Case Study On Medical Case Management

796 Words 4 Pages
Tina Castle of Maxcis Insurance Company referred this file for medical case management. Instructions were given to meet with Anthony Candela and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.

INTERVIEW SETTING

On 11/30/17 I met Mr. Candela at the office of American Anesthesiology. Mr. Candela is alert and oriented. He is neatly dressed. Mr. Candela is willing to provide his medical history and is happy to work with a nurse case manager. Mr. Candela turns his body keeping his neck stiff.

MEDICAL FACTORS

Mr. Candela reports that while he was transporting customers across a parking lot in a golf cart he hit a curb. This caused a sudden jerk and an increase in speed hitting a
…show more content…
Vibert’s office. Ms. Castle has been provided a copy.

CURRENT STATUS Mr. Candela rates his pain at a 5. He reports he is not able to turn his neck, he turns his body instead. He reports this is interfering with his sleep and everyday living. The examination showed good strength to the upper body. Mr. Candela reports taking Motrin only when he needs it.

CURRENT TREATMENT PLAN

Mr. Candela was seen by Mr. Heath a PA for the pain clinic. He recommends doing one cervical epidural to see how that works. Wait a month and if there is an improvement do another injection. We also clarified that Mr. Candela is allowed to start physical therapy. He was told to set up his evaluation then wait until after the injection to see if there is some improvement. The epidural is scheduled for 12/11/17.

ADDITIONAL CONTACTS

N/A

ATTENDING PHYSICIANS

Name: Dr. Salvia (family physician)
Address: 42755 Mound Rd, Sterling Hgts, MI 48314

Phone: 586-247-0410
Last office visit: September 2017
Next office visit: January 2018

Name: Dr. Vibert Orthopedic Surgeon
Address: 1555 E. South Blvd, Rochester Hills, MI
…show more content…
Candela reports he was taking the following medications before his injury:
Bystolic for heart rhythm

Mr. Candela reports he is taking the following medications for the injury:
Motrin 800mg

Mr. Candela denied any allergies.

DURABLE MEDICAL EQUIPMENT

N/A

ADL’S

Mr. Candela reports he is able to perform his ADL’s independently. He is unable to do household services.

MEDICAL/SURGICAL HISTORY

Mr. Candela reports he has the following medical conditions and surgical conditions :
Cervical fusion 2011
Mr. Candela denied a medical history but is taking a heart medication.

Mr. Candela is a smoker, he has been counseled on smoking and healing, he reports only social drinking and denied drug use.

EDUCATIONAL HISTORY

Mr. Candela graduated from high school in 1975.

EMPLOYMENT HISTORY

1. Place of Employment: Crest Automotive, Inc.
• Job Title: car salesman
• Start date: 5/2/2017 Stop date: current
• Hours per week: 40
• Job requirements and physical demands: sit, stand, walk

• 27 years as a car salesman

CURRENT EMPLOYER CONTACT INFORMATION

Ms. Castle will update the employer after each medical appointment.

WORKERS’ COMPENSATION

Related Documents