Nursing Case Interview Paper

On 8/10/16 I met Mr. Abraham at the office of Dr. Yacisen. Mr. Abraham arrived with his mother. He wore the brace to the right leg and used a cane to ambulate. Mr. Abraham said his left shoulder has improved dramatically since he started physical therapy. An x-ray of the shoulder was taken and did not show any defect. The right knee still had slight swelling which Mr. Abraham said goes down when he has the brace off. Examination showed the MCL was scarred down. The patella was stable. Dr. Yaisen said he wants Mr. Abraham to really work more aggressively in physical therapy. He demonstrated and had him repeat back new exercises to do at home. Dr. Yacisen also wants him to remove the brace and discontinue use of the cane. He told Mr. Abraham unless he gets aggressive with building the

muscles that support the ACL he will need surgery. Dr. Yacisen said they do not do a ACL reconstruction on a man this age but would go in with a scope and clean up the knee. Dr. Yacisen said he is about 50% and still will continue to improve over the next few months. He is now able to do sit down work. Prescriptions for the therapy was faxed over to the therapy location. Mr. Abraham will only need to be seen for the shoulder only if needed.

On 8/25/16 Mr.

Abraham said his appointment with Dr. Yacisen has been moved to 9/12/16 by Dr. Yacisen’s office. Mr. Abraham arrived to the appointment on 9/12/16 with his Mother. He walks stiff legged to the right knee. He reports his pain in the right knee is about a 2 to 3 with twisting. Examination showed the knee to be slightly swollen but stable. Dr. Yacisen still feels he may need to have a scope done. With discussion on the length he will be working and the type of work he does Dr. Yacsien may still do an ACL repair. Mr. Abraham said he is very apprehensive about going back to work. Much discussion was given to restrictions and when he would go back. Dr. Yacisen would like physical therapy to continue and added a work conditioning also. He wants Mr. Abraham to have a custom ACL brace and must be wearing it to return to work. The brace was measured but would take about 3 weeks to come in. The left shoulder has good range of motion. Mr. Abraham said he has slight pain in the shoulder, he declined a injection. He was given a home exercise program to do by Dr. Yacisen in conjunction with formal physical therapy. Mr. Abraham said he is also driving

locally.

RETURN TO WORK ACTIVITY

Mr. Abraham may return to work with the following restrictions:
Allow frequent change of position, avoid bending, twisting squatting, kneeling, pivoting with weight, and no weight with going up and down stairs and must wear the ACL brace while at work. There are no restrictions for the left shoulder. Mr. Abraham must be allowed to attend physical therapy. Mr. Abraham will be released to full duty work on 10/4/16. An update along with a copy of the restrictions were provided to the employer on 9/12/16.

ASSESSMENT

Mr. Abraham is apprehensive about returning to work. He is concerned on how he will be able to drive to work and physical therapy.

PLAN/RECOMMENDATIONS

1. Contact Mr. Abraham every 2 to 4 weeks for a medical status update.
2. Attend appointment with Dr. Yacisen on 11/14/16 obtain current work status and treatment recommendations.
3. Facilitate treatment recommendations by a physician.
4. Update the employer of the outcome of physician appointments.