CASE EXAMPLES - SPINAL CORD INJURY CASE

SPINAL CORD INJURY CASE REPORT

Demographic Information:

Chief Complaint(s)

Current Disability

Spinal Cord Injury

Bowel/Bladder

Sexual Issues

Turning/Transfers

Nursing/Attendant Needs

Transitional Living Program

History of Complications

Miscellaneous Information

Psychosocial Issues

Physical Limitations

Environmental Influences

Present Medical Treatment

Medical Summary

Activities Of Daily Living

Sleep Pattern

Independence In

Social Activities

Personal Habits

Socioeconomic Status

Income

Other Agency Involvement

Education & Training

Military Experience

Employment History

Observations

Tests Administered

Conclusions:

SPINAL CORD INJURY CASE REPORT

Marion Gold is a 36-year-old Caucasian female seen for evaluation at her home in Minneapolis, Minnesota. Also present and participating in the evaluation is her father David Gold and her mother, Deborah Gold. Marion was referred for a rehabilitation evaluation by her attorney, Carl Sutherland. The purpose of this evaluation is to assess the extent to which handicapping conditions impede her ability to live independently, handle all activities of daily living, and toassess the disability's impact on her vocational development status.

Demographic Information:

Client Name : Marion Gold; Social Security #: 453-27-4476; Address: 534 South Ocean Drive, Minneapolis, MN 55420; County: Hennenpin; Closest Metro Area: Minneapolis; Phone: 760-364-3384; Birthdate: 6/25/67; Age: 36; Sex: Female; Race: Caucasian; Marital Status: Single; Birthplace: Hillsboro, WI; Citizen: Yes; Elementary/Secondary Education: Elementary and High School education in Wisconsin; Employer at time of injury: All Star Inn & Suites; Position/Grade: General Manager; Bilingual: No; Glasses: No; Dominant Hand: Right; Height: 5’1”; Weight (present): 225 pounds; Weight (pre-injury): 185 pounds; Date of Onset: 3/8/99.

History: She was the driver involved in a single vehicle, roll over accident. She was driving a Nissan Pathfinder. She denies loss of consciousness. She has a full recall of events at the scene. She had to be extricated from the vehicle by emergency personnel. She was taken by ground ambulance to Gotwalt Memorial Hospital where she was stabilized. Subsequently she was transferred by ground ambulance to West Park Hospital in Holcombe, Wisconsin. She was evaluated there, but it was determined that she should be transferred to Mayo in Rochester. She was transferred part of the way by ground ambulance and the balance of the way by air ambulance. She was finally seen at The Mayo Clinic Hospital where she was admitted. There she was told that she had C5/C6 and C7 spinal cord damage.

Loss of Consciousness or Altered State of Consciousness: No.
Length of Unconsciousness or of Altered State: N/A.
Independent Recall: Yes. She reports and demonstrates a full, independent recall of all events.

Rehabilitation Program(s) [In/Outpatient Since Injury]: She was initially taken to Gotwalt Memorial Hospital ER where she was kept only briefly awaiting transport. She was then transferred by ambulance to West Park Hospital in Holcombe, WI. She was only there for an hour, then she was transferred to Mayo Clinic in Rochester, MN. There was a big storm that day so they took her by ambulance to a point closest to the Minnesota border and Life flight picked her up from there and brought her to the Mayo Clinic.

Marion was admitted to the Mayo Clinic after midnight on March 9, 1999 and she remained there until June 1, 1999. She was admitted for acute care and surgery, (a fusion to the best of Marion’s recall-see medical summary), at the Mayo Clinic. Within two weeks, she was transferred to the Rehabilitation unit in the Mayo Clinic. She was at the Mayo Clinic for a total of three months. She did participate in a full rehabilitation program consisting primarily of physical and occupational therapy.

She was discharged to the Dawson Rehab. Center in Bloomington, MN on June 2, 1999. She remained at the Dawson Rehab. Center for 16 months. She continued to have therapy during her stay at the Dawson Rehab. Center. Part of her Occupational Therapy program included some transitional living training. She left the Dawson Rehab. Center on October 12, 2000. She left to have a Mitrofanoff bladder surgery. She reports she had a lot of complications with her surgery. On discharge, she moved into her apartment.

She was transferred to an Independent Living Apartment on November 14, 2000. The program is called The Village, Inc. out of Richfield, MN. She notes the on site manager is Claire Mills. Her apartment is wheelchair accessible. Personal care attendants are part of the independent living program. They provide personal care assistance with bathing, dressing, bowel and bladder care. They also provide cleaning, laundry and cooking. They provide approximately four hours per day of personal care assistance. Marion notes she is authorized by the state to get eight hours a day of personal care assistance. She notes they bill the State for the eight hours and pool the hours with seven other residents. She could get more hours if in fact she needed it. She has to provide her own transportation, but someone from the program will accompany her to the grocery store and provide assistance. An important key to this program is she has onsite access to help twenty-four hours a day if she requires it on an emergent basis. The cost of the program is $4,000 per month and this is billed to Medicaid as far as she knows. Without this program and the opportunity for, “shared caregivers and immediate on site, on call personnel,” cost of care to provide coverage would be considerably more. There are twenty-three apartments in this building, but only seven are offered the personal care assistance service the rest have to hire privately. This means that bed space for these apartments is severely restricted. There are only units for this company in Minneapolis, Las Vegas and Colorado. Marion researched the availability of similar alternatives near her parents and friends, but none existed.

She has not had any additional therapy since she left Dawson Rehab. Center in October 2000.

Prior Medical History:
ACL ligament repair in 1982.
Tonsilectomy at age 10.
Denies any prior history of accidents or injuries requiring medical care.
Denies any prior history of chronic illnesses requiring ongoing medical treatment.
Denies any prior history of psychological or psychiatric treatment or psychotropic medication.

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Chief Complaint(s)

Current Disability

Disabling Problems: (By client/family history and report. No physical examination occurred).

Marion, “I am a C5/C6, C7 quadriplegic, basically paralyzed from the chest down. I have limited use of my upper torso, including my arms and my hands. I am a complete break. Basically, this means there is not going to be a medicine or surgery out there that is going to let me walk again. I have no control over my bowel movements. I have to have a personal care attendant come in on a daily basis to do a bowel program. This consists of a suppository insertion and digital stimulation every fifteen minutes for two hours. This is done daily. I cannot fully do any of my personal care, and I have to rely on my personal care attendant for showers, dressing and grooming. They have to get me dressed in the morning and transfer me from the bed to the wheelchair. I have no bladder control, so I have to self-catheterize by inserting a catheter into my stoma every four hours throughout the day. I cannot prepare any of my own meals. The attendant must cook for me and then cut up my meals for me. The attendant also must put me down at night, which means helping me transfer from my chair back into the bed. She must do the range of motion on my legs. I cannot do housekeeping or laundry tasks, so this is also done by the attendants.”

Marion continues, “I see a lot more doctors than I ever have seen before. I have a lot of UTI’s and see a urologist once a month. The UTI’s cause a lot of pain and headaches. Being on antibiotics a lot causes reoccurring yeast infections for which I have to get treated. Since I have limited movement, I have to be careful about decubitus ulcers since I am in my wheelchair thirteen hours per day. I have to watch out for blood clots in my legs due to immobility. I am on medication every day just to stabilize my health. I have blood pressure that tends to be very low, (80 over 60). I intermittently suffer from dysreflexia either related to my bladder or bowel program. I am on Baclofen for spasms. I have spasms, which are moderate. I get bronchial infections every winter largely because I don’t have a productive cough.”

