Andrew Rider of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with Chris Simonson and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
On 8/25/16 I met Mr. Simonson at the office of Mid Michigan Orthopedics. Mr. Simonson drove independently to the appointment. He is alert and oriented. He is willing to provide information and work with a nurse case manager.
MEDICAL FACTORS
Mr. Simonson said he was driving a semi truck and was heading for Kentucky. He reports upon entering a round about his load shifted and the truck tipped over on the passenger side. He was wearing a seat belt and was slammed around the cab of the truck. His left shoulder appeared to be out of place. The EMS that arrived on scene pushed the shoulder in place and pain was decreased immediately. Mr. Simonson said he was taken by ambulance to Covenant hospital for left shoulder pain. He was told the x-rays of the shoulder were fine. No other testing was done. He said he was discharged with Motrin and Valium with instructions to follow up with his family doctor.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS …show more content…
Branch PMR examined the shoulder. When Mr. Simonson keeps his arm below chest level he reports his pain is low. When Dr. Branch went through range of motion to anything over head Mr. Simonson reported pain to the top of the shoulder radiating inwards. Dr. Branch said that he will request the x-ray report from Covenant hospital. Dr. Branch said that dislocating the shoulder can tear the labrum. He would like Mr. Simonson to have a MRI done at the MSU, MRI department. They have a specific protocol to evaluate the labrum and this is close to Mr. Simonson’s home. Dr. Branch will also allow light duty work to continue until the next appointment and review of the MRI. At that point we will know if physical therapy is appropriate or if surgery may be
INTERVIEW SETTING
On 8/25/16 I met Mr. Simonson at the office of Mid Michigan Orthopedics. Mr. Simonson drove independently to the appointment. He is alert and oriented. He is willing to provide information and work with a nurse case manager.
MEDICAL FACTORS
Mr. Simonson said he was driving a semi truck and was heading for Kentucky. He reports upon entering a round about his load shifted and the truck tipped over on the passenger side. He was wearing a seat belt and was slammed around the cab of the truck. His left shoulder appeared to be out of place. The EMS that arrived on scene pushed the shoulder in place and pain was decreased immediately. Mr. Simonson said he was taken by ambulance to Covenant hospital for left shoulder pain. He was told the x-rays of the shoulder were fine. No other testing was done. He said he was discharged with Motrin and Valium with instructions to follow up with his family doctor.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS …show more content…
Branch PMR examined the shoulder. When Mr. Simonson keeps his arm below chest level he reports his pain is low. When Dr. Branch went through range of motion to anything over head Mr. Simonson reported pain to the top of the shoulder radiating inwards. Dr. Branch said that he will request the x-ray report from Covenant hospital. Dr. Branch said that dislocating the shoulder can tear the labrum. He would like Mr. Simonson to have a MRI done at the MSU, MRI department. They have a specific protocol to evaluate the labrum and this is close to Mr. Simonson’s home. Dr. Branch will also allow light duty work to continue until the next appointment and review of the MRI. At that point we will know if physical therapy is appropriate or if surgery may be