Mr. Thomas enjoyed taking day trips in his car, traveling, and going to Six Flags Amusement Park. He attended the St. George Coptic Orthodox Church.
Mr. Thomas could not provide a history or description of the events that led to him falling off a plane at the airport. (Later information states he worked as a truck driver; he fell off a truck while restocking a plane.) He was screaming when he arrived at the Emergency Department of The University Hospital at about 2:40 PM. His Glasgow Coma Score was 8. (This is a standardized score with 15 being the highest possible score and 3 being the lowest possible score.) Rescue squad workers had inserted intravenous needles into his inner elbows of both arms. The emergency department nurse stated the patient responded to pain. No one knew how long he was on the ground before being found.
In his fall, Mr. Thomas suffered from soft tissue and orthopaedic injuries, which are shown in the two PDF files. Michael Barrett of Wilentz Goldman and Spitzer asked Pat Iyer to summarize the voluminous medical records to detail Michael’s pain, suffering, and treatment. Pat included these exhibits in her report.
1. Glasgow Coma Scale
2. Exhibit 2
3. Exhibit 3
4. Level of Responsiveness 12/4/07 – 1/3/08
5. Examples of Restlessness and Agitation 12/16/07 – 1/1/08
6. Signs and Symptoms at The University Hospital 12/4/07 – 1/3/08
7. Selected Medications for Symptoms 12/4/07 – 1/3/08
8. Examples of Pain Reactions 12/17/07 – 12/30/08
9. Signs and Symptoms at Kessler Rehabilitation Institute 1/3/08 – 3/28/08
10. Posey bed
11. Muscle Strength Testing Scale
12. Strength on 3/31/08
13. Examples of Progress 4/7/08 – 6/20/08
14. Examples of Responses to Cognitive Rehabilitation 4/22/09 – 5/6/09
Norbert suffered from lingering problems related to his head injury.
Safety: When the therapist tested the patient, Mr. Thomas understood many aspects of safety. He did not display knowledge of medication names, dosages, and storage places. He could not locate important numbers in a phone book.
Cognitive symptoms: Mr. Thomas could concentrate on a thinking task for 80 minutes; he could participate in a physical task for 30 minutes before needing to rest. He had many internal distracters: feeling tired, headaches, pain, nausea, and dizziness. He identified many emotional distracters: panic, feeling nervous, fear, sadness, stress, acting without thinking, flashbacks, frequent worries, racing thoughts, and mind wandering.
He identified many environmental distracters that affected his ability to focus on a task: sudden or a lot of movement around him, too much detail or clutter, loud noise, radio or television, when more than one person spoke to him at a time, feeling hot or cold, in a large area like a mall, and in places with many sights and sounds.
These factors affected Mr. Thomas’ ability to sustain attention: eye pain, mental fatigue, trouble staying interested in a task for several minutes or hours, feeling frustrated, restless, and staying focused on a phone call or what a doctor told him. He had trouble watching a show for 30 minutes, reading a newspaper in one sitting, a chapter in a book, a short magazine article or a novel for several hours. He had trouble staying focused on a conversation during a meeting, information that was presented too quickly, or was too complex.
Mr. Thomas had trouble with divided attention: he had difficulty shifting his concentration between two or three things and from unimportant to important things.
Mr. Thomas had trouble with simultaneous attention.
Norbert’s attorney settled his case this year.
Patricia Iyer MSN RN LNCC is president of Med League. Contact us if you are an attorney who needs help summarizing medical records. We’re happy to help.