Can a Medical Summary Report also refute the question of a pre-existing medical condition?
We recently had a case of a 43-year-old woman who was broadsided in an auto crash in which the offending vehicle hit the front drivers side panel causing the client’s car to be totaled. During the accident the woman was struck with enough force that despite being properly restrained, she hit the steering wheel with her forehead.
The client had the immediate onset of severely painful recurring frontal headaches radiating posteriorly. The headaches were accompanied by photophobia (sensitivity to light) and nausea. Since the accident the client continued to get severe headaches 2-3 times per week. She describes the pain as starting in her forehead and radiating to her temples bilaterally. On a pain rating scale with 0 being no pain and 10 being pain severe enough to lose consciousness the client stated these headaches rate a 7-8/10.
After reviewing the medical records and interviewing the client via Zoom it was our opinion the headaches were post-concussive and the result of a concussion the client sustained as a direct result of her blow to the head in the auto crash.
It should be noted that the client had a history of headaches that accompany the onset of her menstrual period. She stated these headaches started in her twenties and always correlated with the onset of her period. She describes these headaches as lasting 2-3 hours and rates the pain as 1/10. She describes these headaches as being diffuse headache pain without associated symptoms such as dizziness, nausea, or photophobia. The client reported that there is a very different set of symptoms and quality of pain with the headaches starting after hitting her head in the auto crash.
It was also our opinion to a reasonable degree of medical probability that the headaches the client has experienced since the auto crash are different in cause, form, nature, symptoms, and degree of loss of function than the menstrual headaches she has experienced in the past and it was our further opinion the client’s current headaches are not due to a pre-existing headache problem.
This situation is another example of how we can assist you with all the medical issues in your cases such as addressing questions regarding possible pre-existing conditions.
Please call 650-649-5352 to schedule a time to talk or receive the sample Medical Summary Report from which this case is drawn.
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