Grady Insurance Case
Lori Pounds of Hartford Insurance Company referred this file for medical case management. Instructions were given to meet with Larry Stevens and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
On 5/26/17 I met Mr. Stevens at the office of Dr. Jones. Mr. Stevens arrived with his girlfriend. He is alert and oriented. Mr. Stevens was willing to speak with me and to provide his medical history and current status.
MEDICAL FACTORS
Mr. Stevens said while he was in Arizona he was a restrained driver when a car ran a red light hitting him on the driver side door, no airbags were deployed. He reported the he was evaluated at the scene by EMS. He said he hit his head …show more content…
on the driver door, had a small laceration to the left wrist and hit his left shoulder. Mr. Stevens said he decline going to the emergency room. Mr. Stevens said a few days after the accident he began having headaches which increased. He said he was evaluated for the left shoulder and was sent for an MRI, he was not given a disc only a report which said he had a torn labrum. Mr. Stevens said he flew back to Michigan on 4/7/17. Mr. Stevens’ reports on 4/19/17 due to his headaches being worse he went to his PCP which is the Saginaw VA. Mr. Stevens said he was sent right over to Covenant hospital and had brain surgery that day with Dr. Mark Jones. Mr. Stevens reported he was told he had 2 bleeds and 6 cc's of blood were removed. Mr. Stevens said he was put on a medication for seizures which he will finish in 4 days, also Oxycodone which he said he only takes at bedtime. He said he was released to drive by the Neurosurgeon Dr. Mark Jones on 5/7/17. Mr. Stevens said he also was evaluated by Dr. Carrie White Orthopedic Surgeon on 5/2/17. Mr. Stevens said she did not feel he had a torn labrum. She wants him to have 4 weeks of physical therapy then recheck with her so an appointment had not been made yet. He will start physical therapy on 5/8/17 with Evergreen therapy in Harrison MI.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
No medical records have been provided for review.
CURRENT STATUS
Mr.
Stevens reports he has some gait issues and feels he is losing his balance at times when walking. He has headaches but not until the end of the day. He also reported that he takes a nap every afternoon which is very unlike him. He denied any seizures. He has completed the seizure medication. Mr. Stevens has limited range of motion to the left shoulder. When he reaches chest level it becomes very painful. He is in physical therapy for that. The examination done by Dr. Jones showed good strength and reflexes. Dr. Jones reviewed the recent MRI and said there is a collection of fluid on the left side of his head. There is no longer any fluid on the right. They had done burr holes in the skull to release the blood collection from the accident. Dr. Jones said that his age was a good thing since out brain shrinks with ages giving some more room.
CURRENT TREATMENT PLAN
Dr. Jones wants to repeat the CT of the brain again on 6/8/17 to monitor the fluid on the left side. He will then see Mr. Stevens again to review the results. In the meantime he would like Mr. Stevens to add a gait program to his current physical therapy program. I will meet Mr. Stevens at the appointment with Orthopedic Surgeon Dr. White on 6/6/17. Mr. Stevens has a large hernia that is not related that will be repaired soon. Dr. Jones said that was okay for him to have the sedation for the surgery
ADDITIONAL …show more content…
CONTACTS
Evergreen Physical Therapy, 158 N. 1st St. Harrison, MI 989-539-4167
ATTENDING PHYSICIANS
Name: VA of Saginaw (family physician)
Address: 1500 Weiss St. Saginaw MI
Phone: 989-497-2500
Last office visit: 11/16
Next office visit: 6/8/17, no treatment related to the auto accident
Name: Dr. M. Jones Neurosurgeon
Address: 2520 W. Wackerly St. Midland, MI 48640 Phone: 989-698-3033
Last office visit: 5/26/17
Next office visit: 6/16/17
Name: Dr. Carrie White Orthopedic
Address: 2890 Health Parkway, Mt. Pleasant, MI Phone: 989-953-9777
Last office visit: 5/2/17
Next office visit: 6/6/17
MEDICATIONS
Mr. Steven reports he took the following medications before the auto accident:
Metformin
Simvastatin
Clonazepam
Mr. Steven reports he is taking the following medications related to the auto accident:
Oxycodone
Mr Steven denied medication allergies.
DURABLE MEDICAL EQUIPMENT
N/A
ADL’S
Mr. Steven is independent with his personal care and household services.
MEDICAL/SURGICAL HISTORY
Mr. Steven reports he has cirrhosis of the liver, hernias, Diabetes, HTN, and gall bladder problems.
