Sample Case Evaluation Reports - Personal Injury Expert Witness


Patient with Long Psychiatric and Medical History Assaulted in Hotel, Becomes Obsessed with Mugging, Trying to Create a Case. New!

The Medical Review Foundation, Inc. has received your overnight package containing 201 pages of medical records and related documents. Each page is numbered from 001 to 201, and although the records are not always in sequential order, I will give you my opinions as I refer to each of the specific pages and then summarize my conclusions following this part of the review. This woman was assaulted in her hotel room apparently at a resort in Puerto Rico on May 18, 2005.

Page 001: Nine months after the injury, on December 12, she told an unknown Physician, in his progress notes, that she tended to be depressed in the winter time and her mood definitely worsens when the season changes. She noted that she had headaches secondary to being hit on the head. She claimed recent weight loss secondary to being hit on the head and diarrhea off and on that was worse in the winter. She also claimed to have gastritis since being hit on the head. This record notes that she had a suicide attempt in the past (in the 1960s), and that she had a history of mania and cycles of depression. Thus, this patient had a long history of a psychiatric problem, that is, manic depressive illness, even to the point of suicide in the 1960s.

She had taken tranquilizers (anxiolytic drugs) for a short time in 1974. Currently, she was taking the drug, Paxil, which is an antidepressant, in the same general class as Prozac. It says she was taking 1/2 tablet a day, but does not specify the dosage. Tablets range in concentrations from 10 to 40 milligrams.

The other drug she was taking was Ambien, which is indicated for the short-term treatment of insomnia.

On page 4, of the records received from your office, she was getting cervical physical therapy, by the note of June 20, 2005, and a splint to the left hand by the note of January 10, 2006.

On page 8, she had left upper extremity paresis (weakness) secondary to pain, and a neck examination revealed full range of motion. The impression was a cerebral contusion with a post-concussion syndrome and questionable injury to the left brachial plexus (the nerves that go down the arm from the neck and armpit area). They noted that the CAT scan of the head was basically negative.

On page 9, there was an examination dated March 29, 2005. The patient was referred to this unnamed Physician by Dr. Lawrence. It noted the history of March 18, 2005, when she was hit on the front side of the head and that she had some amnesia for event and “loss of consciousness” (LOC). There was swelling in the left orbital region and she could not see out of that eye at that time.

It noted a drooping of the left lid (ptosis) since the trauma and ringing in the right ear (tinnitus) and decreased hearing in the left ear. She also had decreased ability to control her left hand and dropped some objects.

On page 11, they noted that the MRI of the head was normal, and that she had some headaches in the left temporal area. The impression was probable left occipital neuritis, and the occipital nerve runs behind the ear, up the back of the head. It was not involved in the area of her injury. On the one before, she was complaining of a strange sensation on the left side of her face.

Page 12 refers to the April 29, 2006 note where the patient complained of left-sided headaches at the site of injury and noted that the MRI was negative.

On page 13, there was some tenderness in the area of the left temple, noted on September 20, 2005.

On page 14, Dr. Edwards, by referral of Dr. Lawrence, performed a neurologic evaluation and noted that she had multiple injuries including "a cerebral concussion, loss of balance, pain in her left ear and eye, loss of control of the left hand, impaired memory, mental changes, tinnitus (ringing in the ear) in her right ear, loss of hearing in the left ear, and shaking of her head." His examination, "revealed loss of sensation over the left face and weakness of the left upper extremity." He refers everything to the result of her attack. I dispute this finding for many reasons.

First of all, if there is injury and numbness, a specific nerve will have to be damaged. There is no detailed delineation of any specific nerve injury. Generalized loss of sensation in the area of the face is not an anatomic diagnosis. According to subsequent notes, the patient was awake and never lost consciousness, and the examinations following her injury did not reveal any loss of control of her left hand or impaired memory. There were no other notations of "shaky of her head."

Therefore, in my opinion, the conclusion of Dr. Edwards does not follow anatomic or medical standards.