Marion says, “Due to my injury, it is physically impossible for me to go back to the line of work I was in as the general manager of a hotel, due to the long hours and some of the physical requirements that the job brings forward. I can’t write very much, maybe a sentence or two and that is about it. I can only type 12 words per minute on a computer. Due to blood pressure problems and some incontinence, I may not be able to tolerate much time in the chair on a daily basis on occassion. Socially, I basically have no social life. Before the accident, I enjoyed playing softball, darts, bowling and league activities. Some of the businesses are not handicapped accessible and this further proibits me. Since my accident, I have a fear of driving on a freeway going faster than fifty miles an hour. I only have one hand strapped to a tripod on the steering wheel in the current setup, with the other hand controlling the brake and the pedals. I can’t really go back home to visit my parents because the personal care attendant at the apartment is not allowed to go with me for the weekend. This bothers me because that is where ninety percent of my friends live.”

Marion’s long term goal is to relocate to be near her parents. She feels she can not at this time because of the lack of affordable, suitable housing and caregivers in their area. She has concerns about availability of Medical care close by. She feels realistically she would have to relocate closer to Madison, WI. She is not under a contract at her current location. She can move out on thirty days notice.

Spinal Cord Injury

Level of Lesion: C5, C6, C7

Complete/Incomplete Lesion (Sensory & Motor): Complete motor and sensory. ASIA-A based on patient report.

Pain above or below level of lesion: She has pain in her neck and both shoulders. This is a constant burning pain. She is a complete motor lesion, but there is a current indication that she is an incomplete sensory lesion in that she is having pain when certain personal care attendants are doing her digital stimulation. She has had a colonoscopy and is going to see her physiatrist to discuss this. There is concern that the attendant is either pressing on the wall of the bowel or going up to high.

Pattern of Paralysis (sensation loss): She has loss of sensation from just above her breast down. She has arm range of motion and she can open and close her hands. She has no grip strength. She is able to demonstrate simultaneous, bilateral ROM without losing balance or falling forward or to the side. Grip strength, although bilaterally very weak, is stronger on the left than right.

Bowel/Bladder

Type of Bowel Program: Suppository, Eneemez, inserted one time per day and then digital stimulation every 15 minutes for 2 hours. She requires help from setup to cleanup. From start-up to clean-up the bowel program lasts two hours and thirty minutes.

Independent: No.

Type of Bladder Program: Mitrofanoff done 9/27/2000. She is able to self-cath through her stoma. Sterile cath technique every 4 hours during the day and 8 hours at night. Marion opens a new sterile catheter, (not a kit), every time she catheterizes. She throws the catheter away after use and opens a new sterile catheter the next time. Once per day, she flushes with 500 ML of sodium chloride water. She flushes and caths directly into a urinal/bucket. No bags needed. No diapers needed for bowel or bladder.

Independent: Yes.

Urine Check: 1 X / month.

Urinary Tract Infections: She has frequent UTIs. Usually has infection one time per month. Takes Cipro about one time per month when she has an infection. (BID for 5 days.)

Hospitalizations for UTI: No.

Sexual Issues

Sexual Education Received: None.

Sexual Counseling Received: None.

Fertility Issues: None.

Sexual Aids Used: None.

Turning/Transfers

She can not turn independently. She has a Turn Soft bed by Hinz Manufacturing that rotates her to prevent sores. She can not transfer by herself. An attendant comes and gets her up in the morning and transfers her back to bed at night. She stays in her wheelchair all day.

Independent: No.

Nursing/Attendant Needs

She does not have any services other than the ones provide by the Independent Living Program. The program will provide her a total of 8 hours per day. This care is all done by an attendant including the bowel program. They do independently contract a skilled nurse that comes out periodically to check the patients for pressure sores, etc. Marion has only been seen once by the nurse. Outside of this program, she would require a live-in attendant plus a visit from an LPN for the bowel program until age and disability combined to require help with her bladder program. At that point, she would require 24 hour LPN. At current program, they are getting around the issue of LPN doing bowel program by having onsite nurse supervision, although the nurse is not onsite all the time.

Transitional Living Program

Yes, Dawson Rehab. Center.

History of Complications

Dysreflexia: She does have periodic problems with this and it is usually associated with needing to cath or needing to do her bowel program. Averages problems one time per month.

Spasms: Spasms are moderate to severe. She has to have her feet strapped in. She is on Baclofen & Valium for spasms. Baclofen pump might be needed in the future.

Decubiti (recent/past): Occasionally does have pressure sores on her tail bone, (coccyx). She does have one now, but it is only surface (Grade I). They use Comfeel dressing that is applied by the caregivers. She has to use these dressings maybe once every 5 months.

Thrombophlebitis: None.

Respiratory Infections: No problems.

Overheating: Problems denied with regulating body temperature.

Chilling: Problems denied with regulating body temperature.

Miscellaneous Information

Psychosocial Adaptation to Disability: She feels like she has adapted “pretty good.” Denies depression. She does admit to intermittent anxiety and stress. She also indicates being aware of some feelings of anger.

Architectural Renovations Completed: She currently lives in an accessible apartment within an Independent Living Facility.

Auto Insurance/Driving Evaluation: Yes.

Adaptations to Auto/Van: She has an adapted van. Dodge Caravan 1996, with lift, wheelchair tie downs and hand controls. She does not currently have a cell phone and we discussed the importance of this. She indicated she would get one.

FES/Biofeedback (Neuromuscular Re-education): None.

Anticipated Treatments: Baclofen Pump may be needed in the future.

Psychosocial Issues

Patient: She denies depression and feels she has adjusted pretty well. She does admit to intermittent anxiety and stress. She also indicates being aware of some feelings of anger.

Family, Emotional Impact on Spouse/Children: Deborah notes that when Marion was in Mayo it was so stressful that David went into cardiac arrest and he was admitted into Mayo. They continue to feel a great deal of stress and remain very concerned. They travel down to Richfield once per month to visit.

Physical Limitations

Loss of Tactile Sensation: Mid chest down.

Reach: Can put arms through full range of motion, but they are weak due to poor muscle strength.

Lift: She feels she could lift maybe one-half of a pound.

Prehensile/Grip: She had a tendon transfer on 4/25/00 for right hand so she is now able to open and close her right hand. Her fingers on both hands are typically held in a curled position, but since the tendon transfer she can open and close her right hand.

Sitting: Remains in her wheelchair about 13 hours per day. She does weight shifts with her power chair about 7 to 8 times per day.

Standing: No access to standing equipment.

Walking/Gait: Nonambulatory.

Bend/Twist: Nonfunctional.

Kneel: Nonfunctional.

Stoop/Squat: Nonfunctional.

Climb: Nonfunctional.

Balance: She says that her balance is pretty good. She can maintain a sitting balance if propped on the side of the bed. She can pull with her arms to right herself if she slumps over in her chair.

Breathing: No problems breathing when awake, but she has sleep apnea and uses a CPAP at night.

Headaches: She averages a headache one time per week that is not associated with dysreflexia. She takes Advil for her headaches.

Vision: Intact.

Hearing: Intact.

Driving: Yes with adapted van.

Physical Stamina (average daily need for rest or reclining): Tires easily.

Environmental Influences

Problems on exposure to:

Air Conditioning: No.
Heat: Yes, overheats easily.
Cold: No.
Wet/Humid: Yes, increased spasms.
Sudden Changes: No.
Fumes: No.
Noise: Yes.
Stress: Yes.

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Present Medical Treatment

Over-the-Counter Medication(s): Eneemez suppositories,Mini-enema, Ibuprofen, Benadryl
Drugstore and Phone Number: Moudry Apothecary 613-263-4495.
Assistive Devices: See file and Life Care Plan.

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Medical Summary

Marion Gold is a 36-year-old female who sustained a spinal cord injury at level C5, C6 & C7 as a result of a motor vehicle accident.

GOTWALT MEMORIAL HOSPITAL: 3/8/99

ER Note. Marion was involved in single vehicle accident. Her vehicle rolled and landed on its side. She was restrained and was trapped in the vehicle with her head held at an unusual angle involving torsion and lateral flexion. She was extricated and complained of left shoulder pain. She was found to be anesthetic over her lower body and could not move her lower extremities.

