Independent Medical Exam - Witness

Reason for Referral:

<Accompany client to Independent Medical Exam on 6-29-98 with Dr. Other Side.>

Summary:

<The client was taken back to an exam room at approximately 1:00 p.m. X-rays were ordered since none were available for Dr. Other Side to review. The client returned from x-ray at 1:25 p.m. Dr. Other Side entered the room to examine the client at 2:00 p.m. and spent approximately twenty minutes performing a history and physical e xam. The client was very cooperative and respectful throughout the exam. The client was given the opportunity to ask questions at the end of the exam but had none.>

Observations:

<Dr. Other Side did not have access to any of the client's previous radiology films. Dr. Other Side had not reviewed the record prior to the client's visit (Dr. Other Side made a statement to this fact). Dr. Other Side seemed to confuse or rush the client when the client had difficulty giving a clear-cut answer to his question. This was especially true when discussing the mechanism of injury regarding whether or not the cab of the truck collapsed or actually hit their head. Dr. Other Side stated at one point "it is not a multiple choice answer --- yes or no." The client would sometimes revert to answering the question by "it is hard to say." The client was able to sit during the entire wait period and exam. The client ambulated without difficulty but appeared to be guarded in turning head and neck. Dr. Other Side stated that the report should be ready by end of the week (July 3, 1998).>

Time Line of Events:

1:00pm Client to room
1:10pm Client to x-ray with technician
2:00pm Dr. Other Side entered room
2:00 - 2:12pm History obtained by Dr. Other Side
2:12 - 2:20pm Physical exam performed by Dr. Other Side
2:20pm Concluded; the client was asked by Dr. Other Side if he had any questions