Procedure For Medical Case Management Essay

803 Words Nov 28th, 2016 4 Pages
Joan White of Maxcis Insurance Company referred this file for medical case management. Instructions were given to meet with Todd McClellan and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.

INTERVIEW SETTING

On 11/28/16 I met Mr. McClellan, his step father, mother, wife and wife’s mother at the office of Dr. Nzoma. Mr. McClellan is developmental delay so Mr. Payson coordinates appointments. Mr. McClellan is pleasant, alert and cooperative. He walks without a limp.

MEDICAL FACTORS

Mr. McClellan was at work as a porter. While exiting a customer vehicle he stepped and turn his knee. He did not immediately report the injury. When he did report this on 7/25/16 he was sent to Elizabeth Lake Urgent care. He was told to go to his PCP or an orthopedic doctor if there was no improvement. Mr. McClellan saw Dr. Nzomas had an MRI done and was told he had a medial femoral insufficiency. He has been going to physical therapy and has been off work.

DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS

8/18/16 MRI of the left knee showed Insufficiency fracture of the medial femoral condyle.

CURRENT STATUS

Mr. McClellan is unable to quantify his left knee pain. He reports the pain is to the inner aspect of the knee, it is tender to touch. He reports physical therapy has helped. He doesn’t have any pain going down stairs now just going up. He is able to walk and wears a knee brace.

CURRENT TREATMENT PLAN…

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