Marlene Warmoth of The Hartford Insurance Company referred this file for medical case management. Instructions were given to meet with Thelma Bayne and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
I met Ms. Payne at the Janes Street Health Care Clinic. Ms. Payne was alert and oriented. She arrived alone. Ms. Payne walked carrying a cane. Ms. Payne was dressed neatly she had a sling on the right arm. Ms. Payne was willing to speak with a case manager and provide her health history.
MEDICAL FACTORS
Ms. Payne reports she was a belted passenger in a car that was hit on the passenger side door. The car flipped landing on the roof. She reports she blacked out; she …show more content…
Payne at the Janes Street Medical Clinic. Ms. Payne was seen by one of the medical providers. She reported the headaches, flash backs, cervical pain, right shoulder pain and the right knee pain. The medical provider was able to pull up records from Covenant health system. She reports the CT scan done of the cervical spine, head and shoulder were fine. The right knee showed an old scar from a total knee replacement done in 2016 there was slight swelling and one small bruise. Counseling was recommended for the flash backs and will be scheduled to start on 1/18/17. The provider declined writing any orders for transportation or attendant care she would prefer the orthopedic doctor to do that.
On 12/21/16 I met Ms. Payne at the office of Dr. Linehan orthopedic surgeon. The right shoulder is painful and has limited range of motion. She report cervical and low back pain. We were told she was supposed to follow up with Dr. S. Mohammad for that. The right knee was x-rayed and the knee replacement looked aligned. They feel she just has a bruise and it will get better. A cane order was given. Ms. Payne is to have a MRI of the right shoulder on 1/7/16. In the meantime she can wear the sling for comfort. The next follow up appointment will determine is surgery is …show more content…
S. Muhammad Neurologist
3170 Hallmark Ct, Saginaw MI 48603
Phone: 989-790-1275
Last Office Visit: seen in hospital
Next office visit: 1/9/17
MEDICATIONS
Ms. Payne reports she took the following medications prior to the accident.
Alendronate
Celexa
Flonase
Hydrodiuril
Norco
Claritin
Cozaar
Antivert
Prilosec
Zofran
There appears to be no new medications after the accident.
DURABLE MEDICAL EQUIPMENT
An order for a cane was given on 12/21/16.
ADL’S
Ms. Payne said she is dependent on someone to help her dress, bath, clean her home and cook meals. She is unable to drive.
MEDICAL/SURGICAL HISTORY
Ms. Payne said she had a total knee replacement in February 2016, and gallbladder surgery in October 2016.
Ms. Payne denied drug, alcohol use or smoking.
EDUCATIONAL HISTORY
Ms. Payne said she graduated from Saginaw high school in 1972
EMPLOYMENT HISTORY Ms. Payne said she is retired.
CURRENT EMPLOYER CONTACT INFORMATION
N/A
WORKERS’ COMPENSATION HISTORY
Denied
FAMILY/SOCIAL/FINANCIAL FACTORS
Ms. Payne said she lives alone. She lives in a senior apartment complex which is handicap accessible.
Emergency Contact –Donald Johnson friend 989-392-4181
PHYSICAL DESCRIPTION
Height: 5 foot 8
INTERVIEW SETTING
I met Ms. Payne at the Janes Street Health Care Clinic. Ms. Payne was alert and oriented. She arrived alone. Ms. Payne walked carrying a cane. Ms. Payne was dressed neatly she had a sling on the right arm. Ms. Payne was willing to speak with a case manager and provide her health history.
MEDICAL FACTORS
Ms. Payne reports she was a belted passenger in a car that was hit on the passenger side door. The car flipped landing on the roof. She reports she blacked out; she …show more content…
Payne at the Janes Street Medical Clinic. Ms. Payne was seen by one of the medical providers. She reported the headaches, flash backs, cervical pain, right shoulder pain and the right knee pain. The medical provider was able to pull up records from Covenant health system. She reports the CT scan done of the cervical spine, head and shoulder were fine. The right knee showed an old scar from a total knee replacement done in 2016 there was slight swelling and one small bruise. Counseling was recommended for the flash backs and will be scheduled to start on 1/18/17. The provider declined writing any orders for transportation or attendant care she would prefer the orthopedic doctor to do that.
On 12/21/16 I met Ms. Payne at the office of Dr. Linehan orthopedic surgeon. The right shoulder is painful and has limited range of motion. She report cervical and low back pain. We were told she was supposed to follow up with Dr. S. Mohammad for that. The right knee was x-rayed and the knee replacement looked aligned. They feel she just has a bruise and it will get better. A cane order was given. Ms. Payne is to have a MRI of the right shoulder on 1/7/16. In the meantime she can wear the sling for comfort. The next follow up appointment will determine is surgery is …show more content…
S. Muhammad Neurologist
3170 Hallmark Ct, Saginaw MI 48603
Phone: 989-790-1275
Last Office Visit: seen in hospital
Next office visit: 1/9/17
MEDICATIONS
Ms. Payne reports she took the following medications prior to the accident.
Alendronate
Celexa
Flonase
Hydrodiuril
Norco
Claritin
Cozaar
Antivert
Prilosec
Zofran
There appears to be no new medications after the accident.
DURABLE MEDICAL EQUIPMENT
An order for a cane was given on 12/21/16.
ADL’S
Ms. Payne said she is dependent on someone to help her dress, bath, clean her home and cook meals. She is unable to drive.
MEDICAL/SURGICAL HISTORY
Ms. Payne said she had a total knee replacement in February 2016, and gallbladder surgery in October 2016.
Ms. Payne denied drug, alcohol use or smoking.
EDUCATIONAL HISTORY
Ms. Payne said she graduated from Saginaw high school in 1972
EMPLOYMENT HISTORY Ms. Payne said she is retired.
CURRENT EMPLOYER CONTACT INFORMATION
N/A
WORKERS’ COMPENSATION HISTORY
Denied
FAMILY/SOCIAL/FINANCIAL FACTORS
Ms. Payne said she lives alone. She lives in a senior apartment complex which is handicap accessible.
Emergency Contact –Donald Johnson friend 989-392-4181
PHYSICAL DESCRIPTION
Height: 5 foot 8