Neurosurgery Case Summary

I was contacted by the claims adjuster Renee Dubiel to reopen my case management file on Mr. Heintz, as he still requires a case manager. The previous company has closed their file. I spoke with Mr. Heintz regarding his general status and that I noted he had an upcoming appointment on June 4 with Neurosurgery. Mr. Heintz provided me with the address and reported that his aide would be transporting him to the appointment. Communication seems best with Mr. Heintz through text messages as Mr. Heintz response to them more than phone calls. Gloria Florin RN CCM was able to attend this appointment (June 4) for me as it was short notice and I had a conflicting schedule on this day. I notified Mr. Heintz.

Mrs. Florin reported that Mr. Heintz used a walker for mobility assistance and that his posture is extended and he limps favoring the right lower leg. When he is not using the walker, his steps are short relevant to his height. It was also observed that his hands had tremors. Mr. Heintz’s aide reviewed his current medications and Mr. Heintz rated his mid back to beltline pain a number 7 on the 1-10 pain scale. Mr. Heintz felt the pain is the same as he had prior to surgery. Mr. Heintz denied areas of numbness but felt weak and fatigued. Mr. Heintz reported that he is straight Catherization himself and has bowel issues. The …show more content…
Heintz sensory is intact to his lower extremity but his lower legs are weak. When the accident occurred, Mr. Heintz had no leg movement. The physician felt that at this time, Mr. Heintz is unable to drive as he couldn’t stop a car. Mr. Heintz had a T11-L3 fusion. The physician replied that MMI will be at the one year point and recommended he was ready for outpatient therapy and a CT scan before his next appointment in 6 months. The physician instructed the CM to call one month before the appointment to obtain script and scheduling the CT scan. The next physician appointment was scheduled for December 3rd at 9:30