patient Name] MVA: [Motor Vehicle Accident Details, include date] Dear [Recipient Name], Thank you for allowing me to assess your client ([Patient Name]). Opinions in this report are based on my assessment of ([Patient Name]), which I performed in my office in North Vancouver B.C. on [Date of Assessment], and on review of the records and reports appended at the end of this report.

Medical Legal Introduction

I am a fully qualified medical practitioner licensed by the College of Physicians and Surgeons in the province of British Columbia since 2004. I attended the University of British Columbia where I obtained a Bachelor of Science degree in 1989, Masters in Science in 1993, and Doctor of Medicine in 1999. I completed two years of residency training in physical medicine and rehabilitation at Dalhousie University and completed the remaining three years at the University of Utah, completing in 2004. I received my fellowship in the specialty of physical medicine and rehabilitation from the Royal College of Physicians and Surgeons of Canada in 2004. I have practiced this specialty in the West Kootenays since 2004 and North Vancouver since 2008. Physical Medicine and Rehabilitation is the medical specialty concerned with medical management and rehabilitation of persons with a variety of disability and physical impairment. Training includes the rehabilitation of patients with general medical conditions, neurological disorders, major multiple trauma, spinal cord injury, brain injury, amputation, arthritis, soft tissue injury and acute and chronic pain. I am the former medical director for the Kootenay Boundary Regional Hospital rehabilitation service. I was a member of accreditation program for the West Kootenay Brain Injury program. My private practice focuses on both general rehabilitation medicine, and chronic pain and soft tissue injury. I have extensive training in interventional pain procedures including fluoroscopic guided injections and regional blocks. I am a member of the Canadian Pain Society and American College of Sports Medicine.

Purpose of Report

I have been specifically asked by you to provide diagnosis and prognosis for this patient, to state the assumptions that formed the basis of my report, to provide advice as to any future treatments the patient might require and to comment on any likely restrictions this motor vehicle accident might have on the patient’s employment and recreational activities. I am solely responsible for the contents of this report. In addition to those factual assumptions contained in the narrative of my report, I have relied upon the following in providing my opinion: A. Clinical history reported by the patient. B. Physical examination and findings relating to the patient. C. Information contained within the patient's clinical chart, including diagnostic test results, radiological reporting and consultation reports if any, and D. Information and documents provided to me by council, the patient, and/or collateral information itemized below.

Assumptions

This report is based on the following assumptions: 1. On [Date of Accident], [Patient Name] was involved in a motor vehicle accident. 2. At the time of the accident, [Details of the Accident]. 3. [Patient Name] has not had any significant accidents or injuries since the [Date of Accident] accident. 4. [Other Assumptions if mentioned]

Expert Duty Declaration

I am aware that as an expert, my duty is to assist the Court and not to be an advocate for any party. I hereby certify that I am aware of my duty as referred to in Rule 11-2(1) of the BC Supreme Court Civil Rules, that this report is made in conformity with that duty, and that if called on to give oral or written testimony, I will give that testimony in conformity with that duty.

Accident and Medical Course Details

[Document Each 'Detail of Accident' and Corresponding 'Medical Course' in the following format] Example: [Details of Accident 1]: [ provide a detailed narrative including the date of the accident, the role of the individual involved (e.g., driver, passenger), the type of vehicle they were in, the nature of the collision, and any immediate physical effects experienced by the individual. Include specific details about the sequence of events, such as the number of impacts and the areas of the vehicle affected. Ensure to note any denial of head injury or loss of consciousness.] [Medical Course 1]: [Summarize the progression of symptoms post-accident, noting any aggravation of pre-existing conditions. Include details of medical consultations, physical therapy, and other treatments. Specify dates of significant medical visits and findings, such as pain locations, neurological assessments, and imaging results. Mention any therapeutic interventions and their outcomes, including medications and alternative therapies like acupuncture or massage therapy.] [Details of Accident 2]: [ provide a detailed narrative including the date of the accident, the role of the individual involved (e.g., driver, passenger), the type of vehicle they were in, the nature of the collision, and any immediate physical effects experienced by the individual. Include specific details about the sequence of events, such as the number of impacts and the areas of the vehicle affected. Ensure to note any denial of head injury or loss of consciousness.] [Medical Course 2]: [Summarize the progression of symptoms post-accident, noting any aggravation of pre-existing conditions. Include details of medical consultations, physical therapy, and other treatments. Specify dates of significant medical visits and findings, such as pain locations, neurological assessments, and imaging results. Mention any therapeutic interventions and their outcomes, including medications and alternative therapies like acupuncture or massage therapy.] [Details of Accident 3]: [ provide a detailed narrative including the date of the accident, the role of the individual involved (e.g., driver, passenger), the type of vehicle they were in, the nature of the collision, and any immediate physical effects experienced by the individual. Include specific details about the sequence of events, such as the number of impacts and the areas of the vehicle affected. Ensure to note any denial of head injury or loss of consciousness.] [Medical Course 3]: [Summarize the progression of symptoms post-accident, noting any aggravation of pre-existing conditions. Include details of medical consultations, physical therapy, and other treatments. Specify dates of significant medical visits and findings, such as pain locations, neurological assessments, and imaging results. Mention any therapeutic interventions and their outcomes, including medications and alternative therapies like acupuncture or massage therapy.]