On examination, the shoulder was normal and it was suspected that her pain was radicular in nature. She had no grip, but she could raise her arm in an abducted manner. She could not move her lower extremities and she was anesthetic from the high thoracic area caudad (downward). She was kept immobilized while awaiting transport to West Park Hospital in Holcombe. She was probably a candidate for massive steroid administration and that was to be decided when the air ambulance crew arrived. Impression: Low cervical spinal cord injury.

Nurses notes indicate Marion could feel occasional tingling sensation in toes and various areas of legs, left greater than right. She had decreased sensation from nipple line down. She was unable to move legs or toes. She was able to move arms and hand. IV was started and Foley catheter was placed. She was transferred to Luther ER via ambulance.

DEPOSITION OF STEPHEN HOPPER: 8/12/03

Registered nurse at Gotwalt Memorial Hospital and supervisor of ambulance service (Pg. 8). Responded to Mrs. Gold’s wreck (single car rollover accident) (Pg. 15). Marion was found lying on her right shoulder and part of her upper back into where the window would be on the driver’s door, head down so to speak. Her head was touching the roof (Pg. 29). Her legs were up by the steering wheel by the dash (Pg. 30). Marion informed him on the scene that she had pain in her left shoulder (Pg. 34). Extrication from vehicle took one half hour (Pg. 47). Upon arrival to Gotwalt Memorial Hospital, he informed the nurse in ER that Marion did not have feeling or movement of her lower extremities. He remembered that she had unusual movement with her arms. When she would go to use her hands, she did not have full control of them. She had movement and sensation, but she just was not coordinated (Pg. 58).

Records Reviewed :

Gotwalt Memorial Hospital: 3/8/99

Photographs of Accident Scene

Depositions Reviewed :

Hopper, Stephen: 8/12/03

ADDENDUM: 11/17/03

WEST PARK HOSPITAL: 3/8/99

Transferred from Gotwalt Memorial Hospital. Upon arrival her main complaint was left shoulder and arm discomfort, some mild shortness of breath and paraplegia. Steroid protocol was instituted before leaving Gotwalt Memorial Hospital and carried on en route. She had Foley catheter and IV’s in place. Neurological examination revealed no sensation to pinprick until the upper anterior chest, just below the level of clavicles, approximately T1-2 level. She had sensation to pinprick out on the shoulders and arms. She had some flexion but no extension of UE’s. There was no motor function in the LE’s. Cervical spine x-rays were unable to be evaluated due to her marked obesity. CT scan of the cervical spine revealed complete disruption of the anterior middle and posterior columns with widening at C6-7.

Marion was diagnosed with complete C6 quadriplegia secondary to fracture/dislocation/extraction at C6-7. Hospital personnel were unable to obtain any lateral C spine films to attempt any re-alignment/reduction, although her facets did not appear to be definitely perched as best they could tell on CT reconstruction. She was started on H2 blockers and would need nasogastric tube because of probable gastrointestinal mobility secondary to injury. Multiple attempts to obtain adequate lateral cervical spine films in order to attempt manipulation needed for intra-operative survey for stabilization failed. For that reason, she was transferred to Mayo Clinic.

MAYO CLINIC/ST. MARY’S HOSPITAL/REHABILITATION: 3/9/99 – 3/15/99; 3/15/99 – 6/2/99; 10/26/99 – 11/8/99; 4/24/00 – 4/27/00; 5/15/00 – 5/26/00; 9/25/00 – 11/13/00; 11/1/01 – 11/4/01

Mayo Clinic/St. Mary’s Hospital: 3/9/99 – 3/15/99
Transferred from West Park Hospital via Mayo One Helicopter Service. Examination upon arrival was consistent with complete C-6 lesion. Glasgow Comas Scale was 15. Marion remembered all aspects of the accident and did not lose consciousness. Repeat chest x-ray revealed a widened mediastinum. CT scan of the cervical spine revealed subluxation at C-6, C-7 with jumped or perched facets. The canal was compromised by at least 25-30%. CT of the chest was negative for evidence of midiastinal injury. T-spine x-rays were negative. Marion had contusions over her left shoulder and complained of left shoulder discomfort. X-rays of that extremity were negative for fracture.

Marion was placed in a Keane bed and traction tongs were placed. Additional weight was placed to try to reduce her subluxation. She remained on Methylprednisolone protocol. She was admitted to the Neuro ICU. On 3/10/99, she underwent posterior cervical fusion C5-T1 with bone graft and instrumentation. She tolerated the procedure well. The remainder of her hospital course was uneventful and she was transferred to rehabilitation unit on 3/15/99.

Mayo Clinic/St. Mary’s Rehabilitation: 3/15/99 – 6/2/99
Participated in comprehensive inpatient rehabilitation program. Examination on arrival revealed sensory was intact to superficial pain and fine touch to C6 level on the right and C5 level on the left. Hospital course was as follows:

C6/C7 ASIA A spinal cord injury. Upon admission to PM&R unit, Marion was noted to have decreased wrist extension in the left hand as compared to consult done two days earlier. Neurosurgery was notified. MRI was ordered and revealed increased swelling in the C-spine. She was started on Decadron and slowly improved with recovery of strength.

Pulmonary: Upon admission to unit, oxygen saturations were down to 94%. She was started on chest PT every 3 hours and was changed to oxygen via nasal cannula 3L per minute. Saturation increased to 97%. Her pulmonary status improved dramatically with no requirement for nasal cannula oxygen. Her respiratory status was excellent for remainder of hospitalization.

Skin: There was no skin breakdown on admission. She was placed on decubitus mattress and turned every two hours. At discharge, she did have wound over her buttock, which improved over time with wet-to-dry dressings and Curasol.

Neurogenic Bladder/Bowel: Marion was initially placed on fluid schedule and catheterized every six hours; however, it was decided that an indwelling catheter was a better option and would be for the foreseeable future due to difficulty positioning for self-catheterization. Bowel care program consisted of Metamucil and Theravac enema daily.

Neck Pain: Upon admission, Marion complained of neck pain, which was controlled with Vicodin. Medication was slowly tapered prior to discharge with successful resolution of the pain.

Anxiety: Marion demonstrated anxiety early in her hospital stay and was unable to sleep at night. She was started on Ativan and Benadryl and obtained adequate sleep. Spasticity also interfered with sleep and she was started on Baclofen. Her sleep difficulties and anxiety waned throughout her stay.

UTI: Marion was transferred to the Rehab unit with known urinary tract infection, susceptible to Bactrim. She was treated with Bactrim Double Strength.

Left Elbow Pain: Marion had left elbow pain, worse with therapies, that was thought to be secondary to musculoskeletal pain. The pain persisted and responded well to rest and Neurontin. X-rays, MRI and triple phase bone scan were unremarkable. Pain resolved by discharge.

Hypotension: Marion was noted to have a few occasions of hypotension, which were reportedly occurring on occasion when she would be sitting straight up in a chair. It was thought to be secondary to autonomic instability. The LE’s were wrapped more frequently and tight enough with the hopes that they would prevent further episodes of hypotension. She was started on Florinef as a mineralocorticoid. Her symptoms improved somewhat and she was able to treat episodes by placing herself in a supine position in her chair. She was instructed to continue with wrapping schedule and use abdominal binder as well as Florinef.

From a functional standpoint, PT/OT reported Marion made significant progress with UE function in therapy. Her right biceps/tricep/deltoid/wrist strength were within normal limits, left bicep was good. Bilateral hand function had been returning. She had bilateral thumb function, left greater than right, finger flexion, right greater than left, finger extension, right greater than left and intrinsics, left greater than right. ADL status was dependent for LE dressing, moderate assist with shirt; set-up for brushing teeth with universal cuff, washing face, brushing hair and eating; total assist with toileting and bathing. She had a Permobile power chair and was independent controlling it. Marion’s goal was to live in her own apartment with personal care aide. Continued therapy was recommended.