On page 16, which is dated May 16, 2005, there was some ecchymosis (black and blue discoloration) that was still present but was clearing. There was some tenderness in the left frontal forehead area and in the left orbital area (around the eye). The note says the left hand grip was still weak and there was full range of motion of the neck without any symptoms. There was tenderness in the occipital area of the scalp, but that was behind the head, in an area where the patient was not injured.

On page 17, the MRI of May 6, 2006, was normal. There was no evidence of hemorrhage within the brain, or any stroke, however there was some small blood vessel ischemic disease, that would not be related to the injury but would be related to her age.

On page 19, the electromyogram and nerve conduction study performed on January 4, 2006, was normal involving the left upper extremity and particularly the electromyogram (nerve/muscle test) of the median and ulnar nerves was normal. This is strong evidence against any significant damage involving nerves and muscles.

On page 25, was the TR Physical Therapy Center records of August 29, 2005. There was some tenderness in the suboccipital muscles (the muscles behind the neck), but there was active range of motion of the neck and both upper extremities that was normal. The patient had anxiety and it was believed that she would not return for further therapy.

On page 27, was the result of the April 19, 2005, electromyogram and nerve conduction studies. The nerve conduction studies of the left upper extremity were normal, but there was an abnormal electromyogram indicating mild active denervation in the sixth cervical myotome, bilaterally. This means that there was some compression of the C6 nerve root, exiting the spinal canal, going to both arms. However, since the patient had no range of motion problems involving her neck, nor any injury of the neck, this most likely would be related to other findings that were documented subsequently with regard to impingement of the nerve root canals leaving the spinal column, secondary to chronic degenerative changes. And, as I mentioned, the findings in 2006, noted on page 19, were normal by that time. In my opinion, that would be related to her age and overall health condition, not any physical injury from the accident, based upon all the other findings in the record.

On pages 32-35, are the results of the bone scan and CT of the cervical spine. The bone scan showed degenerative disease of the spine, particularly the left side of the upper cervical spine. This was from degenerative disease, not an acute injury. This is supported by the CAT scan findings of April 26, 2005. At multiple cervical levels, there were chronic bone changes, secondary to degenerative disease, compressing the nerve roots as they exit the spinal canals as well as some compression of the spinal cord itself. Furthermore, there were "well-defined lytic defects in several vertebral bodies," and the question was raised about metastatic bone disease (spread of cancer). The bone scan at that time did not support that diagnosis, but we subsequently know that she did have mantle cell lymphoma, a cancer of the blood and bone marrow, and bone marrow is made in the bones.

On page 36, is the result of the CAT scan of the head, dated March 22, 2005, four days after her assault. There were no fractures seen nor any intracranial abnormalities. There was some thickening on the inside of the skull of the right frontal region, clearly unrelated to a site of external injury, and the questions was raised of a possible benign meningioma, which is a tumor of the surface of the brain lining. This takes years to develop and would be unrelated to the injury, both in location and in nature of the potential tumor.

On page 39, is the audiology impedance testing, which is a hearing test. This was normal. Thus, nine days after her injury, there was no evidence of any hearing deficit.

On page 42, is a record that is undated but appears to be associated with the June 19, 2005 examination and it notes that she is "obsessed with mugging in Puerto Rico."

On page 46, is the result of the flexible sigmoidoscopic examination, the passage of a lighted telescopic tube up the anus and rectum into the lower large intestine, and in June 2005, this was normal. Furthermore, the test of the stool for germs and parasites was also normal. As I will show in further records, the patient had a long history of spastic colon that antedated, by years, the incident in question.

The patient had a long history of skin disorders, including psoriasis of her elbow noted in May 1999, on page 49, as well as skin cancer as noted on page 50. Her left wrist was involved with seborrheic keratosis, a chronic skin condition noted in 2002, on page 51.

On page 53, in November 2004, she was complaining of a skin condition with crusting of skin in the left lower forehead area. This was prior to the injury.

