Medical Reports

Medical examination to support the claim

Doctors and other medical experts are used to provide reports in personal injury litigation.  The value of a claim is generally determined by the opinion of the medical expert as recorded in a medical report.   In all circumstances Court rules encourage joint instruction of medical experts with a view to avoiding the need for the expert to give verbal evidence at trial.   It is important to understand that the medical expert provides his report for the benefit of the Court even though most cases will settle without the need to issue Court proceedings.

Past medical history

It is standard practice for the medical expert to check the injured person's medical records both before and after the accident.      The reasons for this are twofold.     Firstly, there may be some previous history indicating that, if the accident had not happened, the injured person would nevertheless have experienced medical problems at some future point.  Secondly, it can happen that a supervening illness or injury may have affected recovery.

The medical expert's report

A medical report will often be structured and set out in the following manner :-

• details of the accident and how the injury was suffered
• progress of the injury suffered up to date of examination
• relevant past medical history
• family history
• social/employment history
• details of medication taken generally and as a result of the accident
• physical examination
• review of medical records
• assessment of disability suffered
• opinion and prognosis
• conclusion

Common terminology

A medical report can often contain terminology which is confusing to a person with no medical knowledge.   Terminology often used in reports involving whiplash injuries includes:-

Abduction - moving of a body part away from the central axis of the body

Acute pain - pain of recent onset (as opposed to severity) e.g. days or weeks

Acromioclavicular joint -

The joint between the top of the shoulder blade (acromion) and the collar bone (clavicle).

Analgesia - pain relief

Ankylosing spondylitis - arthritis of the spine

Asymptomatic - without symptoms, showing no outward signs of a condition

Atrophy - wasting of tissue

Bone scan - a test used to check altered blood flow to bone

Carpal tunnel syndrome - pain, numbness or weakness in the hand due to compression of the median nerve in the wrist.

Cervical  spine - the top seven vertebrae of the spine.   These are referred to as C1 - C7.  C1 is closest to the skull whilst C7 is closest to the thoracic (chest/rib cage) region of the spine.

Chronic pain - constant pain that either persists beyond injury or is associated with an ongoing painful condition e.g. arthritis.    More difficult to treat than acute pain. 

Clavicle - The collar bone

Clinical signs - findings made by a Doctor on carrying out a clinical examination e.g. reduced range of movement, loss of feeling or reduced muscle power.

CT scan - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross sectional images of the body including the bones, muscles, fat and organs.

Dorsiflexion -  bending the body or a joint in a backward direction

Dysphagia - difficulty in swallowing

Extension - moving a joint into the straight position (opposite to flexion)

Flexibility  - the degree of stretch within muscles, tendons and ligaments before breaking point is reached.

Flexion -  moving a joint into the bent position (opposite to extension)

Fracture -  a broken bone

Glenohumeral joint - the ball and socket joint between the arm and the shoulder

Hypertrophy - excessive overgrowth e.g. of muscle

Lateral - outer side or external (opposite to medial)

Ligaments - elastic fibres that bind joints and bones and keeps them stable

Lordosis - backward curvature of the spine

Lumbar - relating to the bones of the lower back (L1 - L5), nerve roots (L1 - L5 and S1) and soft tissues (e.g. muscles, tendons, ligaments, joints) in this area.   

Magnetic resonance imaging (MRI scan) - a diagnostic procedure that uses radio waves and a computer to construct pictures that are presented as apparent slices through the body and which can detect tissue abnormalities.

Medial  -  inner side or internal (opposite to lateral)

Muscle spasm - a sudden involuntary muscle contraction

Myelogram - x-ray of the spine after injection of an x-ray opaque dye into the spinal column.

Non-steroidal anti-inflammatories (NSAID's) - a class of drugs that inhibit inflammation e.g. aspirin, Ibuprofen.

Osteoarthritis -  a form of arthritis, occurring mainly as a result of aging, and caused by the breakdown and eventual loss of the cartilage of one or more joints.

Osteoporosis  -   abnormal weakening or softening of the bone, common in the elderly and some women after the menopause.

Palpation - a method of feeling with the hands during a physical examination to determine size, consistency, tenderness or other abnormality of a body part

Paraesthesia - a feeling of pins and needles

Paralysis -  loss of active motion

Prognosis -  the forecast of the likely outcome of the injury

Pronation - twisting the forearm, the elbow being fixed, to bring the palm of the hand facing downwards (opposite to supination)

Reflex - an automatic response to a stimulus  

Scapula - the shoulder blade

Spondylosis  - degenerative changes in the spine

Subluxation -  partial displacement of a joint

Supination - twisting the forearm, the elbow being flexed, to bring the palm of the hand facing upwards (opposite to pronation)

Symptomatic - showing outward signs of a condition

Syndrome -  a combination of recognizable signs and symptoms that form a distinct clinical picture as opposed to a recognizable disease.  

Thoracic - relating to the bones of the thoracic (T1 - T12), spinal cord, and nerve roots (T1 - T12) along with the organs of the chest cavity (e.g. lungs).

Tinnitus - ringing in the ears

Transcutaneous Electrical Stimulation (TENS)  - a technique used to deliver electrical current to the body generally using battery operated mall-generators and pads applied to the skin.  

Trapezius muscle - either of two flat triangular muscles of the shoulder and upper back that are involved in moving the shoulders and arms.  

Trauma - injury to the body.

Vertebrae  - the major bones of the spine (33).   Each vertebra has a hole in its centre so that when stacked on top of one another they form a long channel (the vertebral canal) through which the spinal cord runs.

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