Case Study Medical Case Management
Cassie Thorne of Mackinaw Administrators Insurance Company referred this file for medical case management. Instructions were given to meet with Timothy Blackmore and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
On 6/27/17 I met Mr. Blackmore at the office of St. Joseph Bone and Joint. Mr. Blackmore arrived with his wife. He is alert and oriented. He was open and provided medical history and current status of his right hand. Mr. Blackmore is willing to work with a nurse case manager.
MEDICAL FACTORS
Mr. Blackmore said that while he was using a hand crank the handle stuck. It then popped loose and hit his hand. Mr. Blackmore was seen by Dr. Ennes on 6/13/17 the day of the injury. …show more content…
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
6/13/17 x-ray report of the right hand, Impression: Non displaced comminuted proximal fifth metacarpal fracture.
St. Joseph Bone and Joint dictation from 6/13/17, reports that Mr. Blackmore initially reported to the emergency room. He was placed in an OCL splint. The x-rays were reviewed and confirmed the fifth metacarpal fracture. The alignment was good. He is to follow up in 2
weeks.
CURRENT STATUS Mr. Blackmore reports he is not having a lot of pain.
CURRENT TREATMENT PLAN
Could include here outcome of the physician appointment if one attended, Recommendations of Dr.
ADDITIONAL CONTACTS
No additional contact have been made.
ATTENDING PHYSICIANS
Name: Dr. M. Wager (family physician)
Address: 700 German St. Tawas City, MI 48763
Phone: 989-362-4170
Last office visit: May 2017
Next office visit: August 2017
Name: St. Joseph Bone and Joint
Address: 110 Beech St. Tawas City, MI 48764 Phone: 989-362-1015
Last office visit: 6/27/17
Next office visit:
MEDICATIONS
Mr. Blackmore reports he takes the following medications:
Aspirin
Atorvastatin
Clopidogrel
Enalapril
Levothyyroxine
Metoprolol Tartrate
Nicotrol
Nitrostat sublingual
Spiriva Inhaler
Mr. Blackmore reports he is taking the following medication related to the current injury:
Norco as needed.
Mr. Blackmore is allergic to Keflex.
DURABLE MEDICAL EQUIPMENT
No durable medical equipment need identified.
ADL’S
Mr. Blackmore needs some assistance with 2 hand work.
MEDICAL/SURGICAL HISTORY
Mr. Blackmore reports the following medical conditions:
HTN
Myocardial infarction
Mr. Blackmore said he is trying to stop smoking; he drinks socially and denied drug use.
EDUCATIONAL HISTORY
Mr. Blackmore graduated from high school in 1976.
EMPLOYMENT HISTORY
1. Place of Employment: Iosco County Road Commission
• Job Title: heavy equipment operator
• Start date: 8/19/96 Stop date: current
• Hours per week: 40+
• Job requirements and physical demands: climb in and out of equipment, use shovels, reach, push and pull.
CURRENT EMPLOYER CONTACT INFORMATION
I have spoken with Kara on 6/21/17, 6/22/17 and 6/27/17. I updated employer on current medical status.
WORKERS’ COMPENSATION HISTORY
Mr. Blackmore denied prior work injuries with lost time.
FAMILY/SOCIAL/FINANCIAL FACTORS
Mr. Blackmore reports he is able to function in his home. He reports his wife is very supportive and helps when he cannot do something.
Emergency Contact –Mrs. Blackmore 989-362-4205
PHYSICAL DESCRIPTION
Height: 5 foot 9
Weight: 210 lbs
Hair:
Eyes:
Dominant hand: right
CLIENT’S FUTURE PLANS
Mr. Blackmore said he would like to get back to workl.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Mr. Blackmore verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Mr. Blackmore denied legal representation.
IMPRESSIONS
Mr. Blackmore has some health issues; he also is trying to stop smoking. The fracture is a non-displaced fracture and should heal without difficulty. The Official Disability Guidelines
For a non displaced fifth metacarpal fracture is 29 to 46 days. Treatment has been appropriated to date.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Blackmore every 2 to 4 weeks to obtain an update on his current medical status.
2. Attend the next follow up appointment with Dr. Ennis on XX. Obtain a current work status and an updated treatment recommendation.