On page 54, is a March 23, 2005 examination of the patient that showed the ecchymosis (black and blue discoloration) of the left cheek and eye area. She went to a hospital in Puerto Rico, and I am missing those records, except the x-ray report I received by fax was negative. The hospital records from the treatment immediately after the injury should be obtained and translated if they are in Spanish. On this page, 54, the CAT scan is reported as normal. There was a scab on the left upper lip and some swelling and black and blue discoloration of the left cheek and temple area. On that same page 54, there is a note of June 12, 2005, that the patient had resolution of the ecchymosis and the lip now had no scab.

On page 60, Dr. York, apparently an Ophthalmologist, noted on April 16, 2002, that the patient had a history of ocular migraine. This clearly predated the assault.

On page 61, on April 8, 2003, she was complaining of aching pain and recurrent redness involving her left eye. This was two years before the assault.

On page 63, in a note of April 21, 2004, this Ophthalmologist noted that she had mild episodes of possible scintillating scotomata, which is flashing areas of in the eye. This was a year before the assault. It also notes the visit of March 23, 2005, five days after the assault, where the patient had severe periorbital ecchymosis (black and blue discoloration) of the left eye (OS). There was hypesthesia (increased sensation) but no point tenderness. The cornea was clear, and the examination of the inside of the eye was normal. Thus, there was no intra-orbital injury. This was noted on page 64, where there is "no ocular injury OS." There was an early cataract found in the right eye (OD), which was greater than the left eye (OS). Cataracts take years to develop, and would be unrelated to any injury.

On page 64, on August 1, 2005, this was a "stable examination."

On page 68, on June 17, 2007, the record of Dr. York notes that the patient fell on her face "four days ago causing severe ecchymosis below OD (right eye)" and was there for follow up. On that page, his note of August 20, 2007, notes that the patient was told that she possibly had leukemia. She did not have leukemia, but a type of cancer of the blood that is, in layman terminology, somewhat related to leukemia.

On page 69, is the record of Dr. Margaret, noting that she was seen on August 19, 2007, and the abdominal and pelvic CAT scan showed massive adenopathy (large lymph glands) and there were abnormalities in her blood consistent with testing diagnosing mantle cell lymphoma. She notes that this was minimally responsive to therapy. Thus, the patient's longevity is certainly questionable. And, with massive lymph node enlargement in her abdomen and pelvis, this can push on nerves, causing pain. It clearly would be unrelated to any injury sustained in the assault.

The diagnosis of mantle cell lymphoma, based on her blood and bone marrow tests, are well noted on pages 76 and 78.

A year before the injury, on March 18, 2004, on page 82, is the record of the abdominal upper GI series using dye to evaluate her stomach. The patient had a very small sliding hiatal hernia which means that the stomach would slide up into the upper area of the chest and this can result in heartburn and inflammation of the upper stomach and esophagus.

On page 83, is a note by Dr. Lawrence which says, "following the attack, during which she incurred multiple injuries, she suffered: weight loss, painful lumps on her head, neck and hand, persistent severe headache. Vertigo and loss of balance. Stomach cramps and diarrhea. Residual left facial disfigurement, which requires reconstructive surgery, but which might, following surgery, still leave her disfigured. All of the above abnormalities are a consequence of the attack of the patient on March 18, 2005."

I strongly disagree. As the record notes, she had severe headaches years before the injury and subsequent records will document stomach cramps and diarrhea for many years. Her weight was basically stable over years, and the injury to the face had healed, certainly within a year before his letter of June 18, 2006. With regard to the facial disfigurement, it would be important to obtain good close photographs of the patient's face, including close-up views and views from both sides and different angles. In addition, earlier photographs, prior to the injury, should be obtained.

