Tina Castle of Maxcis Insurance Company referred this file for medical case management. Instructions were given to meet with Craig Westenburg and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
On 3/3/17 I met Mr. Westenburg at the office of orthopedic surgeon Dr. Cherwin. Mr. Westenburg arrived alone. He is alert and oriented and willing to work with a nurse case manager.
MEDICAL FACTORS
Mr. Westenburg said he was cleaning off cars in the auto dealership lot when he slipped between two cars. He hit his right shoulder. Mr. Westenburg reported the injury and was sent for examination. Mr. Westenburg was sent for an MRI and referred to orthopedic surgery Dr. Cherwin.…show more content… Westenburg reported taking the following medications before the injury:
Metroprolo Tartrate
Mr. Westenbrug reports taking the following medication for his injury:
Motrin
Norco
No known medication allergies.
DURABLE MEDICAL EQUIPMENT
None determined
ADL’S
Mr. Westenburg reports he is independent with his personal care and household services
MEDICAL/SURGICAL HISTORY
Mr. Westenburg reports he has hypertension.
Mr. Westenburg said he has had the following surgeries:
Cervical disc repair
Left knee arthroscopy 4 times
2 tumors removed under his right underarm
Mr. Westenburg reports he smokes ½ packs of cigarettes a day. I counseled him on smoking cessation and recovery from surgery. He reports he is a social drinker and denied drug use.
EDUCATIONAL HISTORY
Mr. Westenburg graduated from high school in 1984.
EMPLOYMENT HISTORY
1. Place of Employment:
• Job Title:
• Start date: 2007 Stop date: current
• Hours per week: 40
• Job requirements and physical demands: sit, stand, and walk