Marion was discharged to Dawson Rehab. Center for long-term therapy. Discharge diagnoses:

Mayo Clinic/St. Mary’s Hospital: 10/26/99 – 11/8/99
Admitted for severe headaches and labile blood pressure associated with autonomic dysreflexia. History dictates Marion began having crampy abdominal pain around the beginning of October. Bowel program at the time consisted of digital stimulation, Therevac suppository and fiber supplements. Abdominal x-ray taken at outside hospital was negative. On 10/14/99, she had urine culture, which revealed greater than 100,000 colony-forming units per ml of MRSA. It was not treated, as it was thought to be asymptomatic. At about the same time, she began complaining of left neck pain, which she attributed to straining during a transfer. On 10/16/99, she began with severe headaches and blood pressures as high as 190/110. The dysreflexic episodes coincided with bowel management, a kinked catheter and even ROM during PT. On 10/18/99, her caregivers began using Lidocaine gel before bowel care, which did not eliminate the problem. Outside IVP was pending. On 10/21/99, Marion had a dysreflexic episode when her urinary catheter was manipulated and her genital area was being washed. She subsequently began having similar episodes on a daily basis. Of note, on 10/26/99, she began her menses. At time of admission, she complained of left-sided aching neck pain and reported a subjective decrease in function of the left hand and crampy lower abdominal pain.

Hospital course was as follows:
Autonomic dysreflexia: Etiology was not immediately clear: however, the temporal relationship between her menses and probable ovulation time were suspicious for gynecologic problem. She also reported abnormal Pap smears in the past, which had not been followed up. CT of the abdomen and pelvis revealed cystic changes within the adnexa with a tiny amount of fluid within the presacral space. There was small amount of atelectasis in both lungs. Transabdominal and transvaginal ultrasounds were performed and revealed multiple small follicles in the right ovary consistent with polycystic ovaries. Left ovary was not well visualized. Gynecologic consult was obtained and lab work confirmed polycystic ovary disease. Plan was to treat with Lupron Depot for three months to see if it would eliminate the autonomic dysreflexia.

Urinary Tract Infection: Treated with Nitrofurantoin, which cleared the infection. Marion also had Candida in the bladder and was treated with Diflucan. She developed a rash three-days later and Diflucan was discontinued. It was suspected that the yeast seen in the urine was the result of colonization.

Neck pain was treated with hot packs, which resolved during her stay. Obesity was treated with 1400 calorie per day diet. Because of autonomic dysreflexia, Florinef, prescribed for hypotension was discontinued. After dysreflexic episodes resolved, medication was resumed.

IVP that was done at outside hospital was negative. Marion underwent cystogram and urodynamic studies during her stay. She had evidence of neurogenic bladder and was started on Ditropan. Pap smear was also obtained and showed benign cellular changes. She was advised to continue with yearly Pap smears.

Marion was transferred back to Dawson Rehab. Center. Discharge diagnoses:

Mayo Clinic/St. Mary’s Hospital: 4/24/00 – 4/27/00
Admitted for tendon transfers to the right hand. She was taken to the OR on 4/25/00 where she underwent a brachioradialis to flexor pollicus longus tendon transfer on the right and a pronator teres to flexor digitorum fundus tendon transfer on right. On admission, she was noted to have possibly some MRSA from a urine culture done at her facility. She was known to have bladder colonization and had no symptoms from that. During hospitalization, urinalysis was obtained which grew out E. coli sensitive to everything. She was not febrile at any time during stay.

Cast was removed on 4/27/00. Her movement in the thumb was very good. The flexor digitorum profundus function with the pronator teres tendon transfer was a little less than the thumb but also seemed to be functioning. She was advised to continue her arm splint and was discharged back to Dawson Rehab. Center.

Mayo Clinic/St. Mary’s Hospital: 5/15/00 – 5/26/00
Admitted for intensive OT regimen S/P right UE tendon transfer. Therapy was attended 3 times daily. Marion progressed nicely and her splint was adjusted. She would need a follow up weaning schedule for her right forearm extension block splint and was advised to keep the splint off for two hours for two weeks, then four hours for two weeks, then six hours and then discontinue.

During her stay, it was discovered that she had dyspnea in the middle of the night. She underwent overnight oximetry test, which revealed frequent desaturations. She was provided a CPAP device, which she did not tolerate well. Instead, she followed instructions of sleep specialist for positioning i.e. side lying in bed. That proved to be adequate for her dyspnea. Formal sleep evaluation results were pending at discharge.

Functionally, at discharge, Marion had better pinching and increasing right forearm musculature strength.

Mayo Clinic/St. Mary’s Hospital: 9/25/00 – 11/13/00
Admitted for closure of the bladder neck with colovesical bladder augmentation with appendectomy as well as tapered continent ileal stoma and ileocolostomy. She tolerated the procedure well without complication.

On 10/23/00, Marion was transferred to the rehabilitation unit for self-catheterization training and aggressive program to increase mobility, transfers and endurance and OT with focus on improving strength and coordination of right hand. During her stay she developed an episode of hypertension. The episode was felt to be secondary to her polycystic ovarian syndrome and OB/GYN consult was obtained. Labs were ordered and bone mineral density examination was performed. Once done, reproductive endocrinology consult was ordered but could not be performed during her stay. Plan was to follow through with consult as outpatient.

During her hospitalization, Marion was trained on self-catheterization techniques and was independent with self-catheterization at discharge. Her suprapubic catheter was removed.

Functionally, she had greatly improved mobility, transfers and ADL’s. At time of discharge, she was independent with wheelchair mobility, bed mobility, eating, grooming and self catheterization. She required minimal to moderate assist with transfers and dressing. Moderate to maximal assist was required with bathing and bowel care.

Marion was discharged to Grandeville Apartments, assisted living facility. Discharge diagnosis:

At time of surgery, she had right arterial line placed. Due to the significant fluid she received postoperatively, as well as the likelihood of a small hematoma in the area of the arterial line, she developed numbness and decreased ROM in her left hand. She was followed by physical medicine and aggressive rehabilitation was started early in the post-operative period. The function gradually returned and improved over the course of her hospitalization.

Mayo Clinic/St. Mary’s Hospital: 11/1/01 – 11/4/01
Admitted for definitive management of heavy vaginal bleeding and abdominal pain. She had chronic anovulation secondary to polycystic ovarian disease. She underwent vaginal hysterectomy and bilateral oophorectomy. Hospital course was uneventful and she was discharged on postoperative day three.

DAWSON REHAB. CENTER: 6/2/99 – 10/12/00 Outpatient: 4/10/02 – 11/4/02

Dawson Rehab. Center/Inpatient: 6/2/99 – 10/12/00
Marion was admitted from St. Mary’s Hospital with diagnosis of C5 complete quadriplegia. Diagnoses at time of admission included autonomic hypotension, anemia, neurogenic bowel and bladder and polycystic ovary syndrome. Marion had numerous medical issues and was followed by a variety of physicians during her stay. In 8/99 she was experiencing dysreflexia, neck pain and headaches and was referred to Dr. Mason, neurologist. He recommended use of a collar when transferring or during any activity. On 10/26/99, she was admitted to St. Mary’s Hospital for work up to determine cause of dysreflexia and headaches. She suffered extensive hair loss, which was thought to be attributable to the Neurontin. She was seen by endocrinologist, Dr. Alderman, and was placed on Provera, in hopes it would produce menses, which she had not had since her accident. Menses did begin on 9/2/99 prior to taking the medication. Marion consulted an urologist and underwent IVP. She had bladder stones removed in 3/00 by Dr. Peterman. Eye examination was accomplished in 3/00 and artificial tears were prescribed. Marion underwent right tendon transfers in 4/00. In 7/00, she developed necrotic ulceration of left foot and consulted with plastic surgeon. No surgery was needed as foot healed spontaneously. On 9/26/00, Mitrofanoff procedure was performed. Following that surgery, complications developed and Marion’s hospital stay was extended. She was unable to return to Dawson Rehab. Center in the allotted hospital leave days and was administratively discharged on 10/12/00. Prior to admission to hospital for the urinary surgery, Marion had chosen and been accepted, at the Grandeville Apartments in Brooklyn Park, MN. It was an ASI (The Village, Inc.) type setting, with PCA (personal care attendant) staff on site. Marion decided to remain at St. Mary’s for acute rehab to her right hand to learn self-catheterization through the Mitrofanoff site and then transition on to her apartment.