On page 84, is the first page of a letter of a Plastic and General Surgeon in the British Virgin Islands, dated 6 March 2006, a year after the injury. This Doctor noted two hard irregularities of the left frontal bone which he felt was the result of bruising of the surface of the bone (periosteum) and a definite irregularity and asymmetry of the left cheek area where there was previous swelling. He also noted laxity of the skin and some discoloration. He felt that major surgery would be indicated. I clearly disagree. He felt that a face lift would overcome the problems but would have to be done on both sides. In my opinion, it appears he was trying to sell this patient on surgery, and I cannot conceive of any American having surgery in the British Virgin Islands. Furthermore, this Surgeon does not limit himself to plastic surgery, but also does general surgery. Plastic Surgeons of good repute in the United States limit themselves to plastic surgery.

On page 85, is a preliminary letter by Dr. Lawrence where initially he said there was loss of vision of the right eye for two weeks (but the eye doctor’s exam showed no injury to her eye or vision loss), but this is crossed out to be changed to left eye. He said he noticed stiff muscles of the right flank, but no discoloration or bruising. However, in his office records he did not note any findings concerning that issue. He said she was suffering from severe gastritis and upset stomach, and her headaches persisted. However, all this predated the accident by years. Thus, his letter was somewhat inaccurate and, in my opinion, somewhat of an advocacy position.

On page 90, on November 2002, Dr. Lawrence ordered a barium enema x-ray of the large intestine which showed sigmoid diverticulosis, which are out-pouchings of the large intestine that can cause pain and bleeding.

On page 94, is a consultation by a Urologist, Dr. Michael, concerning her chronic urinary tract infections with regard to pain and pain in the left lower quadrant of the abdomen. The kidney x-rays and related studies were unremarkable.

On November 2, 2002, on page 96, is the pelvic sonogram study that also refers to gallstones. The rest of the evaluation was negative. Gallstones can cause recurrent upper abdominal pain. On page 98, in May 2002, three years before the injury, was "mild atrophic age-related macular degeneration of the right eye and mild to moderate pre-retinal macular gliosis (scarring) of the left eye." Neither was affecting her vision. The paracentral scotomata, the flashing of lights that lasted for 20-30 minutes, according to Dr. York, "are most suggestive of ocular migraine and unrelated to any ocular abnormalities."

On page 99, the patient had a lesion of the left upper lid removed by Dr. David.

On page 100, in 1985, the patient had allergies and was being treated by Dr. Roger.

On page 101, there is another copy of the CAT scan report showing no fractures or significant injuries on March 22, 2005.

On page 105 and 106, is a May 17, 2005, letter to an Attorney, concerning a Physicians findings and opinions concerning the assault that I previously discussed. There are handwritten notes that apparently were used to write that letter, and on page 109 is a physical examination that shows that the cranial nerves were normal, that the motor strength was normal (no weakness) as were the sensory findings (no numbness or pain). The abdominal examination was also normal.

On page 116, is a note of March 12, 2007, two years after the assault, and her weight was 116 pounds, and the patient was on antidepressants. She had frequent but normal bowel movements.

On page 117, in November 2006, she had a low-grade temperature, was dizzy, had a bad stomach, and the doctor noted this was "flu syndrome." She was prescribed antibiotics, cough medicine and medicine for diarrhea.

On page 118, in September 2006, her weight was 121 pounds. He noted that she had difficulty gaining weight, but this would be a normal weight for a patient 5' 6" tall.

On page 119, in July 2006, her weight was 117, and she had intermittent diarrhea and had recovered from recent gastroenteritis (inflammation of the intestine and stomach), and nothing that occurred from the year before.

On page 120, there is a note of May 22, 2006, about multiple aches and pains, "many of which have followed her injury. Left facial pain and disfiguration and back pains, and headaches." This is not supported by other documentation.

On page 121, there is a note of May 2006, of occasional headaches "that she relates to injury when assaulted. . ."

On page 122, in January 2006, the patient was complaining of pains and discoloration of the right infrascapular area (below the "wing bone") as well as aches and pains below the rib cage on both sides and easy bruising and ecchymosis (black and blue discoloration). We now know that these were the earliest findings consistent with her mantle cell lymphoma (cancer).

