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Marie Oliver Primary Care Case Study

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Marie Oliver of York Risk Services Group Insurance Company referred this file for medical case management. Instructions were given to meet with Mr. Jones and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. Ms. Oliver would like me to obtain prior medical records from Mr. Jones primary care physician Dr. Wetzel.

INTERVIEW SETTING

On 2/15/18 I met Mr. Jones at the office of Dr. Vakhariya. Mr. Jones was driven to the appointment by his mother. He is dressed neatly. Mr. Jones is willing to discuss his prior and current medical history. He is alert and oriented.

MEDICAL FACTORS AS RELATED TO INJURY

Mr. Jones said that while working on a conveyer belt on 2/1/18 he slipped on an …show more content…
CURRENT STATUS

Mr. Jones moves constantly, he is also rubbing the right thigh. He walks with a limp. Mr. Jones reports his pain is an 8. He reports that he has had a constant headache since hitting his head in the fall. He also reports that he has low back pain with radiation of a burning pain don the right leg. He has numbness to the right and left legs. Mr. Jones reports having difficulty going up and down the stairs so when he is home he stays on the second floor bedroom.

CURRENT TREATMENT PLAN

Mr. Jones was seen by one of the surgeon at the Michigan Spine and Brain group. He was referred to a chiropractor and also to the Pain Clinic. I attended the appointment with Dr. Vakhariya on 2/15/18. We went over the MRI. Per Dr. Vakhariya Mr. Jones has a very large extruded herniation at L5-S1. The goal is to try and heal this without surgery. He approves the continued use of the Gabapentin and the Motrin. He did add Norco but spoke at length with Mr. Jones about only using the narcotic if he really needs to and to not plan on staying on them for an extended timeframe. He also approves of continuing the Chiropractor. Mr. Jones will be getting an epidural injection at this appointment. He will receive the 2nd injection on 3/1/18. We will then meet on 3/13/18 to discuss the outcome of the injections and if we can add physical therapy. I was told by the adjuster that Mr. Jones has had a prior MRI of the low back. I asked …show more content…
Jones reports he is taking the following medications for his injury:
Motrin
Gabapentin
Norco

Mr. Jones denied any allergies to medications.

DURABLE MEDICAL EQUIPMENT

No medical equipment need has been identified.

ADL’S

Mr. Jones reports that his bedroom is on a second floor. He avoids going up and down the stairs due to increased pain. He is dependent on his wife for household chores.

MEDICAL AND SURGICAL HISTORY

Mr. Jones reports the following medical conditions:
Asthma
Mr. Jones denied having any prior back injuries until I asked him about the prior MRI of his low back in 2014. He reports he did have a “disc problem” that he had one epidural injection

Mr. Jones denies smoking, alcohol or drug use.

EDUCATIONAL HISTORY
Mr. Jones said he finished high school and has no additional education.

EMPLOYMENT HISTORY

Place of Employment: Sodecia USA Automotive Corp
• Job Title: Tool Mfg
• Start date: 10/19/16 Stop date: current
• Hours per week: 40 hours
• Job requirements and physical demands: lift, carry, bend, twist, walk, kneel, stand and reach.

CURRENT EMPLOYER CONTACT INFORMATION

Ms. Oliver will make all contact with the employer.

WORKERS’ COMPENSATION

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