Case Study Urgent Care
Andrew Rider of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with John Pero and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
On 2/20/17 I met Mr. Pero at the Mid Michigan Urgent care. Mr. Pero is unable to hear or speak. Communication is through writing and lip reading. Mr. Pero is alert and oriented. He is cooperative and willing to work with a nurse case manager.
MEDICAL FACTORS
Mr. Pero said while carrying a heavy roll of carpet padding on his left shoulder, he developed pain in his low back. As time passed, he also had pain to his hip and left knee. Mr. Pero went to Gladwin hospital on 1/24/17, he was sent to the Urgent care for a follow up on 1/31/17.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
The dictation from the 1/31/17 Urgent Care appointment showed that Mr. Pero went to The Gladwin Emergency room on …show more content…
The PA feels it is an Illiotibial Band irritation. The plan, continue with restrictions, continue physical therapy, if at next appointment on 3/6/17, he still has pain they will do a cortisone injection in the knee, and may set up a MRI of the knee. Medications are Motrin 800 mg and Tylenol #3.
ADDITIONAL CONTACTS
No additional contacts made at this time.
ATTENDING PHYSICIANS
Name: Dr. Jack Wagner (family physician)
Address: 129 W. Brown St. Beaverton, MI
Phone: 989-435-2937
Last office visit: cannot remember the last visit
Next office visit: as needed
Name: Mid Michigan Urgent Care
Address: 609 Quarter St. Gladwin, MI Phone: 989-246-9430
Last office visit: 2/20/17
Next office visit: 3/6/17
MEDICATIONS
Mr. Pero denied taking any medications before the injury.
Mr. Pero was given the following medications for this
INTERVIEW SETTING
On 2/20/17 I met Mr. Pero at the Mid Michigan Urgent care. Mr. Pero is unable to hear or speak. Communication is through writing and lip reading. Mr. Pero is alert and oriented. He is cooperative and willing to work with a nurse case manager.
MEDICAL FACTORS
Mr. Pero said while carrying a heavy roll of carpet padding on his left shoulder, he developed pain in his low back. As time passed, he also had pain to his hip and left knee. Mr. Pero went to Gladwin hospital on 1/24/17, he was sent to the Urgent care for a follow up on 1/31/17.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
The dictation from the 1/31/17 Urgent Care appointment showed that Mr. Pero went to The Gladwin Emergency room on …show more content…
The PA feels it is an Illiotibial Band irritation. The plan, continue with restrictions, continue physical therapy, if at next appointment on 3/6/17, he still has pain they will do a cortisone injection in the knee, and may set up a MRI of the knee. Medications are Motrin 800 mg and Tylenol #3.
ADDITIONAL CONTACTS
No additional contacts made at this time.
ATTENDING PHYSICIANS
Name: Dr. Jack Wagner (family physician)
Address: 129 W. Brown St. Beaverton, MI
Phone: 989-435-2937
Last office visit: cannot remember the last visit
Next office visit: as needed
Name: Mid Michigan Urgent Care
Address: 609 Quarter St. Gladwin, MI Phone: 989-246-9430
Last office visit: 2/20/17
Next office visit: 3/6/17
MEDICATIONS
Mr. Pero denied taking any medications before the injury.
Mr. Pero was given the following medications for this