At time of discharge, bowel program consisted of Therevac mini enemas, and digital stimulation, which was performed, in bed every morning. She also used Lidocaine Gel for bowel program. She had indwelling Foley catheter in place, which was changed every 2 weeks. She required turns approximately every 3 hours at night and could assist with use of side rails. Passive ROM was done to all extremities two times daily.

Psychology reported Marion was active participant in areas of her rehab program. She was self-directed and ambitious. She advocated for herself with her insurance company and her doctors to get what she needed for her rehabilitation. She faced a number of frustrations for which she independently utilized her very effective coping strategies. She worked in individual counseling sessions to address adjustment, the development of coping strategies and to process grief and loss issues. She was seen for consultation to address sleep disturbance and was placed on medication. She tried the medication but ultimately decided to manage her sleep issues on her own. She had significant strengths. She showed much courage and perseverance in dealing with the effects of her injury. She researched different topics and consulted with different people in order to arrive at a plan that fit her needs and her life. She appropriately accessed her support network. She had tendency to hold some of her emotions inside, which put excessive stress on her. She developed an extensive support network, particularly with caregivers. At discharge, she was encouraged to continue her work in individual counseling on an outpatient basis to address continued adjustment issues.

OT reported that therapy centered around areas of functional living skills, ADL’s, ROM, strength/endurance building, adaptive equipment and problem solving particular challenges due to SCI. In most areas, Marion made significant progress. She was independent with most activities that could be performed from a wheelchair. She was independent with UE dressing and assist with LE dressing. Tasks requiring bilateral hand use markedly improved in speed and accuracy. She demonstrated the ability to perform all tasks required to catheterize herself except for opening a new saline bottle. She was able to open a closed cap if the seal was broken. She knew to instruct a PCA to perform the task ahead for her. She displayed fine motor and pinch accuracy with the ability to button, pick up and use straight pins, clothes pins and write a memo. She typed using 2-3 fingers on each hand.

Passive ROM remained within normal limits and active motion in the shoulder was functional for most tasks. Reaching over head remained difficult. Marion continued to complete her gross and fine motor exercises during her own time concentrating on the fine motor areas. Shoulder strength was decreased as compared to prior to surgery and subsequent illness. It was however, improved from re-admittance to therapy after surgery (tendon transfer). At time of discharge, she displayed a right functional lateral and 3-point pinch measuring a 1 pound lateral pinch and a 1/2 pound 3 point pinch strength. Grip strength was 2 pounds. She was able to lift 3-4 pounds at the shoulder, which was adequate for most functional activities, but below recommendations for transfers. Marion was scheduled for Mitrofanoff surgery. Recommendations included continuation of gross and fine motor exercises including neck exercises, typing and writing practice; PCA assistance for personal care; minimal housekeeping assistance; return to work as soon as feasible and functional capacity evaluation prior to return to work.

PT reported significant improvement in all areas of her rehab program. Marion demonstrated independence with sliding board transfers from wheelchair to bed. She required minimal assistance with commode shower chair transfers. She was able to propel her manual wheelchair independently on level and mild uneven surfaces. At time of discharge, she was dependent for most of her functional activities due to having tendon transfers on right extremity. She was restricted on the amount of use with that extremity and was unable to bear weight through that extremity for 4-6 months. Resumption of therapy was recommended when restrictions were lifted. Passive ROM 2X/day from personal care attendants and UE exercise program 3-5X/week recommended.

Dawson Rehab. Center/Outpatient: 4/10/02 – 11/4/02
Attended outpatient mental health services. The most significant issue for Marion was the presence of post trauma symptoms of flashbacks from her car accident. She worked hard in weekly individual psychotherapy sessions to address her fears and develop relaxation and diversion strategies. She worked hard on continued adjustment of her SCI and grief and loss issues. Additionally, she worked hard to sort out frustrations with personal care attendants and systemic issues related to living with a disability. She had gradual relief of her post trauma symptoms. She was hired for a job that in August began to take increasing amounts of her time and it became harder and harder to schedule sessions. In 10/02, Marion decided that her goals had been resolved and she no longer needed psychotherapy sessions.

She had many effective coping strategies. She was a hard worker and was fiercely independent. She continued to struggle with the effects of her injury and continued to hold most of her feelings inside. She worried about being a burden to others. Her support network was good and she was aware of resources and independently accessed resources when the need arose. Self-perception and self-awareness were excellent.

Marion was seen by outpatient OT on 7/16/02 for ADL evaluation to have wheelchair chest straps fabricated due to decreased trunk control. Once fabrication was complete, Marion was able to don/doff chest strap independently. No further OT treatment was recommended.

PARKWAY GENERAL HOSPITAL: 8/19/99; 8/24/99; 10/20/99; 7/14/00; 12/17/00; 2/23/01

Parkway General Hospital: 8/19/99
Presented to ER with complaint of feeling very light-headed, approximately 15-20 minutes after sitting up. She reported some nausea without vomiting and near syncope; however, she had not totally lost consciousness yet. Additionally, she complained of increasing neck pain over the past months, somewhat in midline, but more so left posterolateral neck, which radiated to between shoulder blades. Intermittent headaches were also reported over past month. Due to recent hair loss, her Florinef was decreased about 3 weeks earlier and increased only one day prior to visit in an attempt to stabilize her blood pressure.

Diagnosis was orthostatic hypotension, recently exacerbated by decrease of Florinef. She was discharged back to rehab facility with activity as tolerated with hope recent increase in Florinef would have an effect to stabilize blood pressure. Addendum states urine dipstick indicated UTI and she was switched from Ampicillin to Cipro.

Parkway General Hospital: 8/24/99
MRI of the cervical spine revealed previous fusion at C5-6, C6-7 and transection of the cervical spinal cord at C6-7.

MRI of the brain was normal.

Parkway General Hospital: 10/20/99
Intravenous pyelogram revealed Foley catheter within the urinary bladder and was otherwise negative.

Parkway General Hospital: 7/14/00
Presented for evaluation of wound on left foot, which was possibly infected. Examination revealed necrotic ulceration approximately the size of a quarter on the plantar surface of the foot. There was surrounding erythema, which spread, to the dorsal of the foot. X-rays were negative for osteomyelitis. Diagnosed with necrotic ulceration of the left foot with secondary cellulitis. Augmentin prescribed. Follow up arranged.

Parkway General Hospital: 12/17/00
Presented for ingrown toenail, right great toe. Corner 1/5 of the nail removed and blunt dissection beneath the nail was performed. Diagnosis: Paronychia, right great toe, requiring irrigation and debridement. Three to four day wound check recommended.

Parkway General Hospital: 2/23/01
Presented for fall. She was in Hoyer lift, which was not hooked up appropriately, and her left leg fell down against the wheelchair. She reported some feelings of tingling in the leg when there was any type of pressure applied. X-rays of left femur and left tibia/fibula were negative. Wound was cleansed and antibiotic ointment was applied. Five-day course of Zithromax prescribed.

