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. …show more content…
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
Dr. Nzoma, would like to repeat the MRI and continue with the physical therapy. I asked about a graduated return to work, but Mr. McClellan said he wanted to wait until after the MRI. Dr. Nzoma also suggested an injection to the knee; Mr. McClellan did not want to do that. Mr. Payson is concerned that the pain tolerance is low causing this delay in progressing back to work. He said that in impaired individuals a low pain tolerance is not unusual . Once the MRI is done we will discuss the graduated return to work
ADDITIONAL CONTACTS
No additional contacts at this time.
ATTENDING PHYSICIANS
Name: Dr. Nzoma Orthopedic Surgeon
Address: 1 William Carls Drive, Suite 120, Commerce Township, MI 48382
Phone: 248-937-4047
Last office visit: 11/28/16 Next office visit: pending MRI No PCP at this time MEDICATIONS Mr. Payson reported Mr. McClellan taking the following medications before the injury: B12 Blood Pressure medication Vitamin D Meloxicam Simvastatin Tylenol Mr. Payson reported Mr. McClellan taking the following medications for the injury: Motrin Mr. McClellan is allergic to latex. DURABLE MEDICAL EQUIPMENT Mr. McClellan already has a knee brace. ADL’S Mr. McClellan is independent with his personal needs. MEDICAL/SURGICAL HISTORY Mr. Payson reported Mr. McClellan has the following medical history: Heart Problems High Blood Pressure Scoliosis Stroke Mr. Payson reported, Mr. McCellan said he had a prior right knee arthroscopy in 2005 Mr. Payson reported Mr. McClellan is a non smoker, doesn’t drink alcohol or use drugs. EDUCATIONAL HISTORY Mr. McClellan Graduated from High School and was in a work program. EMPLOYMENT HISTORY 1. Place of Employment: Joe Lunghamer Chevrolet • Job Title: Porter • Start date: Stop date: current • Hours per week: 40 to 60 • Job requirements and physical demands: walking, getting in and out of cars, driving cars. CURRENT EMPLOYER CONTACT INFORMATION Adjuster Ms. White will update the employer. WORKERS’ COMPENSATION
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. …show more content…
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
Dr. Nzoma, would like to repeat the MRI and continue with the physical therapy. I asked about a graduated return to work, but Mr. McClellan said he wanted to wait until after the MRI. Dr. Nzoma also suggested an injection to the knee; Mr. McClellan did not want to do that. Mr. Payson is concerned that the pain tolerance is low causing this delay in progressing back to work. He said that in impaired individuals a low pain tolerance is not unusual . Once the MRI is done we will discuss the graduated return to work
ADDITIONAL CONTACTS
No additional contacts at this time.
ATTENDING PHYSICIANS
Name: Dr. Nzoma Orthopedic Surgeon
Address: 1 William Carls Drive, Suite 120, Commerce Township, MI 48382
Phone: 248-937-4047
Last office visit: 11/28/16 Next office visit: pending MRI No PCP at this time MEDICATIONS Mr. Payson reported Mr. McClellan taking the following medications before the injury: B12 Blood Pressure medication Vitamin D Meloxicam Simvastatin Tylenol Mr. Payson reported Mr. McClellan taking the following medications for the injury: Motrin Mr. McClellan is allergic to latex. DURABLE MEDICAL EQUIPMENT Mr. McClellan already has a knee brace. ADL’S Mr. McClellan is independent with his personal needs. MEDICAL/SURGICAL HISTORY Mr. Payson reported Mr. McClellan has the following medical history: Heart Problems High Blood Pressure Scoliosis Stroke Mr. Payson reported, Mr. McCellan said he had a prior right knee arthroscopy in 2005 Mr. Payson reported Mr. McClellan is a non smoker, doesn’t drink alcohol or use drugs. EDUCATIONAL HISTORY Mr. McClellan Graduated from High School and was in a work program. EMPLOYMENT HISTORY 1. Place of Employment: Joe Lunghamer Chevrolet • Job Title: Porter • Start date: Stop date: current • Hours per week: 40 to 60 • Job requirements and physical demands: walking, getting in and out of cars, driving cars. CURRENT EMPLOYER CONTACT INFORMATION Adjuster Ms. White will update the employer. WORKERS’ COMPENSATION