Mr. Steven report he smokes ½ a day. He has been counseled on smoking. He reported he stopped drinking any alcohol. He denied drug use.
EDUCATIONAL HISTORY
Mr. Steven graduated from high school in 1959. He was in the military.
EMPLOYMENT HISTORY
Mr. Stevens said he is a self employed musician and singer.
CURRENT EMPLOYER CONTACT INFORMATION
N/A
WORKERS’ COMPENSATION HISTORY
Mr. Stevens denied prior work injuries.
FAMILY/SOCIAL/FINANCIAL FACTORS
Mr. Stevens said he lives with his girlfriend; he said she is very supportive.
Emergency Contact –home phone number 989-588-6209
PHYSICAL DESCRIPTION
Height: 5 foot 7 inches
Weight: 185 pounds
Hair: grey
Eyes: blue
Dominant hand: right
CLIENT’S FUTURE PLANS
Mr. Steven wants to resume his normal work and life activities.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Mr. Steven verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
On 5/3/17 I contacted the office of Bellovin and Karnas.
I spoke with Mr. Karnas and was given a verbal to contact Mr. Stevens and attend medical appointments. On 5/4/17 I spoke with legal assistant Victoria from the firm. She again confirmed approval to have contact and meet with Mr. Stevens. I provided her with the address and contact number for Michigan Case Management. I explained written request must be made along with adjuster approval to obtain nurse case manager reports. On 5/16/17 I was sent a written request by the attorney for copies of my medical reports. I have updated the adjuster and received approval from the adjuster to provide a copy of these reports. Any billing for this though would be billed to the attorney
office.
IMPRESSIONS
Mr. Steven was in poor health before the auto accident. He is a very active person though and is motivated to recovery. He needs immediate surgery of a hernia that is not related to the auto accident. This may impair progress in regards to physical therapy and possible surgical repair to the left shoulder. Mr. Stevens is also a smoker and has diabetes. His age is also a factor. The Official Disability Guidelines for a subdural hematoma related to a traumatic event is 40 to 105 days, Rotator Cuff tear 58 to 180 days.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Steven every 2 to 4 weeks. Obtain and update on his current medical status and address any concerns he may have.
2. Attend the appointment with Dr. White on 6/6/17. Obtain a current treatment plan for the shoulder pain.
3. Obtain an update from physical therapy.
INTERVIEW SETTING
On 5/26/17 I met Mr. Stevens at the office of Dr. Jones. Mr. Stevens arrived with his girlfriend. He is alert and oriented. Mr. Stevens was willing to speak with me and to provide his medical history and current status.
MEDICAL FACTORS
Mr. Stevens said while he was in Arizona he was a restrained driver when a car ran a red light hitting him on the driver side door, no airbags were deployed. He reported the he was evaluated at the scene by EMS. He said he hit his head …show more content…
on the driver door, had a small laceration to the left wrist and hit his left shoulder. Mr. Stevens said he decline going to the emergency room. Mr. Stevens said a few days after the accident he began having headaches which increased. He said he was evaluated for the left shoulder and was sent for an MRI, he was not given a disc only a report which said he had a torn labrum. Mr. Stevens said he flew back to Michigan on 4/7/17. Mr. Stevens’ reports on 4/19/17 due to his headaches being worse he went to his PCP which is the Saginaw VA. Mr. Stevens said he was sent right over to Covenant hospital and had brain surgery that day with Dr. Mark Jones. Mr. Stevens reported he was told he had 2 bleeds and 6 cc's of blood were removed. Mr. Stevens said he was put on a medication for seizures which he will finish in 4 days, also Oxycodone which he said he only takes at bedtime. He said he was released to drive by the Neurosurgeon Dr. Mark Jones on 5/7/17. Mr. Stevens said he also was evaluated by Dr. Carrie White Orthopedic Surgeon on 5/2/17. Mr. Stevens said she did not feel he had a torn labrum. She wants him to have 4 weeks of physical therapy then recheck with her so an appointment had not been made yet. He will start physical therapy on 5/8/17 with Evergreen therapy in Harrison MI.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
No medical records have been provided for review.
CURRENT STATUS
Mr.
Stevens reports he has some gait issues and feels he is losing his balance at times when walking. He has headaches but not until the end of the day. He also reported that he takes a nap every afternoon which is very unlike him. He denied any seizures. He has completed the seizure medication. Mr. Stevens has limited range of motion to the left shoulder. When he reaches chest level it becomes very painful. He is in physical therapy for that. The examination done by Dr. Jones showed good strength and reflexes. Dr. Jones reviewed the recent MRI and said there is a collection of fluid on the left side of his head. There is no longer any fluid on the right. They had done burr holes in the skull to release the blood collection from the accident. Dr. Jones said that his age was a good thing since out brain shrinks with ages giving some more room.