PETERMAN, STUART M.D.: 1/7/00 – 12/7/01

Peterman, Stuart M.D.: 1/7/00
PM & R follow up for numerous issues related to SCI, particularly previous uncontrolled autonomic dysreflexia. It was believed that a ruptured ovarian cyst resulted in that condition. She was managed with Lupron every month. After initiating that, she had minimal symptoms of dysreflexia except for with provocative stimulation such as bowel control without Lidocaine anesthetic. She was pleased with control of dysreflexia and was not experiencing any side effects from the Lupron.

Marion had indwelling Foley catheter. She continued to leak around the catheter and had approximately 6 UTI’s in last two months. She could identify the presence of a UTI by significant increase in spasticity. Following treatment, there was resolution. The possibility of Mitrofanoff urinary diversion was discussed. Her hand function was marginal; however, with splinting she could possibly be able to adequately access the continent catheterizable stoma. If not able to do so with splinting, tendon transfer would be a consideration. Citrucel was added to bowel program due to constipation. She had a bowel movement every 2-3 days with digital stimulation and occasional Fleet enema.

Marion had difficulty with spasticity in the evening hours and required some assistance for repositioning in bed as a result. She had foot strap added to her wheelchair to prevent spasticity from triggering displacement of her feet. She did not have significant pain or sleep disruption as a result of her spasticity. Baclofen dose was 20 mg 4X/day.

Trial of right UE tendonitis splint initiated. Detrol, Lupron and Baclofen continued.

Peterman, Stuart M.D.: 3/7/00
Marion had consultation with hand surgeon who felt tendon transfer would likely provide her with significant improvement in RUE function. Consideration would be given to that option. From a urology standpoint, she continued to have periodic bladder spasms with some urinary catheter sediment and occasional leaking around the catheter. She was seen by urology earlier in the day and repeat urodynamic study was planned as well as repeat imaging. Dr. Alvarez indicated he would prefer to defer any urological reconstruction until she had completed UE surgery. Marion continued to have difficulty with LE edema and required LE compression garments for orthostatic hypotension.

Examination revealed only minimal spasticity. ROM testing of the shoulders was excellent. Advised to use moist heat pack for neck pain. Tendon transfer planned. Mitrofanoff urinary reconstruction procedure would be considered if she could easily manipulate a catheter with hand function.

Peterman, Stuart M.D.: 6/16/00
S/P right tendon transfers. She had good ROM and with encouragement could demonstrate excellent strength of the flexor pollicus longus and moderate to good strength of the pronator teres to flexor digitorum profundus. Light strengthening exercises recommended.

Peterman, Stuart M.D.: 7/31/00
Marion was discharged by hand surgeon. He was quite pleased with her thumb strength. Finger flexor strength was not as strong as it could be, however, that would likely continue to gradually improve. She had a left fifth metatarsal pressure sore. Her legs were positioned in abduction in her wheelchair, which resulted in excessive pressure on the lateral aspects of her feet. Plastic surgeon in Minneapolis performed initial debridement and recommended dressing changes.

Examination revealed a 1-1.3 cm pressure sore over the left fifth metatarsal. Wound was re-dressed. Her tendon transfer strength continued to improve. Her finger flexor strength was improved slightly and she was getting better distal interphalangeal joint flexion, strength was relatively poor at present.

Prescription for wheelchair modifications issued. Follow up OT, urology and plastic surgery consults recommended.

Peterman, Stuart M.D.: 9/12/01
Marion requested gynecologic surgery consultation regarding elective hysterectomy and bilateral oophorectomy. She had recently had reproductive endocrinology consult and recommendations included discontinuance of Lupron and initiation of Spironolactone and Desogen. Marion was concerned that resumption of her menstrual flow would become a trigger for dysreflexia resulting in the inability to work and participate in lifestyle activities.

Marion also reported burning foot discomfort on plantar aspects of both feet over last month. Her symptoms did not disrupt her sleep or lifestyle. She was on regular weight training program with a cable pulley system, which resulted in some pain, involving the right hand. She recently attempted to propel her manual chair, however, after approximately 20 minutes she was exhausted and lightheaded.

Plan was to start Desogen and Spironolactone. Referral for gynecological consultation issued.

Peterman, Stuart M.D.: 9/13/01
Seen for fabrication of left and right wrist orthosis. Bilateral splint fabricated to avoid further stress on her tendon transfers.

Peterman, Stuart M.D.: 12/7/01
Follow up S/P transvaginal hysterectomy. Her postoperative course was uneventful. Due to problems with oral estrogen, she was placed on Climara patch. She had not experienced any autonomic dysreflexia since her immediate post-op problem with dysreflexia. Skin rash from allergy to Premarin was resolved. She reported only sleeping 4 hours per night and awakened frequently with breathlessness. She previously used CPAP and inquired as to new prescription. Continued neck pain at night reported. Prescriptions for cervical pillow and CPAP machine issued.

LITTLE, GEORGE M.D./HAND CLINIC: 3/7/00 – 7/31/00

Little, George M.D.: 3/7/00
Referred for consideration of UE reconstruction. She used a tenodesis splint on her right hand. On left side she had fair pinch and used her left hand to write and feed herself. She had a weak pronator teres there. She had fairly strong pinch and he was sure a tendon transfer would add much although consideration for brachioradialis to thumb opposition perhaps was a possibility. On the right, she had may more options. She had an excellent pronator teres and brachioradialis and yet she had absent pinch and grip. He felt normal finger extension would be possible with a single set of finger and thumb flexion tendon transfers to restore gross pinch and grip to her right hand. He felt that would have significant functional benefits. Marion would discuss surgery with her family and doctor.

Little, George M.D.: 3/21/00
Marion wished to proceed with surgery. He suggested tendon transfers of the brachial radialis to the flexor pollicus with thumb interphalangeal joint arthrodesis and transfer of the pronator teres to the flexor digitorum profundus.

Little, George M.D.: 4/24/00
Marion had urine culture suggesting re-colonization of her bladder with MRSA. Dr. Nixon was contacted and he suggested it would be reasonable to admit her to hospital, get her started on Vancomycin and plan to go ahead with the tendon transfer surgery.

Little, George M.D.: 6/16/00
Two months S/P tendon transfers. She was doing moderately well. She spent a week at St. Mary’s to begin her tendon transfer re-education. Advised to begin working on strengthening and voluntary activation of her tendon transfers.

Little, George M.D.: 7/31/00
Doing very well and was pleased with her strong pinch. She was now able to catheterize herself. Advised to increase activity as comfort permitted. She had good function on the left side and he did not think she would need any surgery there.

LEGACY MEDICAL CLINIC: 5/7/01 – 7/23/03

Legacy Medical Clinic: 5/7/01
Presented for urine check. Urine was positive for nitrates and large amount of leukocytes. Diagnosed with UTI.

Legacy Medical Clinic: 7/6/01
Presented for infected left great toe. Nail bed removed. Cipro prescribed.

Legacy Medical Clinic: 4/2/02
Treated with Cipro for UTI.

Legacy Medical Clinic: 8/13/02
Presented for refills of Florinef and Valium. Prescriptions issued.

Legacy Medical Clinic: 9/6/02
Presented for left shoulder pain. She reported care attendants helped her get upright in bed 3 nights ago due to cough and she had pain since that time. Naproxen prescribed. Advised to make appointment with Dr. Courtney at Dawson Rehab. Center for evaluation and possible PT.

Legacy Medical Clinic: 1/21/03
Pre-operative visit for scheduled bladder stone removal.

Legacy Medical Clinic: 3/12/03
Treated for bronchitis and UTI.

Legacy Medical Clinic: 4/21/03
Evaluation for right side pain from mid to low back. Referred to Dawson Rehab. Center for PT/massage/ultrasound to low back 2X/week for 4-6 weeks.

Legacy Medical Clinic: 6/4/03
Represented for right low back pain of three months duration. Noticed increase in pain during digital rectal exams done by two specific personal care attendants. Examination revealed right low back tenderness near waistband. Referral to Dawson Rehab. Center for PT and massage issued. Advised to make appointment with neurology to discuss further.

