Medical Case Management Case Study

Melissa Teregan of Mackinaw Administrators Insurance Company referred this file for medical case management. Instructions were given to meet with Michael Benjamin and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. Ms. Teregan has requested clarification of the cause of the injury if the tear is acute or degenerative.

INTERVIEW SETTING

On 12/26/17 I met Mr. Benjamin at the office of Dr. Elbanna. Mr. Benjamin arrived with his wife. He is neatly dressed. Mr. Benjamin is alert and oriented. He was willing to discuss his current medical history and his prior medical history. He said he is happy to work with a nurse case manager.

MEDICAL FACTORS AS RELATED TO INJURY

Mr. Benjamin …show more content…
Benjamin reports that while he was at work he was climbing up into a truck when he struck the top of his left shoulder on a bolt that was hanging out of the bottom of a side mirror. He did not say anything about being knocked to the ground. He said he thought it would get better and just kept working, the next day he reported to the supervisor. He was seen at the work clinic and then sent over to Dr. Elbanna for an evaluation. He rates his pain at a 5/6; he is taking Aleve but did ask for some Motrin 800mg. He reports he has for the last 2 weeks had a problem with his arm going numb down into his hand, he is able to change positions and it will get better. He reports that 10 years ago during a tornado he was hit in the shoulder with a 2 by the 12-inch board. This caused a hairline fracture. The fracture healed but about 6 months later the range of motion in the shoulder decreased. He ended up having a scope and they trimmed the bone spur and shortened his clavicle. He recovered without any problems after going to physical therapy. Mr. Benjamin reports he was told not to do much with the arm and has followed that …show more content…
Benjamin verbalized understanding. He read and willingly signed the Authorization for Release of Medical Information form.

ATTORNEY

Mr. Benjamin denied any legal representation.

IMPRESSIONS

Mr. Benjamin has had several prior injuries from working on his active farm. He has had a prior left shoulder fracture with a subsequent scope to clean up bone spurs. He works for the road commission and his farm concurrently. Mr. Benjamin says that his underlying health is good. The Official Disability Guidelines for a frozen shoulder are 37 to 68 days. There has been some delay in getting Mr. Benjamin into a physical therapy program. His employer is unable to accommodate light duty work so that will extend his return to work timeframe.

PLAN/ RECOMMENDATIONS

1. Contact Mr. Benjamin every 2 to 4 weeks for an update on his current symptoms.
2. Connect Physical therapy for an update on Mr. Benjamin's attendance and progress in his therapy program.
3. Attend the appointment with Dr. Elbanna on 3/26/18. If the symptoms subside move the follow-up appointment to a sooner date. Obtained an updated work status.
4. Update Ms. Rosser from the Shiawassee County Road Commission after each

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