(author Kari Williamson]

Introduction

The nurse reviewer of the following case study noticed a pair of patterns that were found in the medical records from an Motor Vehicle Accident (MVA) that served to the mitigation points to the adjuster of insurance. This article will go over the main aspects of the case as well as the patterns that were observed by the nurse reviewer. It will examine the pre-DOL history for the individual, numerous significant discrepancies in records of the doctor, inconsistencies in complaints about pain, as well as objective clinical evidence derived from the pattern. The conclusions from the case might be useful to defense adjusters as well as casualty attorneys.

The facts of the case

• The plaintiff was a 32 year old female driver who was restrained in an sideswipe MVA where the vehicle was able to spin.
• She was taken by emergency medical services (EMS) in the emergency department ED and was diagnosed by the ED with injuries to soft tissues. She was neurologically healthy and had no sign of head trauma. She also displayed an normal gait.

Mechanism of Injury (MOI)

The MOI of the report of police was identical to that claimed in the report of claimant. Moreover:

• The subjective claims that the victim of injury matched to the MOI,
• The regions of impact upon the car (see Diagram 1) and on the body of the claimant corresponded with subjective complaints and
• The initial MOI was correlated with the medical records/EMS.

After the incident, and a three-week lapse in time The patient was referred to the chiropractor with complaints of loss of consciousness and the inability to walk.

Initial evaluation by the chiropractor identified subjective complaints of back discomfort and left shoulder pain along with bilateral knee discomfort that was secondary to MVA. The patient was ambulatory on the scene, was not immobilized and then transported to an ER. The initial examination at the ED was positive for mild shoulder tenderness and bilateral paraspinal tenderness along with a left knee contusion with no swelling or bruises.

There were several times that the treatment timeframe. Inconsistent care can hinder the healing process and progress, and also suggest an unintentionally less severe group of symptoms. The Lumbar spine MRI was done and the plaintiff received bilateral sacroiliac facet joints injections for pain relief. She continued to receive treatment for the management of pain and filed an application for $250,000.

^{1. Damage to vehicle of the claimant}.

Comparison of the Pre- and Post-Date of Loss (DOL)

The medical records were not provided to be reviewed. This is a major “red red flag” in many ways, due to:

• Medical records of the pre-DOL must be reviewed in order to establish a baseline of claimsant’s medical condition(s).
• It was also noted that the claimant had reported the loss of an MVA 7 months before the loss. The review of documents related to the nature of the effect and treatment are suggested to aid in the evaluation of the current claim.
• The patient was recommended to a neurosurgeon 5 months prior to seeing. The time frame between follow-up by referrals and chiropractic gaps in treatment is not consistent with claims of claimants reporting severe pain. Keep in mind that extreme pain can be uncontrollable and typically requires medical intervention using opioids in order to function.
• Facet joint pain can be described as an arthritic disease of the spine which is usually caused by degenerative changes to the facet joints causing discomfort. The cartilage in the joints breaks down, which causes discomfort and inflammation. In this instance there is no indication that of Sacroiliac (SI) joint was damaged during the incident. Furthermore SI complaints were reported to the DOL. SI complaints were reported at the end of six months following the DOL. Sacroiliac (SI) joint pain is often caused by abnormal gait patterns , which can be caused by scoliosis.

As per standard procedure, facet injections are carried out for diagnostic and therapeutic reasons not exceeding two levels of injections at a time. If a patient experiences at least a 50% reduction in pain, then the facet joint can be identified as the reason for discomfort. However it is advised to seek out conservative treatment prior to having facet injections. In this situation the completeness of conservative treatment is not recommended because of the treatment failures.

The medical records for this instance did not show improvements in symptoms that would warrant injections. The lawyer for the plaintiff informed the insurance adjuster she was treating. Injections and pain management were not suggested as being related due to the prolonged intervals in treatment that were incompatible with healing of soft tissues.

Inconsistencies

The plaintiff began treatment after an interval of three weeks, allowing for the occurrence of events that occurred during this time. Although chiropractic treatment without spinal manipulation is recommended to treat soft-tissue injuries in order to alleviate inflammation and pain, according to MDGuidelines the recommended frequency is as high as 12 visits over the course of six weeks of treatment.

The patient did not show any improvement in her condition during treatment. The claimant reported that the discomfort caused severe symptoms which hindered her activities of daily living. Recent reports of loss consciousness (LOC) at the time of loss as well as inability to walk at the time of loss were not in line with the prior evidence regarding the death.

Additional questions:

• The referral to MRI of the lumbar spine is a questionable matter in relation to the time of loss since no acute pain associated with a neurologic deficits progressing was noted. The claimant experienced more pain during the drive to towards Florida. In addition, the claimant was unable to have any radicular symptoms. Sitting for long periods of time can cause the lumbar spine discomfort.
• The procedure of securing the knee with strapping is not connected to the loss. Strapping (application of Kinesiology tape) is advised for knee arthritis However, x-rays taken in the ER don’t reveal any evidence of arthritis.
• The physical examination was mostly negative, with only one exception: subjectively-influenced reduced mobility (ROM). The results of ortho and neuro testing was found.
• The headache complaints were not specific and could be due to various illnesses. Although headaches are often a to cervical strain The claimant must be able to improve within three weeks of the incident as she was diagnosed as having soft tissue injuries but no objective radicular signs. The post-accident referral to neurosurgery is not certain due to the absence of objective evidence.

The client was referred for consultation with a neurosurgeon about five months prior to having a visit and observed several lengthy gap in chiropractic treatment which are not in line with reports of pain that is severe. In the majority of cases, severe pain is painful and requires medical intervention and the use of narcotics. The lack of treatment options were not evidence of failed treatment.

The reports of chronic discomfort with no treatment were incongruous. The difference between acute and regular radiological examinations were crucial for the defense. The MRI found did not contain any findings that could be indicative of the pathology of trauma. For acute pathologies, the MRI signal is intense and non-acute manifestations show an equivocal signal.

Conclusions and takeaways

Based on the initial evaluation and the impact within the ER The claimant sustained soft tissues cervical, thoracic and lumbar injury , as well as an injury to the left knee. Although the claimant was able to attend 29 chiropractic appointments over seven months but there were several significant gapin treatment that did not align with the normal healing process such as the claimant experienced delayed treatment for five months after referral to the pain management.

Furthermore:

• The plaintiff complained of severe pain after seven months post-loss. This does not correspond with the capacity to do the daily activities required for living.
• The gaps in treatment can allow injury to develop in the intervening time.
• The claimant was a victim of previously filed an MVA six months earlier than the date of this incident without submitting any prior documents.
• Nurse reviewer suggests that an independent medical exam (IME ) could be beneficial since the plaintiff’s attorney stated that the plaintiff was still being treated.
• The EMS system, ER, and six chiropractic visits were all related in the absence. The absence of treatment was not in line with the symptoms that were reported.

Two main concerns emerged, namely:

• The presence of large gaps in treatment across all providers could suggest some degree of relief from the condition(s) or the fluctuation in chronic diseases.
• The records consistently recorded subjective complaints without the presence of consistent and clear objective medical evidence, such as the absence of neurological markers and acute symptoms.

Consultants and nurses are able to help attorneys and adjusters in bodily injury cases by providing a thorough analysis of the chronology and case as shown in this short case report.

Acknowledgments

The authors would like to express our gratitude to Kari Williamson for her insight and experience that greatly aided this study.

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