Legacy Medical Clinic: 7/23/03
Presented for right-sided lower back pain. Marion still had rectal pain occasionally with digital stimulation by personal care attendants. She had negative colonoscopy on 7/3/03. Diagnoses: (1) UTI (2) Low back pain. Cipro prescribed. Follow up with neurology again suggested.

ALVAREZ, MANUEL M.D.: 7/19/00 – 5/30/01

Alvarez, Manuel M.D.: 7/19/00
Evaluation for continent urinary diversion. She had problems with Foley, which required changes every 4-5 days due to sediment clogging the catheter. Ultrasound revealed prompt bilateral upper tract function with no evidence of stones, however, medullary sponge kidneys were present. Cystogram revealed an incompetent bladder neck with no evidence of vesicoureteral reflux. Urodynamics revealed a noncompliant bladder with detrusor pressures raising at approximately a 5-degree angle; total fill noncompliance was found. There was an uninhibited detrusor contraction that occurred that could result in detrusor pressures greater than 120 cm. Cystoscopy revealed normal urethra. Bladder had evidence of chronic cystitis and multiple stone fragments were present.

Marion was good candidate for possible bladder augmentation, closure of the bladder neck and concomitant bladder stoma. Diagnoses: (1) C7 spinal cord injury (2) Noncompliant hyperreflexic neurogenic bladder with detrusor leak point pressure of 21 cm (3) Autonomic dysreflexia.

Alvarez, Manuel M.D.: 8/28/00
Underwent evaluation of catheterization technique in preparation for possible continent urinary reservoir.

Alvarez, Manuel M.D.: 1/9/01
S/P closure of bladder neck with an ascending colon bladder augmentation and creation of continent catheterizable stoma using ileum in 9/00. Marion was remaining completely dry in between catheterizations.

Alvarez, Manuel M.D.: 4/30/01
Telephone call. Marion reported pouchitis infection. She was treated locally by physician with Ciprofloxacin. She had increased the frequency of her catheterization to every 2 hours. She felt better after 24 hours on medication. No treatment rendered.

Alvarez, Manuel M.D.: 5/30/01
Urine sample. Marion was using Mentor soft 14 Fr. catheter every 4 hours while awake. She had one episode of pouchitis since last visit.

HICKS, JOHN M.D.: 8/1/01
Reproductive endocrinology evaluation for complaint of decreased bone density perhaps related to effects of SCI and reduced weightbearing activity plus use of Depo-Leuprolide. Anovulation had been long recognized in Marion’s situation. Depo-Lupron had been used to prevent heavy bleeding and the potential for pelvic pain related to ovarian cyst. Treatment options included discontinuance of Depo-Lupron after final dose in August. Leuprolide possibly contributed to decreasing bone density. A combined oral contraceptive of average dose would be protective against further bone loss and would provide benefits to cosmetic complaints related to androgens. Dr. Peterman would make final decision on combined oral contraceptives and Spironolactone 100 mg could be taken.

MCNULTY FOOT & ANKLE SPECIALISTS: 8/20/01 – 10/2/02

McNulty Foot & Ankle Specialists: 8/20/01
Underwent nail excision of left hallux due to ingrown toenail.

McNulty Foot & Ankle Specialists: 8/27/01
Marion reported no problems with surgical site of the left hallux. Soaking was to continue until drainage stopped. Nail excision site showed some mild redness, but no signs of infection.

McNulty Foot & Ankle Specialists: 9/17/01
Reported development of painful ingrown lateral border of right hallux. Underwent P & A (removal of nail bed) of the right hallux and excision of the medial border 2 nd digit nail, left foot.

McNulty Foot & Ankle Specialists: 9/26/01
Right hallux showed some improvement although there was continued drainage and some mild redness. Cipro and soaking continued.

McNulty Foot & Ankle Specialists: 10/22/01
Marion developed painful medial border of 2 nd right digit. She underwent temporary removal 2 nd digit nail on right foot.

McNulty Foot & Ankle Specialists: 7/10/02
Underwent total P & A (nail bed removal) of the 2 nd digit, left foot.

McNulty Foot & Ankle Specialists: 7/17/02
Underwent total P & A (nail bed removal) of the 3 rd digit, left foot.

McNulty Foot & Ankle Specialists: 7/24/02
Left 3 rd digit nail excision site looked good.

McNulty Foot & Ankle Specialists: 10/2/02

Underwent P & A (nail bed removal) of medial border of 3 rd digit right and also spicule of the medial borer right hallux.

MENARD, VICTOR M.D.: 10/3/01; 12/7/01

Menard, Victor M.D.: 10/3/01
Seen for complaint of ovarian cyst leading to autonomic dysreflexia/intolerance of medical management. Marion had significant nausea with Spironolactone and Desogen. Menstrual flow was a hygienic problem for her that led to problems with skin breakdown in the past. She wanted definitive management in the form of hysterectomy with removal of tubes and ovaries. Surgery planned.

Menard, Victor M.D.: 12/7/01
Six weeks S/P hysterectomy and bilateral salpingo-oopherectomy. Doing well. Climara patch prescribed.

CARR, JUSTIN M.D.: 12/4/02
Urological evaluation for complaint of flank pain. Marion was on clean intermittent catheterization every 4 hours. She had CT performed in November, which was consistent with pyelonephritis with perinephric stranding. Culture was positive for staph aureus species and gram-negative bacilli, sensitive to Oxacillin. She was prescribed Doxycycline.

She presented with continued right flank pain, somewhat increased. Her abdomen was soft and Mitrofanoff stoma appeared intact. Impression: Recurrent UTI and pyelonephritis. Doxycycline and Vicodin prescribed. Repeat scan of abdomen, pelvis ordered.

REILLY, THERESA M.D.: 6/11/03
PM & R evaluation for complaint of problems with bowel program. She had daily program in the morning using Enemeez with no laxatives. She used Cholestryramine for meals to firm stools. Over past three months, she developed severe pain with digital stimulation of the rectum. Her pain was in the right flank or lower quadrant. It would last all day and was sometimes sharp in character, did not occur on the left side and did not occur when Enemeez was placed.

It was suspected she had referred pain due to anal fissure and/or trauma associated with digital stimulation, despite the lack of occult blood. Recommendations included Anusol HC cream twice daily as well as re-institution of the 2% Xylocaine jelly after installation of her Enemeez and only in the external sphincter area before digital stimulation. She was also advised to take Senecot in the evening prior to bowel program to better move the stool into the rectal vault. If symptoms did not resolve, anoscopy or sigmoidoscopy and perhaps total colonoscopy would not be excessive.

Trial of Midodrine and knee-high compressive stocking suggested for postural hypotension. Wheelchair positioning was improved with new Roho cushion.

Records Reviewed :

All Star Inn & Suites Employment Records: 8/5/98 – 4/15/99
Alvarez, Manuel M.D.: 7/19/00 – 5/30/01
Carr, Justin M.D.: 12/4/02
Dawson Rehab. Center: 6/2/99 – 10/12/00: Outpatient: 4/10/02 – 11/4/02
Equipment Invoices (In File)
Gotwalt Memorial Hospital (Complete ER Record): 3/8/99
Hicks, John M.D.: 8/1/01
Legacy Medical Clinic: 5/7/01 – 7/23/03
Little, George M.D.: 3/7/00 – 7/31/00
Mayo Clinic/St. Mary’s Hospital/Rehabilitation: 3/9/99 – 3/15/99; 3/15/99 – 6/2/99; 10/26/99 – 11/8/99; 4/24/00 – 4/27/00; 5/15/00 – 5/26/00; 9/25/00 – 11/13/00; 11/1/01 – 11/4/01
McNulty Foot & Ankle Specialists: 8/20/01 – 10/24/02
Menard, Victor M.D.: 10/3/01; 12/7/01
Parkway General Hospital: 8/19/99; 8/24/99; 10/20/99; 7/14/00; 12/17/00; 2/23/01
Peterman, Stuart M.D.: 1/7/00 – 12/7/01
Reilly, Theresa M.D.: 6/11/03
School Records
West Park Hospital: 3/8/99

ADDENDUM: 12/1/03

DEPOSITION OF MARION GOLD: 8/21/03

Has Bachelor of Science in hospitality management (Pg. 20). She has not held a job since the accident (Pg. 27). She is able to manipulate a mouse on a computer keyboard (Pg. 28). She can type very slowly by using her two index fingers. She can write but not very legibly (Pg. 29). She owns a handicapped accessible van. It is not in good operating condition. She drives it about twice per week to go grocery shopping, to a restaurant or to a movie (Pg. 36).

