This is the report of the medical exam by the doctor paid for by the workers compensation insurance company. Keep in mind, Dr. Stirrat was aware of the trip to China and did not comment on it.  Dr. Stirrat did not dispute the three weeks away from work as recommended by Dr. Gordin's 8/9/96 note.

September 16, 1996
William Silverstein
Page 2

is no obvious loss of  motion or decrease of pulses Cubital tunnel exams are negative for nerve irritability, subluxation or flexion tests. No lateral spicandylitis. Carpal tunnel exams do not show Tinalls, Phalan's or direct pressure signs. Phalan's test will cause the complaint of some pulling in the forearm extensor muscle surfaces, but there is not true lateral epicondylitis. No dequervain's noted on either side. ECU tendons do not appear to be inflamed. No evidence for wrist instability. Thumb basilar joints are unremarkable. No ostearthritis in the fingertips. No trigger finger recognized. Static two point sensation is in the normal 5 mm range. Grip strength on the right is 30 kg; left 30 kg. Key pinch right 8 kg; left 8 kg.

X-RAYS: Outside x-rays from 5/22/95 were reviewed for the right and left wrist. On the right side there may be slight dorsal positioning of the distal ulna of questionable significance. The AP x-ray does not suggest any shift of the joint space. Left side is all unremarkable.

IMPRESSION: Patient has a history of upper extremity complaints associated with keyboard activities. He has been diagnosed as having tandonitis with myofascial pain syndrome and underlying "hyponotabolism". He has received conservative treatments including therapy, massage and acupuncture. On his exam today there are no true objective findings. He does have the loss of supination in the forearm but I think this is more likely related to a prior injury than to the current problems. He filled out a pain diagram which indicates diffuse complaints throughout the upper extremities. I would agree with the diagnosis of tendonitis. The myofascial pain syndrome certainly is a reasonable description of his diffuse complaints through the upper extremities. I am a bit doubtful on the hypometabolism as  I think that is a rather vague description of the patient's general health and I am not sure how it can be well documented. Evidently Dr. Gordin feels that dietary supplements are an advantage and patient alleges that he feels better taking them, but I would be uncertain how much of that is placebo-effect. From a hand surgery perspective it is my feeling that most of what is being seen in this gentleman is a life style issue. He basically is spending all of his time on a keyboard whether it be at home or work. He alleges his home keyboard time is less than it was. As hobbies he was doing bicycling and resistance training. These two activities would certainly provoke even more irritation through the upper extremities. Since the onset of his