Question: Draft a summary based on the following client information form and medical records. Assume the report is for your supervising attorney who has no information
Draft a summary based on the following client information form and medical records. Assume the report is for your supervising attorney who has no information about the client or the case. Your summary should include the following:
General contact information; Background information on the client(s), witnesses, defendant(s), medical providers; Facts; Harm/injuries; Medical treatments; Medical providers; Insurance; evidence; discussions with others as well; pictures; property damage; personal injuries and anything else the client shares.
Case Number: 2024-1-PI-780 Intake Date: 8/28/24 Team: CM/TG Name: Bella Young DOB/Age: 07/22/1994 Address: 3792 Penny Lane, Macon, GA 31201 Telephone: (478) 555-0987 Alt Phone: (478) 555-5878 Email: Bella Young@cmail.com Employer/Position: American Red Cross / Accountant Employer Address: 82 Capital Street, Macon, GA 31201 Physical Requirements: Sitting 8+ hours/day: typing; completing forms by hand: holding telephone; travel W/week to events Education: BS Accounting Fort Valley College Hobbies: volunteering, sports and computer gaming Date of Injury: August 21, 20xx-1 Location: 62 New Castle Road, Macon GA 31201 Witnesses: Kate Lundy (478) 555-4448; David Carline 478-555-1212 Diagnosis: multiple dog bites: contusion Treatment: multiple procedures = PI x6 months - MMI as of 12/12/20xx-1; cast; surgery Treatment Providers: EMT to Macon Hospital - Dr. Shayla Biggs; Fort Valley Physical Therapy, Peach Radiology; CVS; Family Or - Coulter Macon Family Practice Damages: Medical expenses: Lost wages x12 weeks; permanent impairment; scars Description of Incident: Client bitten by dog1. My name is Rashad Jamal King. M.D. and I am competent to make this affidavit. 2. I received my bachelor's degree at Howard University in 19xx-30, and my medical degree at Morehouse Medical College in 19xx-28. After a residency in the University Hospital Department of Surgery. I completed a clinical fellowship in trauma at Grady Memorial in Atlanta. I am now an attending surgeon in Atlanta, Georgia, where I have been the Director of the Trauma Center for seventeen years. In addition to fulfilling duties in patient care. I am a virtual (Internet) consultant for the Georgia Dog Bite Center Research Laboratory that has an emphasis on aberrant healing processes including hypertrophic soar formation and chronic non-healing wounds. I have published 34 articles in the area of wound repair, treatment for Dog Bites, and scar prevention. I have been a member of the National Dog Bite Association since 19xx-25 and have served on that organization's Research, Ethics, and Outreach Committees. I am also on the editorial board of the National Dog Bite Journal. 3. I have reviewed Bella Young's medical records in this case. 4. The opinions expressed in this affidavit are based on my education, knowledge, experience, and review of relevant records. My opinions are made to a reasonable degree of medical certainty. 5. The most crucial element of Dog Bite treatment is to evaluate the extent and degree of the injury. A skin Dog Bite is damage to the dermis caused by ripping and tearing. Extreme ripping and tearing causes cell damage through rapid protein denaturation. The depth of the Dog Bite depends on how deeply the ripping and tearing penetrates the skin. The patient in this case suffered a level five with level four deep punctures, bruises and tears. A Level Five is a Dog Bite Of multiple times in which he'she might bite the victim more than two times in a single attack with bites of level four, which is the bite makes one in four deep punctures and there are bruises and tears caused because of the bite. A Level Five with severe biting becomes a level six if the victims dies. 6. Dog Bites are usually classified in terms of level. First-degree Dog Bites are minor and extend only on the surface, usually no skin to teeth contact and be zestful obnoxious behavior or aggression. First-degree Dog Bites are characterized by no pain at the site. Level Two. In this level skin and teeth contact is made but there are no punctures made, but there may be a small fear with minor pain. Level Three: In this level of dog bite there are one to four punctures made from one bite on the victim, and there is a chance of small tears being made from the victim pulling hisber body part away from the biting dog