On 4/23/18 I met with Ms., Atkinson at the office of Dr. Keller. Ms. Atkinson is alert and oriented. She is appropriately dressed.
MEDICAL FACTORS AS RELATED TO INJURY
While at work Ms. Atkinson reports she miss stepped causing her to fall and land on her right arm. She initially went to an urgent care clinic. After having x-rays at the urgent care clinic and learning she has a fracture in her right arm she made an appointment with an Orthopedic specialist Dr. Keller. Treatment continues with Dr. Keller.
DIAGNOSTIC STUDIES/DIAGNOSIS/SURGICAL INTERVENTIONS
• 10 pages of medical dictation provided. X-ray showed a fractured Humerus.
CURRENT STATUS
Ms. Atkinson reports that she is not taking any pain medications. She will have a sharp …show more content…
Atkinson reports she needs help with dressing, and chores around her home.
MEDICAL AND SURGICAL HISTORY
• Cardiac Stents
• HTN
• Denied smoking, occasional alcohol, and denied drug use
EDUCATIONAL HISTORY
• Ms. Atkinson graduated from high school in 1975
EMPLOYMENT HISTORY
Place of Employment: Somerset Buick GMC
• Job Title: Service writer
• Start date: 4/6/2015 Stop date: current
• Hours per week: 40
• Job requirements and physical demands: walk, sit and stand
CURRENT EMPLOYER CONTACT INFORMATION
The adjuster Ms. Castle will update the employer. No lifting of the right arm.
WORKERS’ COMPENSATION HISTORY
• Denied
FAMILY/SOCIAL/FINANCIAL FACTORS
Ms. Atkinson reports she lives with her sister. Her sister is able to help her with ADL’s and a home chore.
• Emergency contact is Elizabeth Scutchfield 586-945-8736
PHYSICAL DESCRIPTION
• Height 5 feet 4 inches
• Weight 180
• Hair color blond
• Eye color blue
• Dominant hand right
CLIENT’S FUTURE PLANS
• Ms. Atkinson reports she would like to return to work when she can use her right arm.
CONSENT/EXPLANATION OF BENEFITS AND CASE MANAGEMENT
I explained my role as a medical case manager and Ms. Atkinson verbalized understanding. She read and willingly signed the Authorization for Release of Medical Information …show more content…
Atkinson has a history of cardiac and hypertension. It is unclear if she has ever had a bone density test so we are not sure how well her bones will heal. The fracture is just below the shoulder. She is not able to move the shoulder to allow for the fracture to heal. This puts her at high risk for a frozen shoulder. She is seeing Dr. Keller every two weeks and is being closely monitored. The Official Disability Guidelines for a proximal humerus fracture is 27 to 54 days.
PLAN/ RECOMMENDATIONS
1. Contact Ms. Atkinson every 2 to 4 weeks. Obtain an update on her current medical status.
2. Attend the next appointment with Dr. Keller on 5/14/18. Obtain a current treatment plan with projections for recovery. Address a work status.
3. Update Ms. Castle after each appointment. She will update the employer.
Thank you for this referral. Please feel free to contact me if you have any questions regarding this report. You will be kept informed of any developments in this file and updated immediately following all physician appointments.
Sincerely,
MICHIGAN CASE MANAGEMENT
Leesha Aseltine, R.N., CCM
Medical Case Manager
(810) 963-2258 phone
(810) 275-1266
MEDICAL FACTORS AS RELATED TO INJURY
While at work Ms. Atkinson reports she miss stepped causing her to fall and land on her right arm. She initially went to an urgent care clinic. After having x-rays at the urgent care clinic and learning she has a fracture in her right arm she made an appointment with an Orthopedic specialist Dr. Keller. Treatment continues with Dr. Keller.
DIAGNOSTIC STUDIES/DIAGNOSIS/SURGICAL INTERVENTIONS
• 10 pages of medical dictation provided. X-ray showed a fractured Humerus.
CURRENT STATUS
Ms. Atkinson reports that she is not taking any pain medications. She will have a sharp …show more content…
Atkinson reports she needs help with dressing, and chores around her home.
MEDICAL AND SURGICAL HISTORY
• Cardiac Stents
• HTN
• Denied smoking, occasional alcohol, and denied drug use
EDUCATIONAL HISTORY
• Ms. Atkinson graduated from high school in 1975
EMPLOYMENT HISTORY
Place of Employment: Somerset Buick GMC
• Job Title: Service writer
• Start date: 4/6/2015 Stop date: current
• Hours per week: 40
• Job requirements and physical demands: walk, sit and stand
CURRENT EMPLOYER CONTACT INFORMATION
The adjuster Ms. Castle will update the employer. No lifting of the right arm.
WORKERS’ COMPENSATION HISTORY
• Denied
FAMILY/SOCIAL/FINANCIAL FACTORS
Ms. Atkinson reports she lives with her sister. Her sister is able to help her with ADL’s and a home chore.
• Emergency contact is Elizabeth Scutchfield 586-945-8736
PHYSICAL DESCRIPTION
• Height 5 feet 4 inches
• Weight 180
• Hair color blond
• Eye color blue
• Dominant hand right
CLIENT’S FUTURE PLANS
• Ms. Atkinson reports she would like to return to work when she can use her right arm.
CONSENT/EXPLANATION OF BENEFITS AND CASE MANAGEMENT
I explained my role as a medical case manager and Ms. Atkinson verbalized understanding. She read and willingly signed the Authorization for Release of Medical Information …show more content…
Atkinson has a history of cardiac and hypertension. It is unclear if she has ever had a bone density test so we are not sure how well her bones will heal. The fracture is just below the shoulder. She is not able to move the shoulder to allow for the fracture to heal. This puts her at high risk for a frozen shoulder. She is seeing Dr. Keller every two weeks and is being closely monitored. The Official Disability Guidelines for a proximal humerus fracture is 27 to 54 days.
PLAN/ RECOMMENDATIONS
1. Contact Ms. Atkinson every 2 to 4 weeks. Obtain an update on her current medical status.
2. Attend the next appointment with Dr. Keller on 5/14/18. Obtain a current treatment plan with projections for recovery. Address a work status.
3. Update Ms. Castle after each appointment. She will update the employer.
Thank you for this referral. Please feel free to contact me if you have any questions regarding this report. You will be kept informed of any developments in this file and updated immediately following all physician appointments.
Sincerely,
MICHIGAN CASE MANAGEMENT
Leesha Aseltine, R.N., CCM
Medical Case Manager
(810) 963-2258 phone
(810) 275-1266