Case Study Of The Stonegate Residential Center

Gail Moran of The Hartford Insurance Company referred this file for medical case management. Instructions were given to meet with Ms. McClellan and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. Obtain medical information and update Ms. Moran as appropriate.

INTERVIEW SETTING

On 1/15/18 I met Ms. McClellan at The Stonegate Residential center. Ms. McClellan was in a wheelchair. She had just finished her breakfast. She was alert and oriented and willing to speak with me regarding her medical history and the current injury.

MEDICAL FACTORS AS RELATED TO INJURY

Ms. McClellan reports she was on a field trip with a group from Stonegate Residential Center. She reports the following
Genesee, Lapeer, MI 48446

Phone: [phone]
Last office visit: seen in facility
Next office visit: seen in facility

Name: Dr. McClimans Orthopedic
Address: 307 S. Court St. Lapeer, MI 48446

Phone: [phone]
Last office visit: 1/17/18
Next office visit 2/14/18

MEDICATIONS

Ms. McClellan reports she took the following medications before her accident:
• Acetazolamide 250mg
• Albuterol Sulfate solution 2.5mg/3ml
• Aplisol
• Aspirin 81mg
• Carvedilol 6.25mg
• Citalopram 20mg
• Colchicine 20mg
• Donepezil 10mg
• Ergocalciferol 50,000 unit
• Furosemide 40mg
• Gabapentin 300mg
• Ipratropium-albuterol solution0.5mg
• Levothyroxine
• Loperamide 4mg
• Montelukast
McClellan lives in an assisted living facility. She has a motorized wheelchair.

ADL’S

Prior to the injury Ms. McClellan was able to walk 200 feet with a walker. Since the femur fracture she is dependent on aids to transfer from her bed to her chair, assist with using the bathroom, and all ADL’s. She said she needs staff to roll her over in bed now.

MEDICAL AND SURGICAL HISTORY

Ms. McClellan reports she has had an extensive medical and surgical history.
• Right knee replacement
• 2 left knee replacements
• Congestive heart failure
• Diabetes
• HTN
• Parkinson
• Right ankle fracture
• Left elbow fracture

EDUCATIONAL HISTORY

Ms. McClellan graduated from Davison High School in 1949. She had no further educations.

EMPLOYMENT HISTORY

Ms. McClellan reports she worked on her family farm.

CURRENT EMPLOYER CONTACT