or the hiting dog pulling away. The pain can be great but generally there is no nerve damage. Level Fixes. In level five of a dog bite, the dog bites its victim multiple times in which he/she might bite the victim more than tome times in a single attack with bites of level four, which is the bite makes one to four deep punctures and there are bruises and tears caused because of the hite. There could be great pain but it depends on the extent of nerve damage. The more damage to the nerves, the less pain. Less nerve damage, however, results in excruciating pain. Level Sir. Level six is the most severe level of a dog bite. In this level, the victim dies because of the dog bite. 7. The Dog Bites themselves might be painless, but the treatment and healing can be excruciating. The prime motive of taking care of a wound from a dog bite is said in be the attempt of preventing infection that can be caused because of the bite. About a rough estimation, 30%% of a dog bite introduces bodyis which include wannawoohyun streptococcus, and Pasteurella. Dogs who are unvaccinated or undomesticated have the potential of carrying rabies and treaferring it through a bite, hence a health professional will inquire about the dog that has bitten an individual. 8. The patient in this case suffered Level Five Dog Bites on the front of the right thigh and abdomen and on the right hand, wrist, and forearm. The Dog Bite to the patient's abdomen was a level two Dog Bite. The Dog Bites to the patient's thigh were third level Dog Bites. The Dog Bites to the patient's hand and forearm were Level Fine Dog Bites.MACON, GA 31201 Medical Record #:21-41695 (478) 655-1001 Physician: Biggs, C. (478) 565-1021 (fax) Admit Date: 06/21/20xx-1 HOSPITAL DISCHARGE REPORT - page 1 of 2 DATE ADMITTED: 06 21/20xx-1 DATE DISCHARGED: 07/01/20xx-1 CHIEF COMPLAINT: Status post Dog Bite: It. hand, It. arm, abdomen, concussion. HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old female. She was attacked by a dog. She arrived by ambulance somewhat sedated, but clearly in extreme discomfort. PAST MEDICAL HISTORY: Pertinent for chronic bronchitis, allergic rhinitis, asthma. CURRENT MEDICATIONS: Albuterol. Claritin OTC ALLERGIES: None. SOCIAL HISTORY: The patient denies smoking drinking alcohol, or using illicit drugs. INITIAL PHYSICAL EXAMINATION: The patient had a temperature of 98.6, a pulse of 107, respirations of 43, blood pressure of 172/102. GENERAL: The patient was in acute distress and disoriented HEENT: Ear, noge, and throat were normal HEART: Erratic rate, but without gallops, rubs, or murmurs. LUNGS: Bilateral constriction EXTREMITIES: Acute wounds to right side extremities. Sensation intact to proprioception Normal reflexes at all other extremities at 2+. Pulees were normal NEUROLOGIC: There were no gross neurologic deficits nor lateralizing signs. Cranial nerves II-XII were of concern. PSYCHIATRIC: Patient was sedated and in acute distress. EMERGENCY DEPARTMENT COURSE: The patient's clothing was removed to assess the Dog Bites. The patient was reasonably stable. Intravenous pain and anxiety medication was administered The patient was treated first with a douse of cool water for approximately 10 minutes. This was done to help alleviate the pain, clean the wounds and reduce swelling. Punctured skin on the thigh was covered loosely with a sterile dressing to prevent infection. A broad-spectrum surgical antimicrobial topical scrub (Chlorhexidine gluconate) was used along with adequate amalgesia and preemptive anxiolytic in order to permit adequate wound care. The patient was stabilized and admitted for surgical treatment MACON COMMUNITY HOSPITAL PATIENT: Young BellaMacon Family Practice Treatment Notes - Dr. Madison D. Keaton 07/30/23 - PL. is a 30-year-old female I have treated for eleven years. Last month she suffered severe Dog Bites to her midsection and right extremities when she was attacked by a dog. She was transported from the scene by ambulance and was treated in the emergency room with procedures to her thigh and stomach area. She was admitted to the hospital for surgical intervention for more severe Dog Bites on her arm, wrist, and hand. She was discharged after ten days. She follows with her surgeon, Dr. Shayla Biggs and has had one additional reconstruction surgery scheduled in six weeks. Bella is treating with topical antibiotics and lorazepam prescribed by Dr. Biggs. She continues with compression garments and physical therapy and will likely do so until after her