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
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
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