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Patient Name: Andre Wu Encounter Date: 9/17/2018 Date of Birth: 6/7/1963 Acct #: 5000011657

Chief Complaint Right index finger/left elbow.

History of Present Illness
This is a 55-year-old man who presents with two separate complaints, swelling and stiffness in the right index finger with
no history of trauma.
Second complaint medial sided elbow pain. Evaluated and treated by an orthopedic surgeon in Chelmsford,
Massachusetts. The working diagnosis is osteoarthritis right index finger and medial epicondylitis left elbow. He was
offered a steroid injection but he held off on the injection. He wanted a second opinion. He denies numbness in his left
ring and small finger. No history of trauma in the left elbow. He is not an overhead throwing athlete.

Medical History
Medical Conditions: No known medical conditions
Medical History: The patient snores and is not currently taking blood thinners.
Surgical History: The patient has not reported any previous surgeries.
Current Medications: Effexor 25 mg tablet as directed, simvastatin 10 mg tablet as directed, Wellbutrin 75 mg
tablet as directed
Medication and Allergic Reactions: Amoxicillin, Seasonal
Family History: Mother: Diabetes and Rheumatoid Arthritis.
Sibling(s): None.
Personal and Social History: The patient has never smoked. The patient consumes alcohol socially. The patient
indicates he does not exercise regularly. He does not live alone. He is married. He is currently working. Occupation:
product manager . Employer: Dussaults Sys. .

Review of Systems
Miscellaneous: joint pain and joint/limb swelling.
Vital Signs: Height: 5ft 8.00in, Weight: 160lbs, BMI: 24.33 BMI 24.33

Physical Examination:
This is a 55-year-old man, alert and oriented.
Examination of both elbows, no deformities on inspection. Full range of motion. He has a negative Tinel over the cubital
tunnel. Intrinsic motor strength is 5/5. He has tenderness over the medial epicondyle and flexor pronator mass. No
tenderness along the medial edge of the pronator teres. Distal biceps tendon, there is no tenderness. Pain with resisted

ELECTRONICALLY SIGNED BY Stefan Strapko, MD

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 Patient Name: Wu, Andre
Acct:5000011657
DOB: 6/7/1963

pronation with the elbow fully extended versus fully flexed.

Examination of the right hand, the index finger is swollen and the PIP joint is slightly enlarged. Slightly decreased active
flexion through the PIP and DIP joints compared to the left index finger. He has got some tenderness when I palpate and
I stressed the PIP joint.

Diagnosis Codes:
M77.02 Medial epicondylitis, left elbow left
M19.041 Primary osteoarthritis, right hand right
Office Procedures:

Treatment Plan:
Voltaren 1 % topical gel were prescribed; side effects were discussed and appropriate instructions were provided.
Patient education on medial epicondylitis was given to the patient. The patient is instructed to return if pain or
symptoms arise.
I read the office notes from the orthopedic surgeon in Chelmsford, Massachusetts. X-rays were read as negative for the
elbow and index finger. I agreed with the diagnosis of medial epicondylitis. Good part of today’s visit spent on education
and treatment options. My recommendation would be activity modification, stretching, heat and deep tissue massage. I
do not think his pain is bad enough to warrant a steroid injection. I agreed with the diagnosis of osteoarthritis in the PIP
joint of the right index finger. I think my recommendation would be to try a course of Voltaren gel, prescribed this
morning. He will follow up p.r.n.
Steve I. Strapko, MD/btb
cc: Scott F. Paparello, D.O.

Electronically signed by: Stefan Strapko, MD

Date: 9/18/2018 Time: 8:44 PM

ELECTRONICALLY SIGNED BY Stefan Strapko, MD

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