On page 123, there is a note of residual swelling and pigmentation on the left cheek bone and that she saw a Dr. Shelly concerning the need for plastic surgery. His records should be obtained.

On page 124, her weight was 116 pounds in July 2005, and she had diarrhea for 30 days that ended after a course of an antibiotic, Cipro. This would be related to an infection, not related to any assault four months before. It noted that she was eating again and that her weight was stabilizing.

On page 125, on June 7, 2005, it notes that she had "multiple loose stools since yesterday." She also had intermittent cramping abdominal pain. Again, this is an acute onset unrelated to anything occurring months before.

On page 126, is a significant note of May 16, 2005, where she was "slowly recovering from recent injuries," and that there was "slight discoloration persists on left cheek," and slight headaches persisted but it also says, "otherwise sitting around fully and mentally okay." This was two months after the assault, and she was doing well and was "mentally okay."

On page 127 and 128, is a note of April 25, 2005, where she weighed 126 pounds (her weight was stable), and it refers to the mugging. There was some swelling of the left eye, and she was seeing the Ophthalmologist. He refers to severe headaches and epigastric (upper abdominal) pain. However, based on all these records, she had headaches and abdominal discomfort that preceded the assault by years.

On page 129, is a continuation of a note relating to the injury in March 2005, and it says there were stiff muscles on the flank but no bruises noted. They were obtaining a CAT scan (which was negative) and were referring her to an ophthalmologist (who said there was no intra-ocular injury).

On page 130, is a note from December 6, 2004, where she weighed 128 pounds, had swelling of her left knee, and swelling of the right side of the abdomen with some pain radiating down to the groin. The patient also was moderately depressed. She was given pain medication. This was four months before the assault.

On pages 131 and 132, is a note from March 22, 2005, referring to the assault where there was no loss of consciousness and there was blood from the left nostril. She was taken to a local hospital (whose records we need to see), and there was swelling in the area of the eye with no impairment of vision (not loss of vision for two weeks). Her neck was minimally stiff with full range of motion.

On page 134, a year before the assault, on March 15, 2004, she felt weak and depressed and "gets heartburn." The left side of the abdomen, the stomach area, had pain right after eating. He prescribed the anti-acid medication, Pepcid. She weighed 131 pounds at that time.

On page 135, on December 20, 2003, she was complaining of low back pain and had some abdominal pain.

In April 2003, on page 137, she weighed 132 pounds and had occasional diarrhea and multiple aches and pains with chronic congestion.

On page 139, on November 11, 2002, it says, "still has left abdominal pain daily."

On page 141, in 2002, she fell on her right wrist and had degenerative arthritis on x-ray. On that same page, on the bottom, she also had acute cystitis (bladder infection) treated with antibiotics.

On page 144, on May 20, 2002, she had "arthritis of hands and feet. Gastritis." Her weight was 134 pounds. This was three years before the assault.

On page 149, in May 2001, she had headaches. He believed these were related to the cholesterol-lowering drug, Mevacor.

On page 150, on April 3, 2001, she had pain in her pelvic area, severe headaches more frequently than previously, and stiffness and tenderness involving the cervical and lumbosacral area and both sacral iliac joints. She was prescribed aspirin and physical therapy.

On page 151, on January 23, 2001, she had "osteoarthritis flare-ups of her hands."

On October 2, 2000, on page 152, she had frontal headaches with worsening vision.

On page 153, in January 2000, the patient fell and had pains involving left sciatic neuritis.

On pages 156-158, is a handwritten note by the Physician describing the assault and his opinion about her persisting headaches, etc. This was previously discussed.

On page 159, the record refers to the MRI that showed lytic lesions as well as the osteoarthritis (O.A.) in her cervical spine.

On page 160, is a noted of December 18, 1999, involving her sacroiliitis and right sciatic syndrome. This low back pain clearly predated any assault.

On page 161, on November 3, 1999, her left leg buckled on her and she had left sciatic pain.

