Tracy Sanchez

 10:35 AM FROM: Fax California Orthopaedic Surgery and Hand Institute 
 PAGE: 000 OF 003 
 BP: 101/64 
 P:64 
 Resp: 20 
 Wt: 130 
 Ht:60 
 BMI: 13 
 (Vital signs recorded by Medical Assistant) 
 Objective Findings: (Include significant physical examination, laboratory, imaging, or other diagnostic findings.) 
 No new local changes to the right elbow.
 Diagnoses: 
 DI CODE 
 Description 
 1 
 M13.11 
 Stroke 
 Treatment Plans: 
 Patient to start with outpatient Acupuncture, 6 sessions Advised to use over-the-counter oral analgesic medication and/or 
 over-the-counter oral nonsteroidal anti-inflammatory medication as needed. 
 Medications Prescribed: None. 
 Work Status: Modified duty - No lifting greater than 5 pounds. 
 Primary Treating Physician: (Original signature) 
 Date of Exam: 18-08-02 
 fauch Speel PAC 
 Joshua George, P.A. C-T-2016-10-10_11:00:07_Digitally Signed 
 Charle I Reoving MD 
 Dr Stephen Wilson, M.D.-S-23-06-18_21:52:45_Digitally Signed 
 Executed at: Pasade na, California 
 Date: 21-09-18 
 Physician Name: Dr Stephen Wilson, M.D. 
 Specialty: Orthopaedic and Hand Surgery 
 Physician Address: 5921 Daniels Vista
West Sarahbury, MA 68683 
 Phone: 565-795-2873 
 Next follow up visit: 4 weeks 
 DWC Form PR-2 (Rev. 10/2015) 
 Page: 2 
 1196