Marion can not stretch her fingers out completely (Pg. 44). She can pick up a light pot or pan. She can not pick up heavy objects like a four-pound can. She does not have the grasp to pick it up. She can do some of her own grooming like holding a hairbrush or brushing her teeth. She is somewhat functional but not by any ways normal. She has a scar on her forearm and right thumb from the tendon transfers. She is not participating in PT at present (Pg. 145-146).

Her bowel program is performed every morning and takes two hours. During that time ROM exercises are also performed to LE’s (Pg. 149). She performs UE ROM exercises independently. A pulley system is used (Pg. 150). A care attendant helps with showering (Pg. 152). She is done with hygiene and bowel and bladder care around 11:30 AM and then eats breakfast (Pg. 153). She then spends time on the computer or watching TV. Supper is at 5:30 PM. She does most of her own cooking and her own dishes. She catheterizes every four hours. After dinner, she watches TV and at 10 PM two attendants put her in bed for the night (Pg. 154). She does not generally have any problems sleeping (Pg. 155).

Medications include Baclofen, Flourinef, Diazepam and Estravel dot and Chlorestamine (Pg. 156). She also takes Fosamax. She is able to take all her medications herself. She takes two Advil maybe once per week and a cranberry pill to prevent UTI’s.

She can bend down and grab her knees or feet. She can raise both arms above her head (Pg. 161). She learned how to write left-handed. Her grasp is stronger in the left hand but she is better at picking objects up with her right hand. She has more fine finger skills with her right but stronger grasping motion with her left. The last three fingers on her hands move together, she can not move them individually. Sensation starts in her upper shoulders toward the neck. She can feel hot or cold above her neck and on her arms. Her toes tingle constantly (Pg. 163). Once in a while she has tingling on pads of her fingertips that is associated with touching things (Pg. 164).

She has a lot of problems with bladder pain. The pain is similar to a baby kicking in the womb and occurs daily. She has pain in her upper back and shoulder. She gets what feels like Charley horses (Pg. 165). She gets those pains daily from sitting hunched over at the computer (Pg. 166). She has had skin breakdown on her buttocks due to sitting in wheelchair (Pg. 167). That has occurred 7-8 times, the last being a year ago (Pg. 168). She has had pressure sores on the bottom of her feet from poor circulation. That has happened probably twice, the last being two years ago. The sores lasted approximately two weeks (Pg. 169).

It is impossible for her to do her bowel program, as she does not have the ability to reach that area. She has had bronchial problems in the wintertime that required antibiotics. She was also diagnosed with sleep apnea and uses a CPAP machine at night (Pg. 171). She did not have bronchial problems before the accident (Pg. 172). At night she catheterizes every 8 hours. She has had numerous UTI’s (Pg. 173), close to 50. They are treated with antibiotics, often Gentamicin. She has not had any hospitalizations for UTI’s to date (Pg. 174). She has UTI’s approximately once every two months. Body temperature wise, she tends to always feel hot (Pg. 175). She tries to reposition herself eight to nine times per day just to get a stretch. When she has spasms, her fingers clamp down into a claw like position. Her legs shake and you can hear them jumping on the foot pedals of the wheelchair. She has to strap her feet in; otherwise, they would fall off the foot pedals (Pg. 177). Those spasms last about 6-7 seconds (Pg. 178).

She would ultimately like to move back home but there are no accessible homes and availability of care attendants would be a problem (Pg. 179). There are also no specialized physicians as it is a small town. She would have to drive probably 200 miles to the closest hospital or to specialists (Pg. 180).

She would like to have a standing frame (Pg. 183). With bathing, she is able to wash her hair and can use one hand to wash her upper torso and that is it (Pg. 185). She did receive some psychological counseling after her injury (Pg. 186). Last session was approximately one year earlier (Pg. 188).

Pre-accident, she was pretty much sports oriented. She played softball sometimes five days a week in the summertime. She was in a pool and darts league in the winter. She enjoyed walking (Pg. 188). She was very mobile in her job. She would have to do sales calls from the hotel (Pg. 189).

Marion would like to return to college and become a case manager for persons with disabilities (Pg. 195). She was accepted at a local college (Metropolitan State) but could not start, as she does not have dependable transportation (Pg 196). If she was guaranteed a ride to and from, she would definitely pursue that (Pg. 198).

State of Wisconsin medical assistance program pays for personal care attendants six hours per day (Pg. 216). She will need a PCA for the rest of her life (Pg. 217).

Depositions Reviewed :

Gold, Marion: 8/21/03

Top

Activities Of Daily Living

Sleep Pattern

Arises: 10 a.m.
Retires: 10 p.m.
Average Hours Sleep/24 Hours: 6 hours on average.
Sleep Difficulties: She has a CPAP for sleep apnea.

Independence In

Dressing: Totally dependent for all ADLs.
Housework: Dependent.
Cooking: Dependent.
Laundry: Dependent.
Yard Work: Dependent.

Social Activities

Organizations Pre/Post: None pre or post.
Volunteer Work Pre/Post: None pre or post.
Socialization Pre/Post: Normal social life pre. She socializes very little now. No organized socialization within the independent living program.

Hobbies (Present): She does work on her computer and she reads. She uses a stand to hold her book. She operates her computer using the fingers on her right hand. No adaptive software.
Hobbies (Previous): Softball, pool league, bowling leagues and dart leagues.

Personal Habits

Smoking: No.
Alcohol: No.
Drugs: No.
History of Abuse and/or Treatment Programs: None.

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Socioeconomic Status

Number in Residence: 1.
Type of Residence: Accessible Apartment.

Income

Disability Policy: None.
S.S.D.I.: $662.00
Wages: $84 / month for 7 hours of data entry.
Food Stamps: None.
Other Income: None.
Medicaid: State Medical Assistance, which they indicate, is not part of Medicaid.
Medicare: Yes.

Current Financial Situation: Contact # for Medical Assistance is 1-800-654-3424 or 677-767-8876.

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Other Agency Involvement

State Vocational Rehabilitation: Yes, they are working with her. Looking into employment/education. Nelson Otto is counselor.
State Employment Services: No.
Rehabilitation Nurse: No.
Other Agency: No.
Felony Convictions? No.

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Education & Training

Highest Grade Completed: Bachelor’s Degree - Major-Hospitality Management.
Last School Attended: University of Wisconsin – Stout. Graduated in 1997.
Literacy: Yes.
Licenses/Certifications: None.
Miscellaneous Education Information: Work experience in the Hotel / Motel and Restaurant Management.

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Military Experience

Branch: No.

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Employment History

Released to Return to Work: She has been released to start looking for vocational options or reeducation.

Work History Since Injury: Currently works 7 hours per month from home.

Employer: DotsonConsultants; City/State: Minneapolis, MN; Position: Data Clerk; Start Date: 8/02; End Date: Continues to be employed.; Schedule: Part-time; Length: Obtained through Dawson Rehab. Center; Wage: $12/hr.; Duties: Data Input/Currently working seven hours/month entering data into spread sheets. At