On page 162, in 1999, the records says, "seems to bump into things." She also has "occasional dizzy spell."

On page 163, in July 1999, she had swelling and pain involving her left knee that was recurrent.

On page 164, is apparently her first visit to her physician, dated October 6, 1979. She was 47 years old at the time, and he noted that she had a "longstanding spastic colon," and now "has typical irritable colon with spastic recurrent stools, cramps, etc.

On page 165, she had pains in her foot, and was in an auto accident in April 1979, and "since then has had weakness in right shoulder and weakness in right hand." Her weight was 116 pounds at the time and his impression was irritable colon syndrome. Thus, 116 pounds is a reasonable weight for this patient.

On page 166, on October 21, 1980, the patient "has noted ecchymosis left upper lid and more bruises recently on body, apparently unrelated to trauma." Various blood tests were performed with minimal abnormalities. Thus, this patient had a history of easy bruising, even without any trauma.

On page 167, in April 1983, she had "varied aches and pains" and weighed 107 pounds. In November 1985, she weighed 132 pounds. Thus, this patient's weight had changed from year to year, but was stable before and after the assault.

On page 171, May 10, 1998, she had "acute cervical root syndrome." Medication and exercise were prescribed. On the same page, on October 5, 1998, she had "persistent coccydynia (pain of the tailbone) and low back strain and was getting physical therapy (PT).

On page 172, November 1997, she had sprained her right ankle from a fall two weeks before. In March 1998, she had a painful left shoulder, as well as coccydynia that was very tender. This shoulder and tailbone situation occurred seven years before the assault.

On page 173, in November 1998, she had only slight improvement of her coccydynia (tailbone pain).

On page 174, is a significant note of May 2, 1999, where "fell in street three days ago. Hit right shoulder/hand and left side of face.” Thus, it would be important to obtain any photographs that predated the assault.

On page 175, in May 1999, she had a cyst of the left upper eyelid and was referred to a Physician for surgery. Also, in June 1999, she tripped and fell and injured her right ankle and leg.

On page 178, is an interval psychiatric summary by Dr. John, for care from December 2006 through September 2007. However, he refers to her six or seven visits (which was it?) from February 28 through September 4 of "this year." The February visit came from an exacerbation of her earlier symptoms relating to the attack in Puerto Rico, and she had not taken her antidepressant (Paxil) for some weeks at that time. When was it first prescribed? He noted that "clearly there has been some lessening of her acute distress over the past 2-1/2 years. ." but refers to her facial disfigurement and the uncertainty of her future condition.

But on page 179, in his letter dated December 12, 2006, he says, "...I know the patient well, having seen her intermittently in psychotherapy for many years." Since he was treating her for many years, it is important to get all of the psychiatric office records of Dr. John, prescription records, as well as any hospitalization records for psychiatric care, if she had been hospitalized.

In his letter, he said the patient was told she had "two brain tumors," one of the bone and one undiagnosed lesion. She had some thickening of the bone and a possible meningioma. He refers to the diagnosis of Dr. Lawrence of "cerebral concussive syndrome," and noted that the brain scan was negative. Dr. John noted modest improvement and his prognosis was guarded because of "...her conviction that she is stigmatized for life by virtue of her facial disfigurement which may not be satisfactorily repairable through surgery." Again, good photographs are necessary in this patient who has cancer and will probably succumb from the effects of her tumor. The cancer is unrelated to the assault.

On page 184, are some drawings by an unknown Physician, describing fibrosis (fibrous tissue) that is subcutaneous (under the skin) in the left temporal area and some hyperpigmentation in the area of the cheek. This appears to be from April 14, 2005, and is on page 184.

On page 185, is a note by that doctor, of August 31, 2005, with regard to follow up to "face bruise." In those records dated June 5, 2006, it notes that there is "still with atrophy and depression of left cheek, better, about 70%, from initial visit on July 2005."

