Nursing Case Study: Genesys Occupational Medicine
On 10/11/17 I met Mr. Blue at the office of Dr. Mosier. Mr. Blue arrived to the appointment alone. He had an orthopedic brace on the left leg and was using a cane. He was alert and oriented. Once I was able to explain my role as a case manager he was open to working with a nurse case manager.
MEDICAL FACTORS
Mr. Blue reports he slid down a ditch and had immediate pain in his left foot. He was seen at Genesys Occupational Medicine for treatment. He is being referred to an orthopedic doctor for further evaluation.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
I was provided with 10 pages of medical documentation. Genesys Occupational Medicine provided visit summaries. He was sent for an MRI of the left ankle. The test was done …show more content…
Mosier said that the left ankle has several torn ligaments. I did confirm that this is new and not related to the prior met tarsal fracture in 2015. She told Mr. Blue he can live with it but the ankle will not be stable or he can have the ligaments repaired. She said the cause was a severe sprain from rolling his ankle. She would recommend doing a scope and repairing the torn ligaments. He would be in a cast for 6 weeks, and would be non weight bearing. He would then start physical therapy. It would be 3 to 3.5 months after surgery before he would return to full duty work. She reports that he would be 90% better and should be able to function in his current job. Mr. Blue said he would like to have the surgery. This will be done on …show more content…
Blue reports his wife is a nurse and is very helpful.
Emergency Contact –Mr. Blue refused to provide that information.
PHYSICAL DESCRIPTION
Height: 6 foot 6 inches
Weight: 320 pounds
Hair: grey brown
Eyes: brown
Dominant hand: right
CLIENT’S FUTURE PLANS
Mr. Blue said he wants to get better and back to work.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as a medical case manager and Mr. Blue verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Mr. Blue denied any legal representation.
IMPRESSIONS
Mr. Blue reports his overall health is good. He has had a recent prior injury to the left ankle so this may complicate his recovery. The Official Disability Guideline for an unspecified injury to the left foot is 16 to 33 days of recovery time. This timeline is almost exceeded.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Blue every 2 to 4 weeks for an update on his left foot pain.
2. Attend the appointment with Dr. Mosier on 11/7/17. Obtain a treatment plan and outcome of the surgery on 10/27/17work status.
3. Update the employer after each medical
MEDICAL FACTORS
Mr. Blue reports he slid down a ditch and had immediate pain in his left foot. He was seen at Genesys Occupational Medicine for treatment. He is being referred to an orthopedic doctor for further evaluation.
DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS
I was provided with 10 pages of medical documentation. Genesys Occupational Medicine provided visit summaries. He was sent for an MRI of the left ankle. The test was done …show more content…
Mosier said that the left ankle has several torn ligaments. I did confirm that this is new and not related to the prior met tarsal fracture in 2015. She told Mr. Blue he can live with it but the ankle will not be stable or he can have the ligaments repaired. She said the cause was a severe sprain from rolling his ankle. She would recommend doing a scope and repairing the torn ligaments. He would be in a cast for 6 weeks, and would be non weight bearing. He would then start physical therapy. It would be 3 to 3.5 months after surgery before he would return to full duty work. She reports that he would be 90% better and should be able to function in his current job. Mr. Blue said he would like to have the surgery. This will be done on …show more content…
Blue reports his wife is a nurse and is very helpful.
Emergency Contact –Mr. Blue refused to provide that information.
PHYSICAL DESCRIPTION
Height: 6 foot 6 inches
Weight: 320 pounds
Hair: grey brown
Eyes: brown
Dominant hand: right
CLIENT’S FUTURE PLANS
Mr. Blue said he wants to get better and back to work.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as a medical case manager and Mr. Blue verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Mr. Blue denied any legal representation.
IMPRESSIONS
Mr. Blue reports his overall health is good. He has had a recent prior injury to the left ankle so this may complicate his recovery. The Official Disability Guideline for an unspecified injury to the left foot is 16 to 33 days of recovery time. This timeline is almost exceeded.
PLAN/ RECOMMENDATIONS
1. Contact Mr. Blue every 2 to 4 weeks for an update on his left foot pain.
2. Attend the appointment with Dr. Mosier on 11/7/17. Obtain a treatment plan and outcome of the surgery on 10/27/17work status.
3. Update the employer after each medical