last procedure. Bella reports mild resting or "background" pain that is almost always present, particularly in the thigh and stomach area. She reports more severe pain, likely neuropathic, in the arm, wrist, and hand. This is caused by damage to and regeneration of nerve endings in her skin. Bella has returned to work, but continues to limit her activities due to ongoing healing of her wounds and limited mobility. She is having some difficulty sleeping. Upon examination, wounds appear to be clean and healing nicely. I prescribed Zolpidem to help her with muscle relaxation as a companion to pain medication prescribed by Dr. Biggs. I also prescribed Soma to help her sleep. /ADT 09/22/23 - Pt. returns for follow up after severe Dog Bite injury to significant portions of her body. Bella's treatment required two additional operations to correct or release the injuries on the hand and wrist. Extensive physical therapy was required following each restoration procedure. Bella has been receiving steroid injections and applications to speed improvement. In spite of these efforts, Bella is not likely to regain full function of the right hand and wrist. In addition, Bella will have permanent scarring on the thigh and arm and permanent scarring and deformity on the hand and wrist. Upon examination, wounds appear to be clean and healing is progressing as to be expected. Ongoing pain continues to be a problem. Bella reports breakthrough pain that comes and goes throughout the day, likely due to wound healing. She rates this pain as a 5 or 6 on a 10-point scale. Bella reports that continued pain is interfering with many aspects of her life, including: difficulty falling asleep and staying asleep and limitations on her ability to function and concentrate on the job. She shows signs of depression and anxiety, and I believe that psychological intervention is necessary at this time and will refer. I encouraged her to continue her physical therapy and medications. She is to contact me immediately if any of her symptoms worsen. Otherwise, we will follow up in a couple of months. /ADT 12/12/23 - Pt. returns for follow up. I have followed Bella's rehabilitation and reconstruction treatment since discharge from the hospital. Dr. Biggs released her last month and sends a good report. Bella says today that her pain is nearly completely resolved and she is no longer taking medication for pain or muscle relaxation. She has been discharged from physical therapy and has been given home exercises. She is sleeping better and has resumed normal activities. She has began therapy with Middle Georgia Mental Health. The Dog Bite site on Bella's abdomen remains discolored, but is expected to have a completely normal appearance. The Dog Bites on Bella's thigh and forearm near the elbow are hypertrophic - raised scars that are thick and red. Generally, hypertrophic scars improve with time. Unfortunately, Bella has what is called a contracture scar on the area between the right forefinger and right thumb extending down and around to the inside of the right wrist. A contracture is a permanent tightening of skin that develops when the normal elastic connective tissue is bitten and inelastic fibrous tissue replaces it during the healing process. The muscles and tendons beneath the surface of the skin contract preventing normal movement. Contractures limit mobility and can ultimately result in degeneration of the nerves. Bella should be physically able to resume activities such as sports at some point in the future, I would expect the skill level to be diminished as a result of the permanent loss of strength and dexterity in the affected areas. She is at MMI and released to return here as needed. /ADTWAGE AND SALARY VERIFICATION EMPLOYEE: Bella young DATE OF INCIDENT: 1. OCCUPATION: Accounting 2. DATES OF EMPLOYMENT: FROM guly 2005 THROUGH _preand 3. WAGE OR SALARY AS OF DATE OF INCIDENT: 4. USUAL NUMBER OF HOURS WORKED PER WEEK: 40 5. HOURLY RATE OF PAY: 17/A bsalaried employzel 6. DATES ABSENT FOLLOWING INCIDENT: (June 1, 2021 - Geptember 15, 2028 7. HOW MUCH, IF ANY, OF EMPLOYEE'S SICK LEAVE OR VACATION WAS USED DUE TO THIS INCIDENT: 8. ADDITIONAL NOTES: DATE: SIGNED: DeShow Carter TITLE: HR Manager COMPANY: American Red Cross Thank you for your assistance. Please return completed form by MAIL to: Jessie Howell, Esquire Law Offices 1000 Eisenhower Boulevard Suite 401 Macon, GA 31201 Or by FAX to: (478) 555-0484 ATTN: Paralegal
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