Megan Steele Case Summary

Michelle Johnson of Pioneer State Mutual Insurance Company referred this file for medical case management. Instructions were given to meet with Megan Steele and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.

INTERVIEW SETTING

On 7/20/16 I met with Ms. Steele at the U of M acute rehabilitation center. Ms. Steele requires a 24/7 sitter. Her rancho level is a 3-4. I introduced myself she was pleasant. Ms. Steele did not engage in much conversation. She was in a wheelchair and was in constant movement with her arms and leg.

MEDICAL FACTORS

Ms. Steele has no recall of the accident. Details have been provided by the emergency room consultation. Ms. Steele had a motor vehicle collision

traveling 55 mph. Airbags were deployed. Ms. Steele was found outside of the vehicle. Her glasco coma scale was 8. She was intubated and transferred to a local hospital. She was stabilized and then air lifted to U of M. She has been admitted to the acute rehabilitation unit. A possible transfer to Litehouse inpatient acute rehabilitation will be determined at a later date.

DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS

29 pages of medical records have been provided from the U of M health system and reviewed.
Chest x-ray: normal no rib fractures.
CT abdomen and pelvis: splenic laceration grade II.
CT scan cervical, thoracic, and lumbar: acute subarachnoid hemorrhage within bilateral sylvian fissure, C1 C2 rotary subluxation, punctuate ossific density left occipital condyle may represent small avulsion fracture.
CTA neck and head: Subarachnoid hemorrhage, subluxation of cervical 1 and 2.

CURRENT STATUS

Ms. Steele is a rancho 3-4. She needs 24/7 sitters. She is in constant movement and is impulsive. She is alert and recognizes her family and friend.

CURRENT TREATMENT PLAN

I was able to meet with Dana Rogers MSW assigned to Ms. Steele. He reports that she will remain in the acute rehabilitation setting possible until 8/17/16. She requires a 24/7 sitter. Her Rancho Los Amigos Scale level is a 3-4. They will evaluate her need for Litehouse rehab at the time of discharge. In the meantime Litehouse is holding a bed. I was told that team meetings are briefly and weekly and they will update me after they occur.

ADDITIONAL CONTACTS

No additional contacts other than Mr. Steele.

ATTENDING PHYSICIANS

Name: Dr. Greenwell (family physician)
Address: 117 Hubinger St. Frankenmuth, MI 48734

Phone: [phone]
Last office visit: Unable to obtain this information
Next office visit: As needed

Name: Dr. Scott Beasecker Sport’s Medicine
Address: 506 N. Franklin St, Frankenmuth, MI 48734

Phone: [phone]
Last office visit: unknown
Next office visit: unknown

MEDICATIONS

Mr. Steele and Ms. Steele are in the process of a divorce and do not live together. Mr. Steele has limited information regarding current medications. He did say he was told she was took the following medications:
Xanax
Anti-depressant
Medical dictation showed she took Vimpat prior to the injury.

U of M medication listed the following medications related to this injury:
Actaminophen
Ampicillin
Calcium gluconate
Chlorhexidine gluconate
Famotidine
Fentanyl
Lamotrigine
Levetiracetam
Lidocaine Epinephrine
Magnesium oxide
Potassium and sodium phosphates
Potassium chloride
Sertaline

There are no known medication allergies.

DURABLE MEDICAL EQUIPMENT

A complete determination will be made closer to discharge. Ms. Steele will be transferred to the Litehouse after spending several weeks in the U of M acute rehab.

ADL’S

Per the U of M staff, Ms. Steele is dependent on personal care and needs 24/7 sitters for impulsive behaviors.

MEDICAL/SURGICAL HISTORY

Mr.

Steele said that during Ms. Steele’s pregnancies she needed to take a blood thinner due to a clotting issue. He also said she has lupus and had a seizure 15 years ago.

Medical dictation stated Ms. Steele is a non smoker. Ad drug screen done at the time of the injury was positive for amphetamines, benzodiazepines and cannabinoids.

EDUCATIONAL HISTORY

Per Mr. Steele, Ms. Steele had a Licenses Nurse degree prior to obtain the Registered Nurse degree.

EMPLOYMENT HISTORY

1. Place of Employment: Covenant Hospital
• Job Title: RN NICU
• Start date: 40 + Stop date: current
• Hours per week:
• Job requirements and physical demands: bend, lift, carry, critical thinking and decision making.

CURRENT EMPLOYER CONTACT INFORMATION

Employer contact unknown at this time.

WORKERS’ COMPENSATION HISTORY

Mr. Steele denied any prior work injuries for Ms. Steel.

FAMILY/SOCIAL/FINANCIAL FACTORS

Per Mr. Steele, he is still very supportive of her well being and medical care. At this time Mr. Steele is still her legal guardian. Mr. Steele said that her parents are very supportive and willing to help. Ms. Steele lives with her four children.
Emergency Contact – Luke Steele 989-551-5385

PHYSICAL

DESCRIPTION

Height: 5 foot 5 inches
Weight: 143 pounds
Hair: brown
Eyes: brown
Dominant hand: right

CLIENT’S FUTURE PLANS

Ms. Steele would like to get better and resume her work and home life.

CONSENT/EXPLANATION OF CASE MANAGEMENT

I explained my role as medical case manager and Luke Steele, husband verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.

ATTORNEY

Mr. Steele reported there is no legal representation at this time.

IMPRESSIONS

Per Mr. Steele, Ms. Steele’s over all heath was good. She did have some issue with depression and anxiety and was under treatment. The Official Disability Guidelines for a TBI is 26 to 334 days, a spleen laceration is 39 to 85 days, and a subarachnoid hematoma is 40 to 105 days. Ms. Steele is undergoing an intensive acute rehabilitation program. Per Dana Roger’s social worker Ms. Steele is at a 3-4 level on the Rancho Los Amigos Scale. A level 8 is the goal.

PLAN/ RECOMMENDATIONS

1. Contact Luke Steele husband every 1-2 weeks for an update on Ms. Steele’s current condition.
2. Contact U of M case manager Larry McCamon or Dana Rogers social worker for an update on Ms. Steele’ medical status and plan of care.
3. Contact Lori case manager from the Litehouse once Ms. Steele is transferred.