Workcover Initial

Initial Worker's Compensation Consultation: Date of Injury/Incapacitation: 1 November 2024 Employer: ACME Corp Occupation: Construction Worker Other Attendees: None History of Injury: - Patient reports a fall from scaffolding while working on a construction site. He landed on his left shoulder. - Left shoulder - None - X-ray of the left shoulder was performed and showed a fracture. Current Symptoms: - Patient reports severe pain in his left shoulder, rated 8/10. He also reports some bruising and swelling. He denies any numbness or tingling in his arm or hand. Past Medical History: - Patient has a history of hypertension, well-controlled with medication. - None Medications: - Lisinopril 20mg daily - Paracetamol 1g as needed for pain Allergies: - NKDA Examination: - Inspection reveals bruising and swelling over the left shoulder. Palpation elicits tenderness over the left clavicle. Range of motion is limited due to pain. Neurovascular examination of the left arm is intact. Diagnosis: - Left clavicle fracture - Possible rotator cuff injury Work Capacity: - Patient is currently unfit for work. - Patient is restricted from any activities involving lifting, pushing, or pulling with his left arm. - Return to work is estimated in 6-8 weeks. Management Plan: - Patient advised to rest, ice, and elevate the injured arm. Sling provided. Follow-up with an orthopaedic surgeon recommended. - X-ray of the left shoulder (already done). - Paracetamol 1g as needed for pain. - Referral to Dr. Smith, Orthopaedic Surgeon. - Follow-up appointment in 2 weeks.