CURRENT TREATMENT PLAN
Dr. Jones wants to repeat the CT of the brain again on 6/8/17 to monitor the fluid on the left side. He will then see Mr. Stevens again to review the results. In the meantime he would like Mr. Stevens to add a gait program to his current physical therapy program. I will meet Mr. Stevens at the appointment with Orthopedic Surgeon Dr. White on 6/6/17. Mr. Stevens has a large hernia that is not related that will be repaired soon. Dr. Jones said that was okay for him to have the sedation for the surgery
ADDITIONAL …show more content…
CONTACTS
Evergreen Physical Therapy, 158 N. 1st St. Harrison, MI 989-539-4167
ATTENDING PHYSICIANS
Name: VA of Saginaw (family physician)
Address: 1500 Weiss St. Saginaw MI
Phone: 989-497-2500
Last office visit: 11/16
Next office visit: 6/8/17, no treatment related to the auto accident
Name: Dr. M. Jones Neurosurgeon
Address: 2520 W. Wackerly St. Midland, MI 48640 Phone: 989-698-3033
Last office visit: 5/26/17
Next office visit: 6/16/17
Name: Dr. Carrie White Orthopedic
Address: 2890 Health Parkway, Mt. Pleasant, MI Phone: 989-953-9777
Last office visit: 5/2/17
Next office visit: 6/6/17
MEDICATIONS
Mr. Steven reports he took the following medications before the auto accident:
Metformin
Simvastatin
Clonazepam
Mr. Steven reports he is taking the following medications related to the auto accident:
Oxycodone
Mr Steven denied medication allergies.
DURABLE MEDICAL EQUIPMENT
N/A
ADL’S
Mr. Steven is independent with his personal care and household services.
MEDICAL/SURGICAL HISTORY
Mr. Steven reports he has cirrhosis of the liver, hernias, Diabetes, HTN, and gall bladder problems.
Mr. Steven report he smokes ½ a day. He has been counseled on smoking. He reported he stopped drinking any alcohol. He denied drug use.
EDUCATIONAL HISTORY
Mr. Steven graduated from high school in 1959. He was in the military.
EMPLOYMENT HISTORY
Mr. Stevens said he is a self employed musician and singer.
CURRENT EMPLOYER CONTACT INFORMATION
N/A
WORKERS’ COMPENSATION HISTORY
Mr. Stevens denied prior work injuries.
FAMILY/SOCIAL/FINANCIAL FACTORS
Mr. Stevens said he lives with his girlfriend; he said she is very supportive.
Emergency Contact –home phone number 989-588-6209
PHYSICAL DESCRIPTION
Height: 5 foot 7 inches
Weight: 185 pounds
Hair: grey
Eyes: blue
Dominant hand: right
CLIENT’S FUTURE PLANS
Mr. Steven wants to resume his normal work and life activities.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Mr. Steven verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
On 5/3/17 I contacted the office of Bellovin and Karnas.
I spoke with Mr. Karnas and was given a verbal to contact Mr. Stevens and attend medical appointments. On 5/4/17 I spoke with legal assistant Victoria from the firm. She again confirmed approval to have contact and meet with Mr. Stevens. I provided her with the address and contact number for Michigan Case Management. I explained written request must be made along with adjuster approval to obtain nurse case manager reports. On 5/16/17 I was sent a written request by the attorney for copies of my medical reports. I have updated the adjuster and received approval from the adjuster to provide a copy of these reports. Any billing for this though would be billed to the attorney
office.
IMPRESSIONS
Mr. Steven was in poor health before the auto accident. He is a very active person though and is motivated to recovery. He needs immediate surgery of a hernia that is not related to the auto accident. This may impair progress in regards to physical therapy and possible surgical repair to the left shoulder. Mr. Stevens is also a smoker and has diabetes. His age is also a factor. The Official Disability Guidelines for a subdural hematoma related to a traumatic event is 40 to 105 days, Rotator Cuff tear 58 to 180 days.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Steven every 2 to 4 weeks. Obtain and update on his current medical status and address any concerns he may have.
2. Attend the appointment with Dr. White on 6/6/17. Obtain a current treatment plan for the shoulder pain.
3. Obtain an update from physical therapy.