Mary Stuart, PA - 08/23/2023 9:00 AM CDTFormatting of this note is different from the original.Images from the original note were not included.NEW PATIENT VISITSubjective CHIEF COMPLAINTHe had concerns including Pain of the Right Wrist.HISTORY OF PRESENT ILLINESSPatient here with complaints of right wrist pain. He reports a fall 8 months ago. He was playing with his niece and this was an accidental fall. Symptoms initially got better slowly with time, however he is continued to experience ongoing ulnar-sided pain. It limits him with rotation and extension type activities. Symptoms are exacerbated by use. They improve with rest. A constant dull aching sensation. He states history of chemo induced neuropathy of the right wrist and hand, which is stablePain AssessmentPain

Assessment: 0-10Pain Score: 2PAST MEDICAL HISTORYHe has a past medical history of Anemia, Cancer (CMS/HCC) (HCC), and Peripheral neuropathy.PAST SURGICAL HISTORYHe has a past surgical history that includes Colon surgery.MEDICATIONSHe has a current medication list which includes the following prescription(s): levothyroxine.ALLERGIESHe has No Known Allergies.SOCIAL HISTORYHe No alcohol history on file.FAMILY HISTORYHistory reviewed. No pertinent family history.REVIEW OF SYSTEMSReview of Systems Constitutional: Negative for chills, fatigue and fever. Eyes: Negative for pain and visual disturbance. Respiratory: Negative for chest tightness and shortness of breath. Cardiovascular: Negative for chest pain and leg swelling. Gastrointestinal: Negative for abdominal pain, constipation, diarrhea and vomiting. Genitourinary: Negative for dysuria, frequency and urgency. Musculoskeletal: Negative for myalgias. Skin: Negative for rash and wound. Neurological: Negative for dizziness, weakness and light-headedness. Hematological: Does not bruise/bleed easily. Psychiatric/Behavioral: Negative for confusion and hallucinations. Objective PHYSICAL EXAMBP 141/89 | Pulse 62 | Ht 182.9 cm (6’) | Wt 100.2 kg (221 lb) | BMI 29.97 kg/m² Right hand/wristInspectionErythema: absentEffusion: absentEdema: presentSurgical scar/wound: absent. PalpationTenderness: present. The tenderness is located in the ulnar forveal, ulnar triquetral and DRUJ.Range of motionThe patient has reduced range of motion of the right wrist.The patient has pain with range of motion of the right wrist.Strength Thumb extension: 5/5Thumb flexion: 5/5Thumb opposition: 5/5Wrist extension: 4/5Wrist flexion: 5/5Interossei: 3/5Grip: 4/5NeurovascularThe patient has normal vascular on the right side of their body.The patient has normal sensation with exceptions as noted below.Median: paresthesiasRadial: paresthesiasUlnar: paresthesiasTestTinel’s sign: negativeUlnar Impaction sign: positiveLeft hand/wristThe patient has normal inspection, palpation, range of motion, strength, and stability of the left hand and wrist.REVIEW OF X-RAYS/STUDIES/LABSXR Wrist Right 3 or More Views Radiographs of the right wrist reviewed, interpreted, and compared with earlier views obtained at an outside facility. No acute fractures are seen. On tunnel view, there subacute changes at the trapezial process, likely reflective of prior injury or subacute fracture. No bony entrapment is present upon carpal tunnel. Positive ulnar variance appreciatedFriedman, Michael, MD - 07/28/2023Formatting of this note might be different from the original.EXAM DESCRIPTION: XR WRIST LIMITED 2 VIEW RIGHTREASON FOR STUDY: Two views submitted without comparison.

FINDINGS: Two views submitted without comparison.No acute fractures are identified. Ulnar positive variance ispresent. The joint spaces are normal. There is no dorsal wristsoft tissue swelling.THIS IS AN ELECTRONICALLY VERIFIED FINAL REPORT7/28/2023 11:06 AM- Electronically signed by Michael Friedman M.D.Michael Friedman M.D.MF: MFD: 7/28/2023 11:06 AMT: 7/28/2023 11:06 AMReport ID: 3444913Reading Location: FRIEDMANDXLT-19

IMPRESSION: Right ulnar positive variance.Exam End: 07/26/23 16:09 Specimen Collected: 07/28/23 11:06 Last Resulted: 07/28/23 11:09 Received From: OSF Healthcare Result Received: 08/23/23 08:56 Assessment/Plan Alexander was seen today for pain.Diagnoses and all orders for this visit:TFCC (triangular fibrocartilage complex) injury, right, initial encounter- XR Wrist Right 3 or More Views- Ambulatory referral order to Occupational Therapy -; FutureClosed displaced fracture of trapezium of right wrist, sequela- Ambulatory referral order to Occupational Therapy -; FutureCongenital positive ulnar variance of right wrist- Ambulatory referral order to Occupational Therapy -; FuturePeripheral neuropathy due to chemotherapy (HCC)Plan We discussed and reviewed his complaints, clinical findings, and images today. We discussed conservative versus surgical management of his above diagnoses.We discussed the benefits of hand therapy, including further reduction in pain, inflammation, and correction of mechanical/strength deficits. Patient elected to proceed and order placed. Splinting per discretion of OT. Follow up in 6-8 weeks, if symptoms persist. If he he fails OT may further benefit from injection. Further conservative measures including ice/heat, avoidance of aggravating activities, OTC NSAIDs/analgesics p.r.n. (if able to take), OTC analgesic creams reviewed with him today.All questions were answered. Patient expressed full understanding and agreement of plan. This note was partially completed using M*Modal Fluency Direct speaking software, therefore, occasional wrong-word or ‘sound-a-like’ substitutions may have occurred. Read the chart carefully and recognize, using context, where substitutions have occurred. Mary Katherine Stuart, PAElectronically signed by Mary Stuart, PA at 09/12/2023 10:34 AM CDTdocumented in this encounter