INDICATION: Fracture occurred when the patient was involved in an unspecified motor vehicle collision. It is known that Mr. Blake was the driver of the vehicle.
A 23 year old, Hispanic male is suffering from a hip fracture due to a car accident. The patient unable to bear weight or transfer due weakness in his lower extremities. In this
Initially we had difficulty obtaining his discharge orders as the hospital care manager replied she had forwarded the documentation, but neither I nor Mrs. Bianco had received a copy. Mrs. Bianco made a visit to Mills Creek and met with Mr. Smith at that time she was made aware of an appointment that Mr. Smith attended. Mr. Smith attended a physician appointment on June 28, 2017 with Dr. Leonard, Orthopedic trauma. Mills Creek assisted with the transportation and a mobile x-ray unit was coordinated to obtain x-rays of the femur at the facility as Mr. Smith didn’t bring his slide board to the appointment and couldn’t get onto the radiology table.
I met Mr. Eigner at the office of Dr. Taha. Mr. Eigner reports he is not taking any pain medications at this time. He reports he has a jolting shooting pain to the right and left legs only occasionally. He denied any pain to his right forearm. X-rays taken showed good alignment and healing of the fracture. The incisions are all healed except for a couple small spots on the right ankle. There is some swelling to the right ankle which Dr. Taha said is to be expected. The range of motion to the left ankle and toes was good. The range of motion to the right stores was limited. Dr. Taha said there is scar tissue at times from this type of repair and he would like physical therapy to start working on that. He is still going to be non-weight bearing for another 6 to 8 weeks on the right leg. He is now allowed full weight bearing as tolerated to the left leg. Dr. Taha ordered a rolling scooter to aid with ambulation and stop using the wheelchair. I have contacted Reverence physical therapy and faxed the new orders so the service can begin. I will process the rolled scooter with directions from the adjuster. The attendant care and replacement services will continue through to the next appointment.
Indications: The patient is a 69 year old black female who fell landing on her right hip. She was seen in the Emergency Room where physical exam and x-ray revealed an intertrochanteric right femoral fracture. She was admitted to Dr. Loyd’s service .
Ms. Payne has not had any follow up appointment this reporting period. She has attended counseling appointment’s to talk about her anxiety and panic related to the accident. She felt she will be done with her counseling soon. Physical therapy has been completed for the shoulder, the knee and she has a home exercise program. She also has completed using attendant care for assistance with bathing and light house work. I anticipate that this file is close to
S.P. is admitted to the orthopedic ward. She has fallen at home and she has sustained an intracapsular fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at age 79. Her height is 5’3 and weighs 118 pounds. She has a 50 pack year smoking history and denies alcohol use. She has severe Rheumatoid Arthritis (RA) and had an upper GI bleed in 1993 and had Coronary Artery Disease with CABG 9 months ago. Since that time, she has engaged in “very mild exercise at home.” Vital signs are 128/60, 98, 14, 99 degree farenheight (32.7 degrees C) SAO2 94%
Ms. Tocco was a passenger in her husband’s vehicle. They were T-boned on her side of the vehicle. Pictures of her vehicle showed the passenger side of the vehicle indented from the front bumper to the rear bumper. The seat she was sitting in was crushed and had a large vertical dent in the seat. She was taken to Henry Ford Clinton Township hospital where she was for 5 days.
On 4/4/17 I met Mr. Kobetic at the office of Dr. O’Hara Neurosurgeon. Mr. Kobetic reports he has no back pain. He is allowed to remove the back brace for sleeping and reports his left side muscles are tender when he is lying in bed. X-rays were taken before the appointment today. Mr. Kobetic was examined by PA Ms. Masaud then Dr. O’Hara came in. Examination showed good strength, sensation and strength. The x-rays showed the fracture has healed. Mr. Kobetic may now remove the back brace. He is to increase his activity as tolerated. Mr. Kobetic will follow up with the office only if needed. Mr. Kobetic will be making the stress test appointment with the cardiologist to determine if he had a cardiac issue that caused the auto accident. Mr. Kobetic reports he has no recollection of the accident and what caused it. Once the test is complete and he has a follow up appointment he will let me know. Mr. Kobetic returns to work today.
On 2/21/17 I went to the office of Neurosurgeon Dr. Schell. Ms. Ostrander had arrived and left before I arrived. Dr. Schell will not speak with case managers. I called Ms. Ostrander. She said Dr. Schell looked at the MRI disc and told her the compression fractures to her Thoracic spine had not healed and she needs a vertebral plasty done. This is going to be scheduled. He also told her that she has compression issues in her cervical spine but he would deal with this after the thoracic spine is taken care of. Dr. Schell’s office is supposed to schedule the surgery. The MRI done on 2/16/17 with and without contrast showed that the mild compression fractures at the anterior superior endplates of T5, T6, T7, and T9 are healed.
HISTORY OF PRESENT ILLNESS: Ruby Pearce follows up today for reevaluation of her left proximal humerus fracture sustained secondary to a fall on July 9, 2015. She was seen in the office on July 15, 2015 and a course of nonoperative treatment for proximal humerus fracture was begun. She was given a prescription for physical therapy and instructed on home exercise program including pendulum motions and wall walking. She has not attended physical therapy, but has been diligent with her home exercise program. Her pain is intermittent and sometimes sharp, but is easily controlled with medications. She states she has a 5-6/10 at times. She takes Tylenol to control these symptoms. She notes no neurovascular
Judy is a 53 year old mother of two and grandmother of 3 grandchildren. On a simple trip to the store on afternoon, Judy’s life changed in just a split second. While waiting at a red light, Judy was rear ended and violently hit her head on the steering wheel. Judy states she tried to remove her seatbelt but was unable due to her arms being paralyzed. During this ordeal, Judy also stated that her pain felt as if “a knife had been stuck in her neck.” During her hospital stay the emergency room doctor told Judy that she was suffering from whiplash. While at the hospital, Judy kept telling the doctor that she was in a lot of pain, but no further testing could be performed, such as an MRI, because her insurance wouldn’t cover it. Judy was sent home with a cervical collar and the diagnosis of whiplash. Unable to have very much mobility and having a hard time lying down, one night while
Usually pelvic bone fracture, depending on the intensity of trauma and the type of treatment (operative or conservative), heals in a period of 6-8 weeks. This is the normal time for any bony structure to heal in body. But, considering the diet and the status of bone density before fracture, the healing period may increase upto 12 weeks. So, with adequate rehabilitation, at maximum, your son will be able to walk without crutches in 3 months, after fracture. For him to consider football, diving, or other sports, he must wait for a period of 6 months and during this period, must consult a sports physician so that a proper exercise and training program is
Jane was involved in a single-vehicle accident that resulted in multiple areas of injury from a head trauma, two broken ribs as well as bilateral fractures in her leg’s as well as right arm and wrist fracture. Jane was, transported a hospital that was an hour and half away from her home.
Shai suffered a right femoral neck fracture in a low-speed non-fault bicycle versus car accident in February while living in Israel. He fell backwards landing on a cobbled surface. The fracture was stabilised, surgically and he was discharged the following day to continue his rehabilitation at home. With private physiotherapy, he has made a reasonable recovery.