Case Study On Medical Case Management
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.
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.
Name: Dr. Salvia (family physician)
Address: 42755 Mound Rd, Sterling Hgts, MI 48314
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:
Mr. Candela denied any allergies.
DURABLE MEDICAL EQUIPMENT
Mr. Candela reports he is able to perform his ADL’s independently. He is unable to do household services.
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.
Mr. Candela graduated from high school in 1975.
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.