3. Update the employer after each medical appointment. Provide an updated work status and projections to recovery.
INTERVIEW SETTING
On 6/27/17 I met Mr. Blackmore at the office of St. Joseph Bone and Joint. Mr. Blackmore arrived with his wife. He is alert and oriented. He was open and provided medical history and current status of his right hand. Mr. Blackmore is willing to work with a nurse case manager.
MEDICAL FACTORS
Mr. Blackmore said that while he was using a hand crank the handle stuck. It then popped loose and hit his hand. Mr. Blackmore was seen by Dr. Ennes on 6/13/17 the day of the injury. …show more content…
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
6/13/17 x-ray report of the right hand, Impression: Non displaced comminuted proximal fifth metacarpal fracture.
St. Joseph Bone and Joint dictation from 6/13/17, reports that Mr. Blackmore initially reported to the emergency room. He was placed in an OCL splint. The x-rays were reviewed and confirmed the fifth metacarpal fracture. The alignment was good. He is to follow up in 2
weeks.
CURRENT STATUS Mr. Blackmore reports he is not having a lot of pain.
CURRENT TREATMENT PLAN
Could include here outcome of the physician appointment if one attended, Recommendations of Dr.
ADDITIONAL CONTACTS
No additional contact have been made.
ATTENDING PHYSICIANS
Name: Dr. M. Wager (family physician)
Address: 700 German St. Tawas City, MI 48763
Phone: 989-362-4170
Last office visit: May 2017
Next office visit: August 2017
Name: St. Joseph Bone and Joint
Address: 110 Beech St. Tawas City, MI 48764 Phone: 989-362-1015
Last office visit: 6/27/17
Next office visit:
MEDICATIONS
Mr. Blackmore reports he takes the following medications:
Aspirin
Atorvastatin
Clopidogrel
Enalapril
Levothyyroxine
Metoprolol Tartrate
Nicotrol
Nitrostat sublingual
Spiriva Inhaler
Mr. Blackmore reports he is taking the following medication related to the current injury:
Norco as needed.
Mr. Blackmore is allergic to Keflex.
DURABLE MEDICAL EQUIPMENT
No durable medical equipment need identified.
ADL’S
Mr. Blackmore needs some assistance with 2 hand work.
MEDICAL/SURGICAL HISTORY
Mr. Blackmore reports the following medical conditions:
HTN
Myocardial infarction
Mr. Blackmore said he is trying to stop smoking; he drinks socially and denied drug use.
EDUCATIONAL HISTORY
Mr. Blackmore graduated from high school in 1976.
EMPLOYMENT HISTORY
1. Place of Employment: Iosco County Road Commission
• Job Title: heavy equipment operator
• Start date: 8/19/96 Stop date: current
• Hours per week: 40+
• Job requirements and physical demands: climb in and out of equipment, use shovels, reach, push and pull.
CURRENT EMPLOYER CONTACT INFORMATION
I have spoken with Kara on 6/21/17, 6/22/17 and 6/27/17. I updated employer on current medical status.
WORKERS’ COMPENSATION HISTORY
Mr. Blackmore denied prior work injuries with lost time.
FAMILY/SOCIAL/FINANCIAL FACTORS
Mr. Blackmore reports he is able to function in his home. He reports his wife is very supportive and helps when he cannot do something.
Emergency Contact –Mrs. Blackmore 989-362-4205
PHYSICAL DESCRIPTION
Height: 5 foot 9
Weight: 210 lbs
Hair:
Eyes:
Dominant hand: right
CLIENT’S FUTURE PLANS
Mr. Blackmore said he would like to get back to workl.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Mr. Blackmore verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Mr. Blackmore denied legal representation.
IMPRESSIONS
Mr. Blackmore has some health issues; he also is trying to stop smoking. The fracture is a non-displaced fracture and should heal without difficulty. The Official Disability Guidelines
For a non displaced fifth metacarpal fracture is 29 to 46 days. Treatment has been appropriated to date.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Blackmore every 2 to 4 weeks to obtain an update on his current medical status.
2. Attend the next follow up appointment with Dr. Ennis on XX. Obtain a current work status and an updated treatment recommendation.
3. Update the employer after each medical appointment. Provide an updated work status and projections to recovery.