On pages 190 and 191, is a handwritten note by the patient, dated March 20, 2005, where she noted that she was on special assignment. Is this covered by Workmen's Compensation? She noted that she left the sliding door open, 10-12 inches, since she did not use air conditioning. She said there were no signs indicating that she should close the door. In my opinion, someone visiting a resort where there is ground level access, who is a sophisticated traveler (she frequently went to the Caribbean) should know to lock sliding doors to ground level patios. She noted she could not tell what object it was that hit her, and at the end of her note says, "that right now I am feeling good, but I am very nervous." There was no mention of any pain in her wrist, shoulder, abdomen, or back. There was no mention of any headaches. These are her words two days after the assault.

On page 194 and 195, is the typed translated note by Dr. Lawrence concerning her assault and that she was taken to the hospital where x-rays were taken that revealed no fractures and "the doctor on duty diagnosed hematomas (blood clots under the skin) to her face, temporal and left wrist area." Those hospital records should be obtained. This notes there were no other injuries to her abdomen, her back, or other parts of her body.

On page 200, there is a photograph, allegedly of the patient, but good color photographs should be obtained of this specific photograph as well as all previous and subsequent photographs.


This patient had a long history of abdominal problems with gastritis, gallstones, spastic colon, urinary tract infections and low back pain as well as coccydynia and sciatic pain. All this preceded the assault by years. Furthermore, the patient also fell on her left side of her face and had other sprains and injuries. She had been under psychiatric care for many years and had a long history of depression, treated with medication. Furthermore, her history of headaches also preceded the assault by years, and the ophthalmology examination of the eyes showed no intra-ocular injury or visual problems. Within a few months, the ecchymosis had cleared.

At most, there is some thickening, or loss of fat under the skin, with some depression in the area of the left cheek area. If there is skin depression from loss of fat and/or scarring, this can be injected with a collagen solution to puff up the skin. This can be repeated, as needed, a few times a year.

The electromyogram and nerve conduction studies show no significant nerve damage, and the patient has severe cervical arthritis with compression of the spinal cord and nerve roots as they exit the spinal cord through the vertebral bones. All this is of a chronic degenerative nature, and clearly unrelated to the injury. After the injury, the patient had full range of motion of her neck without any significant problems.

With an injury of the left cheek and forehead area, there would be no injury to the posterior occipital area of her head. Thus, there was no occipital nerve damage, which is a superficial nerve under the posterior scalp area.

Based upon all the above, the patient did sustain an unfortunate experience, but she left the sliding door open 10-12 inches in a room that had been equipped with air conditioning. This was her decision to place her life in danger.

Furthermore, almost all of her symptoms predated any injury.

In addition, with her mantle cell lymphoma, her longevity is quite limited, and much of the abdominal pain and back pain would be related to the massive lymph node enlargements noted in the records of the Oncologist (Cancer Specialist). Her cancer and imminent death would cause severe depression by itself.

It may be possible to show, by photographs before and after the accident, that there may actually be no significant injury to her face since she had already fallen on the left side of her face.

As the records show, she was "obsessed with the mugging." However, she created the zone of danger by leaving the door open.

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Please obtain all the psychiatric records from Dr. John, and should you and your Client decide to pursue this case, I would suggest that the Medical Review Foundation, Inc. have all these records reviewed by our Board Certified Medical Experts in the field of Psychiatry and then Experts in the field of Plastic Surgery and possibly Medical Doctors in the field of Physical Medicine and Rehabilitation. They can comment on the appropriate aspects of her injuries, or lack thereof, based upon their specialties.

You may also want us to have the records reviewed by one of our Board Certified Medical Experts in the field of Oncology (Cancer Therapy) to discuss the short life span anticipated for this patient as well as the nature of the pains and related problems that she has and will further experience secondary to her mantle cell lymphoma. Certainly, when a patient has cancer, that will create a substantial degree of depression and emotional discomfort as well as physical pain, and that needs to be put into proper context. Thank you for allowing the Medical Review Foundation, Inc. to review this interesting case.

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