Medical Course

[Summarize the medical course following the accident, including treatments received, hospitalizations, and any significant medical events.]

Past Medical History

[Document any significant medical history prior to the first accident. Include details of any prior accidents, injuries, or relevant medical conditions. If there are no significant prior issues, state this explicitly.]

Allergies

[List any known allergies or state 'None' if the patient has no known allergies.]

Medications

[List all current medications the patient is taking, including dosages and purposes. Otherwise, state "NONE"] Example: 1. [Medication 1] [Dosage] [Frequency] 2. [Medication 2] [Dosage] [Frequency]

Functional History

[Describe the patient's occupational and recreational activities before and after the accidents. Include details of any changes in employment, physical activity, or daily living tasks. Note any limitations or adaptations made due to injuries.]

Current Symptoms

[Provide a detailed narrative of each of the patient's symptoms, including the location and nature of discomfort, any referral of symptoms, and factors that aggravate or alleviate the symptoms. Include any associated symptoms such as headaches, numbness, or weakness. Ensure to mention any denials of symptoms like clicking, grinding, or dysfunctions. Organize the content in a paragraph style, maintaining the distinction between different body areas such as neck and shoulders, back, Hip and others.] Neck and Shoulders – [Describe symptoms related to the neck and shoulders.] Back – [Describe symptoms related to the back.] Hips – [Describe symptoms related to the hips.] [Other Current Symptoms]

Review of Systems

[Provide a narrative summary of the patient's current symptoms and health status. Include any musculoskeletal symptoms, changes in vision and hearing, weight changes, sleep apnea, mood issues, bowel and bladder issues, and pain-related sleep disturbances. Note any other significant findings or state if the review is otherwise unremarkable.]

Chief Complaint

Medical Legal Report Template -- Physical Medicine and Rehabilitation

PHYSICAL EXAMINATION

[Provide a detailed narrative of the physical examination findings. Include observations on the patient's effort, pain behaviors, and consistency in examination. Note the patient's ability to follow commands and their range of effect. Then follow up with details of each physical exam as below when mentioned] -Head and Neck: [Describe the range of motion in the neck, including flexion, extension, rotation, and tilt. Note any pain or symptoms associated with these movements. Include findings from Spurling's maneuver and any tenderness in the neck and shoulder areas.] - Shoulders: [Detail the range of motion and any pain or restrictions in the shoulders. Include results from rotator cuff and impingement tests, as well as any findings related to the clavicular joints, biceps tendon, and shoulder girdle strength.] - Strength and Sensation: [Summarize the findings on strength and sensation in the arms, including myotomes and dermatomes. Note reflexes and any neural tension signs.] - Back: [Describe any pain or symptoms in the hip girdle and low back during various maneuvers, such as balancing, walking, squatting, and reaching. Include details on spinal glide and tenderness.] - Hips: [Note any tenderness or pain in the hip girdle and low back during provocative maneuvers. Include observations on hip rotation and sensation in the lower limbs.] [Ensure to only include the exam that's mentioned in the encounter, and include any additional relevant findings or observations made during the examination.]

Assessment and Plan

[Provide a detailed assessment of the patient's symptoms related to the neck, shoulders, and back. Include potential causes, differential diagnoses, and any relevant findings from the examination. Discuss possible treatment options, including their mechanisms and potential benefits. Mention any recommended imaging or procedures, and specify the rationale behind these recommendations. If applicable, include considerations for the patient's future activities or career plans. Use a narrative paragraph style to maintain consistency with the original content.]

Causation

[Provide a detailed opinion on the causation of the patient's injuries, specifying the type of injuries (e.g., soft tissue injuries to neck, shoulders, low back) and the incidents that may have contributed to these injuries, including date of the incidents (e.g., specific accident dates). Include any potential injuries that are difficult to attribute to a specific incident (e.g., cervical or lumbosacral facet joint injury, lumbosacral disc injury). Defer comments on mood and causation to a psychologist or psychiatrist if applicable.]

Prognosis

[Provide a detailed prognosis assessment. Include any pre-existing conditions prior to a specific date that could affect recovery. Discuss the impact of subsequent incidents on recovery potential. Note any improvements with treatment and the likelihood of ongoing symptoms, specifying affected areas and activities that may exacerbate pain. Include the patient's current work tolerance and future career plans, noting potential challenges and capabilities for lighter physical demand employment. Assess physical capabilities for routine tasks and exercise, with recommendations for workout intensity. Highlight risks of symptom aggravation or prolonged recovery due to further injuries, and mention any increased risk of degenerative changes due to past injuries.]

Closing

Yours sincerely, William Craig, M.D., F.R.C.P., (C), (P.M. and R.)