Maxcis Insurance Case

Tina Castle of Maxcis Insurance Company referred this file for medical case management. Instructions were given to meet with Robert Kise and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.

INTERVIEW SETTING

On 10/19/16 I met Mr. Kise at the office of Dr. Lewis Infectious Disease. Mr. Kise arrived alone to the appointment. He is alert and oriented and willing to work with a nurse case manager. Mr. Kise is wearing a cam boot to the left leg.

MEDICAL FACTORS

Mr. Kise reports while working in the service department. He said he was handing paperwork to an client when the car began to move and started to roll over his left foot. He said he pulled his foot back. He reported the …show more content…
Castle adjuster provided 22 pages of medical records from the Pine Knob Urgent care clinic for review. An x-ray was done on 9/8/16 and did not show any fractures. A wound culture was done on 9/15/16, but there is no documentation on the results.

CURRENT STATUS

Mr. Kise reports his has a constant pain. He elevated the leg while sitting. He is independent with his wound care. The wound is on the outer aspect of the base of the 5th toe. It is approximately quarter size. It is deep. After the wound was debrided, the wound bed was red and had good tissue granulation. After the debridement the wound was wrapped with gauze.

CURRENT TREATMENT PLAN

Dr. Lewis would like a current x-ray done to determine if there is any bone infection. If there is no infection then Mr. Kise will not take any further antibiotics. If there is a bone infection then Dr. Lewis will send him for a picc line and stat antibiotic infusions. Wound care will change to Aquacell. This wound needs to be washed, Aquacell place on the wound bed and left for three days.

ADDITIONAL CONTACTS

N/A

ATTENDING …show more content…
C. Lewis Infectious Disease
Address: 6060 Torrey Rd Ste 1, Flint, MI 48507 Phone: 810-655-0027
Last office visit: 10/19/16
Next office visit: 11/2/16

MEDICATIONS

Mr. Kise reported taking the following medications before the injury:
Metformin
Glucophage
Synthroid
Baby Asprin

Mr. Kise reported taking the following medications before for this injury:
Bactrim
Mortin

Mr. Kise denied any medication allergy.

DURABLE MEDICAL EQUIPMENT

Cam boot
Wound care supllies will be ordered through Bison home care.

ADL’S

Mr. Kise said he is independent with his personal care. He is dependent on family for household services.

MEDICAL/SURGICAL HISTORY

Mr. Kise reported he has the following medical conditions:
Diabetes
Peripheral Neuropathy

Mr. Kise smokes, he was educated on smoking and wound healing. He said he doesn’t drink alcohol or use drugs.

EDUCATIONAL HISTORY

Mr. Kise said he graduated from Central high school in 1981. He did not attend

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