Case Study Medical Case Management
Andrew Rider of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with Patrick Doyle and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. Assist with coordination of services to restore full function of the right shoulder.
INTERVIEW SETTING
On 3/28/18 I met with Mr. Doyle at the Midland Urgent care clinic. He reports constant pain to the right shoulder and limited range of motion. Mr. Doyle is alert and oriented. He is willing to provide his prior medical history and work with a nurse case manager.
MEDICAL FACTORS AS RELATED TO INJURY
Mr. Doyle reports he was working on a roof when he fell through some rafters. He said he …show more content…
• MRI was done on 3/20/18. Impression: partial tear of the subscapularis
CURRENT STATUS
Mr. Dole reports he has constant pain and limitation with a range of motion. He has pain when lying on the shoulder and reports his sleep has been disrupted. Mr. Doyle reports he is able to use the right arm when he keeps it close to the body. If he is reaching away from the body or overhead causes pain and weakness. Mr. Doyle requested a refill on the Ultram pain medications as he continues to work.
CURRENT TREATMENT PLAN I met Mr. Doyle at the Midland Urgent Care clinic on 3/28/18. Mr. Doyle has been referred to Dr. Yacisen Orthopedic Surgeon on 4/3/18. Dr. McKinnin reviewed the MRI, and he said the bicep tendon is loose and the Subscapularis is sheared. Mr. Doyle will need a surgical repair of the right shoulder. Mr. Doyle asked if he will be able to work after the surgery. He said he is able to supervise his crew and avoid any lifting. He was told to discuss with Dr. Yacisen but he should be able to return to work if he follows the restrictions.
ADDITIONAL CONTACTS
• No additional contacts made.
ATTENDING PHYSICIANS
Name: Midland Urgent …show more content…
Doyle reports he wants to be free of pain and get back to work fully.
CONSENT/EXPLANATION OF BENEFITS AND CASE MANAGEMENT
I explained my role as a medical case manager and Mr. Doyle verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
• Denied
IMPRESSIONS
Mr. Doyle is a very physically active person. He denied any prior medical history other than his cardiac stent. He has worked to date. The Official Disability Guidelines for a repaired torn Rotator cuff is 64 to 191 days. Mr. Doyle has heavy work and is a working foreman. He hopes to be able to work with restrictions.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Doyle every 2 to 4 weeks
2. Attend the appointment with Dr. Yacisen on 4/3/18. Obtain a treatment plan with projections for recovery. Obtain a current work status.
3. Update the employer as directed by the adjuster Mr. Rider.
Thank you for this referral. Please feel free to contact me if you have any questions regarding this report. You will be kept informed of any developments in this file and updated immediately following all physician appointments.
Sincerely,
MICHIGAN CASE MANAGEMENT
Leesha Aseltine, R.N.,
INTERVIEW SETTING
On 3/28/18 I met with Mr. Doyle at the Midland Urgent care clinic. He reports constant pain to the right shoulder and limited range of motion. Mr. Doyle is alert and oriented. He is willing to provide his prior medical history and work with a nurse case manager.
MEDICAL FACTORS AS RELATED TO INJURY
Mr. Doyle reports he was working on a roof when he fell through some rafters. He said he …show more content…
• MRI was done on 3/20/18. Impression: partial tear of the subscapularis
CURRENT STATUS
Mr. Dole reports he has constant pain and limitation with a range of motion. He has pain when lying on the shoulder and reports his sleep has been disrupted. Mr. Doyle reports he is able to use the right arm when he keeps it close to the body. If he is reaching away from the body or overhead causes pain and weakness. Mr. Doyle requested a refill on the Ultram pain medications as he continues to work.
CURRENT TREATMENT PLAN I met Mr. Doyle at the Midland Urgent Care clinic on 3/28/18. Mr. Doyle has been referred to Dr. Yacisen Orthopedic Surgeon on 4/3/18. Dr. McKinnin reviewed the MRI, and he said the bicep tendon is loose and the Subscapularis is sheared. Mr. Doyle will need a surgical repair of the right shoulder. Mr. Doyle asked if he will be able to work after the surgery. He said he is able to supervise his crew and avoid any lifting. He was told to discuss with Dr. Yacisen but he should be able to return to work if he follows the restrictions.
ADDITIONAL CONTACTS
• No additional contacts made.
ATTENDING PHYSICIANS
Name: Midland Urgent …show more content…
Doyle reports he wants to be free of pain and get back to work fully.
CONSENT/EXPLANATION OF BENEFITS AND CASE MANAGEMENT
I explained my role as a medical case manager and Mr. Doyle verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
• Denied
IMPRESSIONS
Mr. Doyle is a very physically active person. He denied any prior medical history other than his cardiac stent. He has worked to date. The Official Disability Guidelines for a repaired torn Rotator cuff is 64 to 191 days. Mr. Doyle has heavy work and is a working foreman. He hopes to be able to work with restrictions.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Doyle every 2 to 4 weeks
2. Attend the appointment with Dr. Yacisen on 4/3/18. Obtain a treatment plan with projections for recovery. Obtain a current work status.
3. Update the employer as directed by the adjuster Mr. Rider.
Thank you for this referral. Please feel free to contact me if you have any questions regarding this report. You will be kept informed of any developments in this file and updated immediately following all physician appointments.
Sincerely,
MICHIGAN CASE MANAGEMENT
Leesha Aseltine, R.N.,