Joan White of Maxcis Insurance Company referred this file for medical case management. Instructions were given to meet with Todd McClellan and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
On 11/28/16 I met Mr. McClellan, his step father, mother, wife and wife’s mother at the office of Dr. Nzoma. Mr. McClellan is developmental delay so Mr. Payson coordinates appointments. Mr. McClellan is pleasant, alert and cooperative. He walks without a limp.
MEDICAL FACTORS
Mr. McClellan was at work as a porter. While exiting a customer vehicle he stepped and turn his knee. He did not immediately report the injury. When he did report this on 7/25/16 he was sent to Elizabeth …show more content…
CURRENT STATUS
Mr. McClellan is unable to quantify his left knee pain. He reports the pain is to the inner aspect of the knee, it is tender to touch. He reports physical therapy has helped. He doesn’t have any pain going down stairs now just going up. He is able to walk and wears a knee brace.
CURRENT TREATMENT PLAN
Dr. Nzoma, would like to repeat the MRI and continue with the physical therapy. I asked about a graduated return to work, but Mr. McClellan said he wanted to wait until after the MRI. Dr. Nzoma also suggested an injection to the knee; Mr. McClellan did not want to do that. Mr. Payson is concerned that the pain tolerance is low causing this delay in progressing back to work. He said that in impaired individuals a low pain tolerance is not unusual . Once the MRI is done we will discuss the graduated return to work
ADDITIONAL CONTACTS
No additional contacts at this time.
ATTENDING PHYSICIANS
Name: Dr. Nzoma Orthopedic Surgeon
Address: 1 William Carls Drive, Suite 120, Commerce Township, MI 48382
Phone: 248-937-4047
Last office visit:
INTERVIEW SETTING
On 11/28/16 I met Mr. McClellan, his step father, mother, wife and wife’s mother at the office of Dr. Nzoma. Mr. McClellan is developmental delay so Mr. Payson coordinates appointments. Mr. McClellan is pleasant, alert and cooperative. He walks without a limp.
MEDICAL FACTORS
Mr. McClellan was at work as a porter. While exiting a customer vehicle he stepped and turn his knee. He did not immediately report the injury. When he did report this on 7/25/16 he was sent to Elizabeth …show more content…
CURRENT STATUS
Mr. McClellan is unable to quantify his left knee pain. He reports the pain is to the inner aspect of the knee, it is tender to touch. He reports physical therapy has helped. He doesn’t have any pain going down stairs now just going up. He is able to walk and wears a knee brace.
CURRENT TREATMENT PLAN
Dr. Nzoma, would like to repeat the MRI and continue with the physical therapy. I asked about a graduated return to work, but Mr. McClellan said he wanted to wait until after the MRI. Dr. Nzoma also suggested an injection to the knee; Mr. McClellan did not want to do that. Mr. Payson is concerned that the pain tolerance is low causing this delay in progressing back to work. He said that in impaired individuals a low pain tolerance is not unusual . Once the MRI is done we will discuss the graduated return to work
ADDITIONAL CONTACTS
No additional contacts at this time.
ATTENDING PHYSICIANS
Name: Dr. Nzoma Orthopedic Surgeon
Address: 1 William Carls Drive, Suite 120, Commerce Township, MI 48382
Phone: 248-937-4047
Last office visit: