THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: August 5, 2014 10:30 AM Tuesday; Rod Welch

VA meeting Podiatry resolve metatarsalgia to hike Half Dome.

1...Summary/Objective
2...Testing Standard of Care Evaluate Response to Treatment
3...Response to Treatment Testing Standard of Care for Evaluation
4...Standard of Care Testing Evaluate Response to Treatment
5...Planning EPC and CTA Testing for Regression Atherosclerosis
6...Metatarsalgia Diagnosed Caused by Extended Exercise Training
7...Referral for Scope of Meeting Not Readily Available VA Computer System
8...Patient History Review Cause Forefoot Pain Hiking 300 Miles Per Month
9...Meeting Doctor Robert Tang Thorough Examination
10...Physical Activity Hiking 300 Miles Monthly for Regression Atherosclerosis
...............Mileage 2014 Miles Minutes
11...Hiking 300 Miles Monthly Drives Regression Atherosclerosis Reduce CVD Risk
12...Metatarsalgia Diagnosed
13...Prescribe Reduce Hiking Required for Regression Atherosclerosis
14...Orthotic Molds Taken for Delivery Shoe Inserts in 2 Months
15...Medical Chart Progress Notes Meeting 140806 VA SF Medical Center
16...Radiology Both Feet


..............
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CONTACTS 

SUBJECTS
VA Podiatry Review Metatarsalgia Pain Balls of Feet Order Custom Ort                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
0803 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0803 -    ..
0804 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
0805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080501 - Follow up ref SDS 28 0000. ref SDS 26 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080507 -  ..
0806 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0807 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0808 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0809 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080901 - VA contact...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080902 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080903 -                415-221-4810 Ext. 4721, 5673                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080904 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080905 -                        5798 4556 5787                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080907 -  ..
080908 - Meeting Doctor Tang at 1030, scheduled by Donna on 140804 0929.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080909 - ref SDS 28 F57O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080911 -  ..
080912 - This morning left house in Concord OA 0510.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080914 -  ..
080915 - Arrived San Francisco VA Medical Center at 0600.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
080917 -  ..
0810 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0811 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0812 - 0625                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
0813 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081301 - Found place to work at GI Diagnostic Center on 3rd floor of building                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081302 - 200, across the street, and around the corner from Cardiology.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081303 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081304 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081305 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081307 -  ..
0814 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0815 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0816 - 0716                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
0817 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081701 - Moved to cafeteria.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081702 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081703 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081705 -  ..
0818 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0819 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0820 - 0938                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
0821 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
082101 - Visit Podiatry Department Clinic Module 3 on Ground Floor.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
082102 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
082103 - The attendant said there might be 15 minutes before the Podiatry                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
082104 - department calls for the patient, and so okay to visit Cardiology on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
082105 - the 2nd floor in Building 200.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
082106 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
082107 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
082108 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
0822 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
EPC CTA Test Standard of Care Evaluate Response to Treatment Hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
1803 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1804 - 0952                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180501 -  ..
180502 - Testing Standard of Care Evaluate Response to Treatment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
180503 - Response to Treatment Testing Standard of Care for Evaluation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
180504 - Standard of Care Testing Evaluate Response to Treatment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
180505 - Planning EPC and CTA Testing for Regression Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
180506 - 
180507 - Met with Karen in Cardiology on 2nd floor of Building 200.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
180509 -  ..
180510 - Karen received the copy of the letter to Doctor Alba, requesting lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
180511 - to test for EPC and radiology test for coronary CTA with calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
180512 - score, submitted on 140731 1048. ref SDS 25 GY4K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
180514 -  ..
180515 - Karen seemed to support testing with EPC lab and coronary CTA with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
180516 - calcium score to evaluate response to treatment, discussed in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
180517 - letter to Doctor Alba on 140731 1048. ref SDS 25 4167 following CABG +4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
180518 - on 091022 0700. ref SDS 2 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
180520 -  ..
180521 - Today, we recalled meeting with Doctor Shunk in Karen's office on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
180522 - 131121.  At that time, we discussed testing for regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
180523 - atherosclerosis. ref SDS 5 MS7G  Doctor Shunk cautioned against doing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
180524 - an invasive procedure, like the angiogram study, ref SDS 5 8D6N, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
180525 - he performed on 091021, ref SDS 1 7L43, and which then led to CABG +4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
180526 - the next day, performed by Doctor Tseng, and her team on 091022.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
180527 - ref SDS 2 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
180529 -  ..
180530 - Karen indicated testing is standard of care to assess response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
180531 - treatment, shown in analysis of Doctor Alba's letter on 140731 1048,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
180532 - ref SDS 25 545J, and citing prior research submitted to the VA on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
180533 - 140626 1652. ref SDS 19 MZ33                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
180534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
180535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
180536 -        Defer EPC and CTA testing...................... 140731 1048, ref SDS 25 GY4K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180537 -        Testing standard of care response to treatment. 140731 1048, ref SDS 25 546K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180538 -        VA in loop..................................... 140731 1048, ref SDS 25 545J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180539 -        VA again recommend 2nd opinion Doctor Egan..... 140731 1048, ref SDS 25 QU4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180540 -        Doctor Egan did not respond.................... 140731 1048, ref SDS 25 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180541 -        Patient requests support Doctor Egan........... 140710 1348, ref SDS 22 DX7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180542 -        VA recommends 2nd opinion from Doctor Egan..... 140703 1938, ref SDS 21 H233                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180543 -        Request referral for 2nd opinion on CTA........ 140626 1652, ref SDS 19 MY51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180544 -        No grounds refuse CTA assess atherosclerosis... 140626 1652, ref SDS 19 MZ33                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180545 -        CTA for CABG common assess atherosclerosis..... 140626 1652, ref SDS 19 MZ54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180546 -        VA no grounds failure order CTA assess plaques. 140612 1048, ref SDS 18 Y68L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180547 -        Follow up on ordering CTA atherosclerosis...... 140610 0903, ref SDS 17 LJ61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180548 -        Request CTA assess atherosclerosis plaques..... 140529 0942, ref SDS 16 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180549 -        Justification coronary CTA order............... 140520 0732, ref SDS 15 VQ48                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180550 -        Request EPC lab predicate to CTA............... 140515 2043, ref SDS 13 YM61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
180551 -        HDL drives regression atherosclerosis.......... 131125 0005, ref SDS 6 HG90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
180552 -        Original research on........................... 131125 0005, ref SDS 6 N73K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
180554 -  ..
180555 - Karen will continue considering ideas and make appropriate inquiries                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
180556 - for VA doctors (which are actually UCSF) to sign off ordering EPC and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
180557 - coronary CTA with calcium score, which was discussed in the letter to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
180558 - Doctor Alba on 140710 1348. ref SDS 14 DX7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
180559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
180560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
180561 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
180562 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1806 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
VA Podiatry Review Metatarsalgia Pain Balls of Feet Enable Physical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
Metatarsalgia Diagnose Extended Exercise Endurance Training Hiking 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2104 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2105 - 1020                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210601 -  ..
210602 - Metatarsalgia Diagnosed Caused by Extended Exercise Training                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210603 - 
210604 - Follow up                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210606 - Good meeting with Doctor Robert Tang and an Intern, Doctor Prema                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210607 - Hampapur.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210609 -  ..
210610 - Sent a letter last night at 2300 notifying Doctor Alba that meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210611 - with Podiatry was expedited and scheduled for 1030 this morning.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210612 - Requested the language in her referral, in order to be prepared for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210613 - meeting with Podiatry.  When I returned from San Francisco received                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210614 - Doctor Alba's letter sent at 1304 this afternoon, and submitting the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210615 - language in her referral needed this morning.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210617 -  ..
210618 - Doctor Alba's letter received after the meeting today says...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210619 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210620 -    1.  Subject:  RE:  Podiatry Meeting on Aug 5th 1030                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210621 -        Date: 2014-08-05 13:04,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210628 -         ..
210629 -    2.  On your referral I wrote that you had metatarsalgia - chronic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210630 -        and worsening despite insoles/orthotics.  Very active hiker.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210631 -        Hopefully you meet Dr Tang soon.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210632 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210633 -            [...below on 140805 1030 during meeting in Podiatry                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210634 -            Department Doctor Tang confirmed diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210635 -            metatarsalgia. ref SDS 0 1E5Y  Progress Notes list                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210636 -            Impressions of metatarsalgia. ref SDS 0 UD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210638 -             ..
210639 -            [On 140806 1753 letter to Doctor Alba with copy to Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210640 -            Tang notifies that Doctor Tang confirmed diagnosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210641 -            metatarsalgia and ordered orthotic inserts. ref SDS 29 X15H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210643 -         ..
210644 -    3.  Best,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210646 -         ..
210647 -        D.A.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
210648 -        Diana Alba  M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210649 -        Clinical Fellow, Endocrinology, Diabetes and Metabolism                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210650 -        University of California San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210652 -  ..
210653 - This responds to the letter submitted to Doctor Alba on 140804 0929.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210654 - ref SDS 28 V69O  Since the doctor expresses hope for a meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210655 - Doctor "soon," she missed the subject saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210656 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210657 -              Subject:  Podiatry Meeting on Aug 5th 1030                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210658 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210660 -  ..
210661 - Referral for Scope of Meeting Not Readily Available VA Computer System                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210662 - 
210663 - During the meeting today at 1030, Prema spent about 10 minutes trying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210664 - to find Doctor Alba's referral on the computer in the examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210665 - office, but no luck.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210667 -  ..
210668 - Prema asked about patient history leading to Podiatry referral?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210670 -  ..
210671 - We reviewed the record submitting patient history of hiking sent to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210672 - the VA on 140731 1048. ref SDS 25 4233  Prema consulted with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210673 - colleagues in the Podiatry Admin area for assistance using the VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210674 - computer system.  They could not find Doctor Alba's referral.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210675 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210676 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210678 -  ..
210679 - Patient History Review Cause Forefoot Pain Hiking 300 Miles Per Month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210680 - 
210681 - We soldiered on.  Gave Prema Internet address in the letter to Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210682 - Alba, for case study on 120101, showing hiking 300+ miles per month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210683 - this year, to increase EPC and HDL for regression of atherosclerosis,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210684 - then sudden decline in late June and continuing in July due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210685 - metatarsalgia. ref SDS 3 7718                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210687 -  ..
210688 - Prema read through several reports doing daily 11 mile hikes, e.g., on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210689 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210690 -                 140608.......... ref SDS 3 SL5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210691 -                 140621.......... ref SDS 3 BZ7I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210692 -                 140624.......... ref SDS 3 EV8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210694 -  ..
210695 - Prema noticed extensive follow up on 140624, working to resolve pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210696 - on balls of feet with different shoes, and that patient had to stop                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210697 - hiking entirely on 140624, due to lack of solution for painful                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210698 - metatarsalgia side effects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
210700 -  ..
210701 - Prema was pleased with the record showing patient doing better with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210702 - Hoka Stinson Trail shoes combined with orthotic inserts, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210703 - 140726, shown in the case study. ref SDS 3 8Q7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210705 -  ..
210706 - Prema smiled and said this was the best patient workup she has ever                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210707 - done.  She left the examination room to brief the doctor, and seemed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210708 - pleased to have a record showing background of problem to solve.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210709 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210712 -  ..
210713 - Meeting Doctor Robert Tang Thorough Examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210714 - 
210715 - About 10 minutes later, Prema and the doctor came into the examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210716 - room.  Enjoyed working with Doctor Tang.  He introduced himself as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210717 - Robert, with hand extended.  We shook hands, and went to work.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210719 -  ..
210720 - Examination seemed very thorough exploring nuances of current                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210721 - condition.  Requested treatment options that can support physical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210722 - activity hiking 300 miles per month to lower CVD risk by increasing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210723 - EPC and HDL that drive regression of atherosclerosis, set out in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210724 - letter to VA on 140731 1048. ref SDS 25 WL6H, and based on research to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210725 - raise HDL reported 131125 0005, ref SDS 6 SH50, and to raise EPC, in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210726 - the same record. ref SDS 6 6O9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210727 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210729 -  ..
210730 - Physical Activity Hiking 300 Miles Monthly for Regression Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210731 - 
210732 - Presented exercise for medical goals, which includes training to hike                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210733 - Half Dome next month on 140817.  Was in excellent condition after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210734 - training six (6) months to test EPC lab and coronary CTA with calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210735 - score assessing regression of atherosclerosis, reported to VA during a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210736 - meeting on 140519 0800. ref SDS 14 MY7J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210738 -  ..
210739 - Doctor Tang noted patient history hiking 200-350 miles per month shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210740 - progress this year toward health goals for endurance exercise to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210741 - enable regression of atherosclorosis, until the end of June...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210743 -                ..
210744 -               Mileage 2014                       Miles     Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210745 -               
210746 -               140202....Jan................. 347     5393 ...... ref SDS 3 YWST                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210747 -               140302....Feb................. 234     3681 ...... ref SDS 3 PYWS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210748 -               140330....Mar................. 207     3313 ...... ref SDS 3 RXPR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210749 -               140427....Apr................. 310     4402 ...... ref SDS 3 RXVV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210750 -               140601....May................. 322     5338 ...... ref SDS 3 SXWV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210751 -               140629....Jun................. 156     2337 ...... ref SDS 3 ZW4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210752 -               140803....Jul.................  81     1023 ...... ref SDS 3 I37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210753 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210755 -  ..
210756 - Hiking 300 Miles Monthly Drives Regression Atherosclerosis Reduce CVD Risk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
210757 - 
210758 - Doctor Tang indicated that hiking 300 miles per month exposes feet to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210759 - severe repetitive stress that risks injury.  The doctor asked why                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210760 - hike 300 miles per month?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210762 -  ..
210763 - Exercise is well recognized for cardiovascular health, reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210764 - research on 131125 0005. ref SDS 6 8X4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210766 -  ..
210767 - Endurance exercise increases HDL cholesterol produced largely in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210768 - liver and intestine, reported in research on 131125. ref SDS 6 U44L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210769 - Extended exercise also increases endothelial progenitor cells (EPC)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210770 - produced in the bone marrow, also reported on 131125 ref SDS 6 8X4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210771 - This has been achieved hiking 300 miles per month the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210772 - shown by lipid labs - LDL-P 851, triglycerides 58, and HDL 67 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210773 - reported on 140514 0950. ref SDS 12 W25L  VA assumes EPC is elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210774 - similar to WBC also produced by the bone marrow, shown in the lab on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210775 - 140508. ref SDS 11 RP4N, indicated in a letter on 140703, relating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210776 - detailed discussion that advised testing EPC is not necessary,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210777 - ref SDS 21 H167, similar to not testing LDL-P, because it can be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210778 - assumed from other labs, reported on 140213 0830. ref SDS 9 WQ8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210779 - Endurance exercise hiking 300 miles per month to increase EPC and HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210780 - enable regression of atherosclerosis that lowers CVD risk, reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210781 - also on 131125, ref SDS 6 RA7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210783 -  ..
210784 - These results were not achieved hiking lessor amounts, shown by lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210785 - history on 140514 0950, ref SDS 12 W25L  Accordingly, VA Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210786 - Notes Plan of Care on 140213, prescribed continuing physical activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210787 - that yielded favorable results. ref SDS 9 E34O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210788 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210789 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210791 -  ..
210792 - Metatarsalgia Diagnosed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210793 - 
210794 - Doctor Tang confirmed diagnosis of metatarsalgia, noting this is a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210795 - general medical problem with numerous forms.  The current issue is to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210796 - relieve pain the last few miles of daily 11 mile hikes in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210797 - maintain prescribed care.  The doctor indicated metatarsalgia pain can                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210798 - be caused by poor fitting shoes that lack adequate arch support,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210799 - commonly called orthotics.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210801 -             ..
210802 -            [...below on 140805 1030 Progress Notes list Impressions of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210803 -            metatarsalgia. ref SDS 0 UD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210805 -             ..
210806 -            [On 140806 1753 letter to Doctor Alba with copy to Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210807 -            Tang notifies that Doctor Tang confirmed diagnosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210808 -            metatarsalgia and ordered orthotic inserts. ref SDS 29 X15H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210810 -  ..
210811 - Doctor Tang demurred on trying cortisone injections.  He suggested                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210812 - taking anti-inflammatory ibuprofen medication, like Motrin, before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210813 - going on long hikes.  He explained ibuprofen taken before leaving on 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210814 - hour, 11 mile hikes will get into the blood stream and begin taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210815 - effect an hour or so later, in time to reduce inflammation after 7 or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210816 - 8 miles, which will reduce prevent pain, rather than mask pain in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210817 - balls of the feet at the end of 11 mile hikes.  The doctor cautioned                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210818 - that masking pain with cortisone injections can compound injury.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210819 - better solution is to reduce inflammation that causes pain, in this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210820 - case with ibuprofen treatment like Motrin.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210821 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210822 -            [On 141125 2220 running out of pills for ibuprofen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210823 -            (Motrin), so ordered 200 pills from Amazon. ref SDS 41 XI5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210824 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210826 -  ..
210827 - Prescribe Reduce Hiking Required for Regression Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210828 - 
210829 - Doctor Tang prescribed backing off extended hikes every day, so the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210830 - feet have more time to rest.  He indicated long hikes are fine, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210831 - not every day of the week.  Try different scenarios, say 11 miles for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210832 - 3 days, then cut back to 3 - 5 miles for a few days.  This is trial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210833 - and error experimentation.  Doctor Tang noted feet are like other body                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210834 - parts that suffer wear and tear with age.  At 70, the feet are less                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210835 - able to maintain the same level of effort as at 20, 40, and this case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210836 - just a few months ago, as shown by sudden mileage decline in June, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210837 - above. ref SDS 0 Y56N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210838 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210839 -            [On 141009 0900 during meeting in Podiatry at the VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210840 -            Medical Center in San Francisco Doctor Tang reviewed the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210841 -            record showing reduced hiking during Jul, Aug and Sep, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210842 -            indicated this aligns with his prescription for recovering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210843 -            from metatarsalgia. ref SDS 38 K69O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210845 -  ..
210846 - This indicates lowering CVD risk with regression of atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210847 - plaques through extended hiking that increases EPCs and HDL, as called                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210848 - out in the letter to the VA team on 140703 1938, ref SDS 21 6X46, must                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210849 - be balanced with avoiding metatarsalgia which otherwise prevents                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210850 - hiking, also cited in the letter to the VA on 140703 1938, ref SDS 21                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
210851 - 6X57, and again more recently in a letter on 140731 1048. ref SDS 25                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210852 - WL6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210854 -             ..
210855 -            [On 120101 0900 after 3 days hiking 14.2 miles training for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210856 -            Half Dome, planning implement guidance on taking next day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210857 -            off to rest feet. ref SDS 3 EI4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210859 -  ..
210860 - Doctor Tang advised that long term solution will be "athletic" shoe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210861 - inserts to distribute the dynamic load of walking and running from the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210862 - balls of the feet to the larger arch area of the feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210863 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210864 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210866 -  ..
210867 - Orthotic Molds Taken for Delivery Shoe Inserts in 2 Months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
210868 - 
210869 - Prema helped Robert make molds of both feet, which will be used to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210870 - make athletic shoe orthotic inserts.  The doctor expects these VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210871 - inserts will provide better support than the Good Feet inserts.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210872 - seemed to indicate the VA inserts will also be more comfortable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210873 - because the inner sole has better cushioning than the Good Feet inner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210874 - soles examined today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210876 -             ..
210877 -            [On 140910 1553 received orthotic inserts ordered by Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210878 -            Tang for size 9.5 Hoka Stinson Trail shoes, during meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210879 -            at VA Medical Center Podiatry Department in San Francisco.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210880 -            ref SDS 35 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210882 -             ..
210883 -            [On 150115 0845 ordered 2nd pair Prolab orthotic inserts.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210884 -            ref SDS 42 BG6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210886 -             ..
210887 -            [On 150207 0845 received 2nd set Prolab orthotic inserts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210888 -            ordered on 150115, by Doctor Tang in Podiatry Department                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210889 -            VA Medical Center in San Francisco. ref SDS 43 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210891 -  ..
210892 - This aligns with the record working with Good Feet.  During initial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210893 - meeting on 140628, Good Feet offered comfortable, and seemingly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210894 - effective inserts. ref SDS 20 S544  However, purchase was delayed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210895 - pending review by VA Podiatry. ref SDS 20 Y24F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210897 -  ..
210898 - Since Podiatry consult at the VA was delayed, shown in the letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210899 - 140703 1938, ref SDS 21 H240, and weeks later on 140731 1048,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210900 - ref SDS 25 WL6M, on 140711, decided to take immediate action trying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210901 - Good Feet orthotic inserts in order to train for Half Dome hike                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210902 - scheduled in September.  However, inserts ultimately provided on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210903 - 140711, by Good Feet seemed less effective than those presented 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210904 - weeks earlier on 140628. ref SDS 23 MF6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210906 -  ..
210907 - Good Feet inserts received on 140711, were initially only partially                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210908 - effective.  Later when combined with Hoka Stinson Trail shoes on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210909 - 140726 1030, ref SDS 24 EJ89, there was improvement, but still not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
210910 - adequate, shown by the record difficulty hiking on 140728, in case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210911 - study on 120101 0900. ref SDS 3 T56H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210913 -  ..
210914 - Doctor Tang noted that timely action is important in health care.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210915 - explained that unfortunately, the VA "athletic" inserts won't be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210916 - delivered for about 2 months, likely in early October, and so will not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210917 - be available for Half Dome scheduled on 140917, reported on 131028                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210918 - 1203. ref SDS 4 5W8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210919 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210920 -            [On 140910 1553 received orthotic inserts ordered by Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210921 -            Tang during meeting at VA Medical Center Podiatry                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210922 -            Department in San Francisco; this is a week before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210923 -            scheduled to hike Half Dome on 140917. ref SDS 35 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
210925 -  ..
210926 - Requested guidance optimizing Good Feet inserts combined with Hoka                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210927 - Stinson Trail shoes, purchased on 140726 1030. ref SDS 24 915F, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
210928 - were worn to the meeting today, for inspection and comment.  As noted,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210929 - these adjustments in the past few weeks have yielded some improvement.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210930 - The problem is getting through the last 5 - 6 miles of hikes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
210932 -  ..
210933 - Robert examined the Hoka Stinson Trail shoes carefully.  He bent and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210934 - pressed them in various ways.  Robert seemed to say that Hoka Stinson                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210935 - Trail shoes would provide better support against metatarsalgia if the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210936 - forward section was less cushiony or pliable, i.e., harder to bend.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210937 - He commented that balancing cushioning and support requires trial and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210938 - error, since VA inserts will have more cushion than Good Feet inserts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210939 - examined today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210941 -             ..
210942 -            [On 141102 2231 article Sacramento Bee article highlighting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210943 -            Hoka leading trend switching to maximal cushioning to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210944 -            prevent feet injuries. ref SDS 40 XN5F  Replaces minimalist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
210945 -            cushioning, even hiking and running barefoot emulating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210946 -            Maasai traditional practices. ref SDS 40 NY95                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
210948 -  ..
210949 - Robert wrote on the back of his business card two (2) other shoe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210950 - brands and models to consider, which he feels might be a better                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210951 - solution for the elements of metatarsalgia in this case.  Turns out                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210952 - cannot read his handwriting - something looks like "New Balance" but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210953 - everything else is a blur.  Will get specifics from Progress Notes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210954 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210955 -            [...below on 140805 1030 VA Progress Notes say in part                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210956 -            "...shoegear recs given," but do not list the actual shoes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210957 -            proposed for investigation to replace Hoka Stinson Trail                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210958 -            shoes. ref SDS 0 UD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210960 -  ..
210961 - His main point was to wear "running" shoes rather than "hiking" shoes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210962 - for extended hiking and running in this case, 200 - 350 miles a month,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210963 - per above. ref SDS 0 Y56N  This aligns with procurement the past year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210964 - or so buying Adidas Response Cushion running shoes.  We migrated to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210965 - Hoka Stinson Trail shoes because they seemed more comfortable and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210966 - caused less pain in the balls of the feet than Adidas Response Cushion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210967 - shoes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210969 -  ..
210970 - We briefly reviewed mounting expense buying and modifying shoes to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210971 - resolve metatarsalgia.  Robert noted that patient history in this case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210972 - indicates that care for feet exposed to hiking 300 miles a month is a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210973 - good investment, in light of favorable results the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
210974 - toward regression of atherosclerosis to lower CVD risk, indicated by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210975 - continually improving lipid labs, most recently on 140514 0950.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210976 - ref SDS 12 W25L  The doctor explained that shoes typically only last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
210977 - about 500 miles, so hiking 11 miles per day to improve cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210978 - health entails continuing expense.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210980 -  ..
210981 - Related buying 12-15 pair of shoes size 9 over the past 6 months or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210982 - so, and rotating them everyday, to extend procurement period from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
210983 - months to several years, since once "good" shoes are discovered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210984 - through trial and error, it is later difficult to replace them,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210985 - because manufacturers change models and designs every 6 - 12 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210986 - chasing the elusive "market share" business model with advertisements                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
210987 - for customers to buy "new improved" products, that often don't work as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
210988 - well as the old products.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
210990 -  ..
210991 - Doctor Tang seems committed to our cause today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
210993 -  ..
210994 - The doctor asked for the size of the Hoka Stinson Trail shoes worn                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
210995 - today, which will be used for continuing endurance exercise hiking?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
210997 -  ..
210998 - Advised the shoes are size 9.5, shown in Fleet Feet invoice 61208 on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
210999 - 140726 1030. ref SDS 24 LG5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
211000 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211001 -            [On 140806 1753 letter to VA with copy to Doctor Tang                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
211002 -            requests changing order for orthotic inserts from size 9.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
211003 -            to size 9. ref SDS 30 XF77                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
211005 -             ..
211006 -            [On 141009 0900 during meeting in Podiatry Department at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
211007 -            the VA Medical Center in San Francisco, Doctor Tang removed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
211008 -            Prolab orthotic inserts from Hoka Stinson Trail shoes size                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
211009 -            9.5 and put them in Adidas Response Cushion shoes size 9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
211010 -            brougt to the meeting, and determined the fit was adequate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
211011 -            without any trimming. ref SDS 37 LS8I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
211013 -             ..
211014 -            [On 141021 1411 VA was able to provide additional care in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
211015 -            Podiatry to further resolve blister problems that got                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
211016 -            progressively worse as hiking increased following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
211017 -            recovery from metatasalgia. ref SDS 39 DR9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
211019 -  ..
211020 - Doctor Tang requested notice when the orthotic inserts are received,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
211021 - expected in early October, per above. ref SDS 0 1F47  The VA will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
211022 - schedule a meeting to review experience wearing the inserts for making                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
211023 - modifications to improve fit and function toward optimizing relief of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
211024 - metatarsalgia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
211025 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211026 -            [...below on 140805 1030 VA Podiatry Progress Notes work                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
211027 -            plan says the patient should return to the Podiatry clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
211028 -            once orthotic inserts are received. ref SDS 0 IJ4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
211030 -             ..
211031 -            [On 140904 0900 meeting with Doctor Tang reminded to notify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
211032 -            VA when orthotic inserts are received. ref SDS 34 5Y4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
211034 -             ..
211035 -            [On 140911 1529 notified VA Podiatry that VA orthotic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
211036 -            inserts were received on 140910. ref SDS 36 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
211038 -  ..
211039 - The doctor also ordered xrays to test for fractures and other problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
211040 - not evident in a manual examination.  He is pretty sure no problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
211041 - will be found, but feels radiology testing should be done to verify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
211042 - the condition of the patient, rather than make assumptions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
211044 -  ..
211045 - The doctor will write up findings and recommendations in Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
211046 - Notes to assist the patient with thorough understanding of diagnosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
211047 - and treatment plans.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
211049 -  ..
211050 - Went to radiology on the 2nd floor.  They took xrays of the feet in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
211051 - several directions.  Results are reported below. ref SDS 0 VK7I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211053 -  ..
211054 - Doctor Tang plans review of progress in a few weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
211056 -  ..
211057 - Few days after the meeting today, received letter from VA scheduling                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
211058 - another meeting with Doctor Tang in Podiatry on 140820 1000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
211059 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211060 -            [...below on 140805 1030 VA Progress Notes Plan of Care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
211061 -            plans RTC after receiving FFO. ref SDS 0 IJ4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
211062 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211063 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211064 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211065 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211066 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211067 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
211068 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2111 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2203 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220401 -  ..
220402 - Medical Chart Progress Notes Meeting 140806 VA SF Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220403 - 
220404 - Follow up ref SDS 9 476K, ref SDS 8 476K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220406 -  ..
220407 - VA website is at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220409 -              https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220411 -  ..
220412 - Customer....                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220416 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220418 -  ..
220419 - On 140810, could not receive Progress Notes for this encounter using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220420 - VA computer system.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220422 -  ..
220423 - Talked to ROI and they said Progress Notes are posted, so should be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220424 - available online.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220425 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220426 -            [On 140812 1400 VA computer system representative advised                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220427 -            that Progress Notes should be filed within 3 calendar days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220428 -            after signature, ref SDS 31 3P9F, however, Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220429 -            with addendum are sometimes not processed correctly.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220430 -            ref SDS 31 UW4L; the VA system has been slowed by expanded                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220431 -            enrollment that currently exceeds original design capacity.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220432 -            ref SDS 31 A163  Service order #1-801103938 filed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220433 -            request posting the record for meeting on 140805.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220434 -            ref SDS 31 V47O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220436 -  ..
220437 - On 140813 stopped at VA Medical Center in San Francisco on the way                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220438 - driving home from Nipomo. 140813 0324, ref SDS 32 5P5M  Got CD for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220439 - Progress Notes on meeting last week - 140805 1030, ref SDS 0 HF6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220441 -  ..
220442 - VA file from CD with Progress Notes for meeting on 140805 are stored                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220443 - at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220445 -               ..
220446 -              F:\05\00003\SM\CC\AGMJ\20140805-112509\WELCH_0144_8-13-14.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220448 -               ..
220449 -              F:\05\00441\CG\GG\HMC\20140805-112509\WELCH_0144_8-13-14.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220451 -               ..
220452 -              F:\05\00441\SM\BGMC\20140805-112509\WELCH_0144_8-13-14.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220453 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220455 -    1.  LOCAL TITLE: PODIATRY CLINIC CONSULT NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220456 -        STANDARD TITLE: PODIATRY OUTPATIENT CONSULT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220457 -        DATE OF NOTE: AUG 05, 2014@11:22 ENTRY DATE: AUG 05, 2014@11:25:09                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220458 -        AUTHOR: HAMPAPUR,PREMA EXP COSIGNER: TANG,ROBERT E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220459 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220460 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220461 -        *** PODIATRY CLINIC CONSULT NOTE Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220463 -         ..
220464 -        The attending physician of record for this patient care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220465 -        encounter is Dr Tang.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220466 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220467 -            [On 140806 1753 letter to Doctor Alba notifies with copy to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220468 -            Doctor Tang results meeting with Podiatry on 140805                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220469 -            following up referral from Doctor Alba to review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220470 -            metatarsalgia. ref SDS 29 XF77                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220475 -         ..
220476 -    2.  CHIEF COMPLAINT: Pain in plantar feet B/L at the level of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220477 -        metatarsal heads.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220479 -         ..
220480 -    3.  HISTORY OF PRESENT ILLNESS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220482 -        The patient is a 69-year-old gentleman who is nondiabetic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220483 -        complaining of pain in the plantar feet B/L at the level of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220484 -        metatarsal heads.  Pt states the pain is a deep, aching pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220485 -        Pt states the pain began in February when he began hiking to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220486 -        help lower his cholesterol.  Pt states he feels something at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220487 -        the bottom of his left foot at the level of the second and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220488 -        third metatarsal heads at the begining of his hike.  Pt states                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220489 -        the feeling becomes pain which progressively gets worse as he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220490 -        hikes and is not tolerable by the eleventh mile.  Pt states the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220491 -        pain eventually is across the ball of both his feet.  Pt states                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220492 -        the pain is worse in his left foot.  Pt denies f/c/n/sob.  Pt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220493 -        states he vomits due to his achalasia.  Pt states he has tried                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220494 -        different shoes and inserts to help with relieveing the pain in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220495 -        his feet.  Pt states he has not had a lot of relief from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220496 -        changing his shoes.  Pt denies taking any pain medication for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220497 -        the pain and denies any other treatment for the pain in his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220498 -        feet.  Pt states he wants to hike Half Dome in September.  Pt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220499 -        denies any new allergies.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220502 -         ..
220503 -    4.  PAST MEDICAL HISTORY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220505 -        1. Esophageal Achalasia * (ICD-9-CM 530.0) 12/08/2009                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220506 -           TABRIZI,RANNA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220508 -  ..
220509 - For some reason, Podiatry does not present nor cite complete medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220510 - history on file at VA.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220512 -  ..
220513 - Past medical history in Progress Notes for meeting on 140519 0800,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220514 - ref SDS 14 OV55, cites prior meetings, and most complete list for this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220515 - team is on 131121 0930. ref SDS 5 W49F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220517 -  ..
220518 - Complete Past Medical History at VA is shown in Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220519 - meeting with Doctor Egan in Cardiology on 140430 0900. ref SDS 10 TX50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220520 - Same list is in Progress Notes issued by Primary Care on 131209 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220521 - ref SDS 7 LB7J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220523 -  ..
220524 - Since Podiatry does not present the Problem list, cannot determine if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220525 - metatarsalgia diagnosed today, has been added to the list.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220527 -  ..
220528 - VA Progress Notes 140805 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220530 -    5.  ACTIVE MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220532 -        Active Outpatient Medications (including Supplies):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220534 -        1.  OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH TWICE A                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220535 -            HOLD DAY 15 MINUTES BEFORE A MEAL FOR SEVERE ACID REFLUX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220536 -            AND ESOPHAGEAL NARROWING.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220538 -             ..
220539 -        2.  Ezetimibe 10 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220541 -             ..
220542 -        3.  ATORVASTATIN 10 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220545 -         ..
220546 -    6.  SURGERIES:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220548 -        1.  Date of Surgery: 12/16/2009                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220549 -            Surgeon: CHANG,JEN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220550 -            Operative Proc(s):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220551 -            LAPAROSCOPIC HELLER MYOTOMY, DOR FUNDOPLICATION - LAP MYOTOMY HELLER                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220553 -             ..
220554 -        2.  Date of Surgery: 10/22/2009                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220555 -            Surgeon: CAMBRONERO,NEIL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220556 -            Operative Proc(s):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220557 -            CABG - CABG ARTERY-VEIN TWO                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220559 -  ..
220560 - VA Progress Notes 140805 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220561 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220562 -    7.  SOCIAL HISTORY:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220563 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220564 -        1.  Pt denies smoking cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220565 -        2.  Pt states he drinks a beer evry couple of months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220566 -        3.  Pt denies use of recreational drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220567 -        4.  Pt states he lives in Concord by himself in a townhouse.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220568 -        5.  Pt is an active hiker.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220570 -         ..
220571 -    8.  FAMILY HISTORY: unknown                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220573 -         ..
220574 -    9.  LOWER EXTREMITY PHYSICAL EXAMINATION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220576 -         ..
220577 -   10.  VASCULAR:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220579 -        1.  DP and PT pulses are 2/4 bilaterally.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220580 -        2.  CFT less than 3 seconds.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220581 -        3.  Temperature gradient is within normal limits.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220583 -         ..
220584 -   11.  NEUROLOGICAL: Grossly intact                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220586 -         ..
220587 -   12.  MUSCULOSKELETAL:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220588 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220589 -        No pain with range of motion to the AJ, STJ or MTPJ.  Limited                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220590 -        AJ ROM noted B/L.  Gastroc-soleus equnius noted in both feet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220591 -        (L>R).  STJ ROM is normal.  Hallux elevatus noted B/L.  Hallux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220592 -        abducto valgus noted B/L.  Pes planus is the foot type.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220594 -         ..
220595 -   13.  DERMATOLOGIC:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220597 -        Hallux nails are elongated, dystrophic and discolored B/L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220598 -        Remaining toenails are slightly discolored.  No interdigital                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220599 -        maceration noted.  Slight fat pad atrophy noted on the plantar                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220600 -        of the feet B/L at the level of the metatarsal heads.  Good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220601 -        skin temperature, texture, and turgor.  Distal digital hair is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220602 -        noted.  No areas of erythema or edema noted.  No open lesions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220603 -        Slight hyperkeratosis noted on the medial aspect of the left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220604 -        1st MPJ.  No clinical signs of infection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220606 -         ..
220607 -   14.  ASSESSMENT AND PLAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220609 -        A 69-year-old gentleman with CAD and hyperlipidemia presents to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220610 -        the clinic with pain on the plantar aspect of the feet B/L at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220611 -        the level of the metatarsal heads.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220612 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220613 -        1.  Pt history taken and pt evaluated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220615 -             ..
220616 -        2.  Recommended custom foot orthotics to help manage the pain in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220617 -            both feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220619 -             ..
220620 -        3.  Prescription for custom foot orthotics (ProAerobic) with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220621 -            reverse Mortons extension written.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220623 -             ..
220624 -        4.  Mold of both feet taken with STS sock cast.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220626 -             ..
220627 -        5.  Informed pt that custom foot orthotics would come in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220628 -            mail.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220629 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220630 -               [On 140910 1553 received orthotic inserts ordered by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220631 -               Doctor Tang during meeting at VA Medical Center Podiatry                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220632 -               Department in San Francisco; this is a week before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220633 -               scheduled to hike Half Dome on 140917. ref SDS 35 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220635 -             ..
220636 -        6.  Recommended pt to take Motrin before hike to help with the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220637 -            inflammation and pain experienced.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220638 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220639 -               [On 141125 2220 running out of pills for ibuprofen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220640 -               (Motrin), so ordered 200 pills from Amazon. ref SDS 41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220641 -               XI5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220643 -             ..
220644 -        7.  Xrays ordered (3 views, WB) for both feet to help exclude                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220645 -            any other pathologies .  Instructed pt to get xrays taken.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220647 -             ..
220648 -        8.  Discussed with pt the importance of allowing feet to rest                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220649 -            in order to help alleviate the pain while continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220650 -            exercise regimen.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220652 -             ..
220653 -        9.  Pt demonstrated verbal understanding of the plan.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220655 -         ..
220656 -   15.  I have discussed the patient with my supervising practitioner,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220657 -        Dr Tang , who agrees with my assessment and plan.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220659 -         ..
220660 -   16.  Clinical Reminder Activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220661 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220662 -        1.  MED REC NON PRIMARY CARE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220663 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220664 -            Medication Reconciliation completed, including non-VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220665 -            medications and discrepancies, if identified, were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220666 -            addressed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220668 -             ..
220669 -        2.  Medication, medication changes and importance of medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220670 -            management were reviewed with the patient/caregiver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220672 -             ..
220673 -        3.  An updated list of reconciled medications has been provided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220674 -            to the patient/caregiver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220675 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220676 -   17.  /es/ Prema Hampapur                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220677 -        MS4, Podiatry                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220678 -        Signed: 08/05/2014 12:18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220679 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220680 -   18.  /es/ ROBERT E TANG,DPM/VA13252                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220681 -        ATTENDING PODIATRIST                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220682 -        Cosigned: 08/05/2014 12:55                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220684 -         ..
220685 -   19.  08/05/2014 ADDENDUM                   STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220686 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220687 -        The above note was scribed for me by Medical Student Hampapur.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220688 -        I Robert Tang, DPM- attending physician personally obtained the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220689 -        complete HPI, performed with physical examination and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220690 -        formulated with medical decision making for this encounter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220691 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220692 -            [On 140806 1753 letter to Doctor Alba notifies with copy to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220693 -            Doctor Tang results meeting with Podiatry on 140805                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220694 -            following up referral from Doctor Alba to review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220695 -            metatarsalgia. ref SDS 29 XF77                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220697 -         ..
220698 -        Encounter Summary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220699 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220700 -        1.  69 y.o. active male seen for consultation for pain,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220701 -            tenderness plantar forefoot of both feet LEFT > RIGHT.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220702 -            Relates to several month duration of experiencing localized                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220703 -            pain, tenderness of the forefoot both feet at the level of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220704 -            the 2nd, 3rd metatarsophalangeal joints.  This pain is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220705 -            mostly noticeable with increased activity.  Patient is an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220706 -            avid hiker and is training to hike Half Dome later this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220707 -            year.  Symptoms begin to occur after 2 or so miles and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220708 -            progress with activity.  Patient is up to hiking 11 miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220709 -            per day, up to several times per week.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220711 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220712 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220713 - "...11 miles per day up to several times per week," implies at most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220714 - 33 miles per week, which is at most 132 miles per month.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220716 -  ..
220717 - Patient hikes 7 days a week - averages 200 - 350 miles per month,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220718 - shown by patient history in case study on 120101 0900. ref SDS 3 7718                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220719 - This was discussed with the team during the meeting today, shown                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220720 - above. ref SDS 0 Y56N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220722 -  ..
220723 - Doctor Alba was asked to submit patient history to Podiatry through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220724 - referral, shown in the letter on 140804 0929. ref SDS 28 H75T  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220725 - doctor's referral said...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220726 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220727 -        ...metatarsalgia - chronic and worsening despite                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220728 -        insoles/orthotics.  Very active hiker. ref SDS 0 JX4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220730 -  ..
220731 - Hiking level of effort applies VA Plan of care prescribed to manage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220732 - CVD risk, shown in Progress Notes on 140213 0830. ref SDS 9 E34O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220734 -  ..
220735 - VA prescription for physical activity, diet and medication has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220736 - effective shown by favorable weight loss and lipid history listed in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220737 - the lab on 140514 0950. ref SDS 12 W25L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220739 -  ..
220740 - VA Progress Notes meeting on 140805 - addendum continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220742 -        2.  Has recently curtailed his training regime 2/2 foot pain.  Has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220743 -            had past hiking shoes modified with soles / cushions with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220744 -            minimal improvement.  Purchase new shoes which seem to have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220745 -            helped as well as insoles- he is not sure how much these                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220746 -            inserts help.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220748 -             ..
220749 -        3.  Lower extremity exam reflects clinical rectus foot type                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220750 -            with moderate hallux valgus / bunion deformity of both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220751 -            feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220753 -             ..
220754 -        4.  Ankle, hindfoot , midfoot ROM is supple free of pain,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220755 -            crepitus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220757 -             ..
220758 -        5.  Ankle joint dorsiflexion is less than 90 deg with KE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220759 -            improved with KF.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220761 -             ..
220762 -        6.  First ray rom is roughly 10mm total with left having an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220763 -            elevated axis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220765 -             ..
220766 -        7.  There is no noted ttp along the metatarsal shafts, (-) ttp                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220767 -            at mtpj's 2-4, (-) noted lachman's.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220769 -             ..
220770 -        8.  There is a (-) Mulder's at the 3rd, 2nd intermetatarsal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220771 -            space of both feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220773 -             ..
220774 -        9.  Plain film- x-rays confirm bunion deformity with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220775 -            navicular-cuneiform fault noted both feet LEFT > RIGHT.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220777 -  ..
220778 - This relates to radiology report shown below. ref SDS 0 6Y51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220780 -  ..
220781 - Progress Notes and radiology report have many technical terms that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220782 - seem to indicate treatable issues, see below left foot, ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220783 - 6Y51, and right foot, ref SDS 0 6Z64, however, no surgical solutions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220784 - are discussed in the doctor's.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220786 -  ..
220787 - This seems to indicate feet have normal wear and tear of 70 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220789 -  ..
220790 - VA Progress Notes meeting on 140805 - addendum continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220791 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220792 -       10.  Shoegear:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220793 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220794 -            current shoegear has adequate frontal plane stability                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220795 -            however soft heel counter, with forefoot flexibility.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220797 -             ..
220798 -       11.  Impressions from this exam are of...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220799 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220800 -            1.  metatarsalgia of mtpj 2,3 likely 2/2 first ray instability.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220802 -                 ..
220803 -            2.  Discussed diagnosis, etiology of condition with Mr Welch.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220804 -                Neutral suspension cast performed this visit as well as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220805 -                shoegear recs given.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220807 -  ..
220808 - Diagnosis of metatarsalgia aligns with Doctor Alba's referral in her                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220809 - letter received earlier this morning, shown above, ref SDS 0 AU9H;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220810 - further aligns with impressions during meeting with the doctor, also                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220811 - above. ref SDS 0 1E5Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220812 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220813 -            [On 140806 1753 letter to Doctor Alba notifies that Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220814 -            Tang confirmed diagnosis metatarsalgia and ordered orthotic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220815 -            inserts. ref SDS 29 X15H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220817 -             ..
220818 -            [On 140910 1553 received orthotic inserts ordered by Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220819 -            Tang during meeting at VA Medical Center Podiatry                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220820 -            Department in San Francisco; this is a week before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220821 -            scheduled to hike Half Dome on 140917. ref SDS 35 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220823 -  ..
220824 - "...shoegear recs given" seems to refer to the doctor's handwritten                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220825 - entry on the back of his business card to consider alternate shoes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220826 - i.e., "shoegear", from Hoka Stinson Trail shoes examined during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220827 - meeting today, noted in the record of the meeting, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220828 - ref SDS 0 1F56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220830 -  ..
220831 - Could not read Doctor Tang's notes on the back of his business card,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220832 - need clarification during next meeting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220833 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220834 -            [On 140904 0900 during follow up meeting in Podiatry at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220835 -            Medical Center in San Francisco Doctor Tang clarified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220836 -            recommendation to investigate Brooks Adrenaline versus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220837 -            Brooks Addiction shoes to investigate for avoiding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220838 -            metatarsalgis forefoot pain. ref SDS 33 CY4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220840 -  ..
220841 - Verify shoe size 9 ordered for orthotic inserts.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220842 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220843 -            [On 140806 1753 letter to Doctor Alba notifies with copy to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220844 -            Doctor Tang, asks Doctor Tang to order orthotic inserts for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220845 -            size 9 rather than size 9.5 discussed during meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220846 -            140805. ref SDS 29 XF77                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220848 -  ..
220849 - VA Progress Notes meeting on 140805 - addendum continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220850 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220851 -            3.  Discuss training regimen advising not to increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220852 -                distance / pace / time of activity no more than 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220853 -                percent per week.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220855 -                 ..
220856 -            4.  Discussed prophylactic NSAID prior to his long hikes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220858 -  ..
220859 - This sounds like ibuprofen - Motrin, per above. ref SDS 0 XO76                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220861 -  ..
220862 - Need dosage recommendations.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220864 -  ..
220865 - VA Progress Notes meeting on 140805 - addendum continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220866 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220867 -            5.  RTc once he receives his FFO.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220869 -  ..
220870 - This aligns with understandings during the meeting, reported in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220871 - record above. ref SDS 0 1F68                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220873 -  ..
220874 - Few days after the meeting today, received letter from VA scheduling                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220875 - another meeting with Doctor Tang in Podiatry on 140820 1000.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220876 - aligns with understanbings during the meeting today, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220877 - ref SDS 0 NU4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220878 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220879 -            [On 140911 1529 notified VA Podiatry that VA orthotic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220880 -            inserts were received on 140910. ref SDS 36 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220882 -             ..
220883 -            [On 140911 1529 notified VA Podiatry that VA orthotic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220884 -            inserts were received on 140910. ref SDS 36 AK6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220885 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220886 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220888 -  ..
220889 - Radiology Both Feet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220890 - 
220891 - There are 2 reports for left and right foot...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
220892 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220893 -    1.  Left foot...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220894 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220895 -        1.  Procedure/Test Name:          FOOT,LEFT,3 OR MORE VIEWS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220896 -            Date/Time Exam Performed:     05 Aug 2014 @ 1131                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220897 -            Ordering Location:            SAN FRANCISCO VAMC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220898 -            Requesting Provider:          TANG,ROBERT E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220899 -            Reasons for Study:            evaluate for djd                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220901 -             ..
220902 -        2.  Clinical History:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220903 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220904 -            69 y.o. male with HAV / bunion , metatarsalgia mtpj's 2-5 both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220905 -            feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220907 -             ..
220908 -        3.  Performing Location:          SAN FRANCISCO VAMC 4150 CLEMENT STREET, SAN FRANCISCO 94121                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220909 -            Radiologist:                  GRISWOLD,VIRGINIA J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220911 -             ..
220912 -        4.  RADIOLOGY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220914 -             ..
220915 -        5.  Report:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220916 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220917 -            3 views left foot weightbearing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220919 -             ..
220920 -        6.  No Prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220922 -             ..
220923 -        7.  Impression:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220924 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220925 -            1.  High plantar arch.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220927 -                 ..
220928 -            2.  There is a small plantar calcaneal spur and there is a spur                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220929 -                at the Achilles tendon insertion on the posterior margin of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220930 -                the calcaneus.  There is also apposition of new bone along                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220931 -                the posterior and the inferior margin of the calcaneus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220932 -                There is mild induration of the fat deep to the Achilles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
220933 -                tendon, Kager fat pad.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
220935 -                 ..
220936 -            3.  Hallux valgus angulation of the left great toe with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220937 -                degenerative changes of the first metatarsophalangeal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220938 -                joint, the joint space is narrowed and there is sclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220939 -                of the base of the proximal fillings and subchondral cysts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220940 -                on both sides of the joint.  There is mild hammertoe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220941 -                changes of the fourth toe.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220943 -  ..
220944 - May be positive there are no evident "fractures" reported.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
220946 -  ..
220947 - Somehow need explanation of how these conditions relate to normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220948 - changes for design life of human feet.  Is an intervention required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220949 - for standard of care to align feet with good health conditions?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220951 -  ..
220952 - Radiology report continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
220953 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220954 -        8.  Primary Diagnostic Code:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220955 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220957 -         ..
220958 -    2.  Right foot...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220959 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220960 -        1.  Procedure/Test Name:          FOOT,RIGHT,3 OR MORE VIEWS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220961 -            Date/Time Exam Performed:     05 Aug 2014 @ 1131                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220962 -            Ordering Location:            SAN FRANCISCO VAMC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220963 -            Requesting Provider:          TANG,ROBERT E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220964 -            Reasons for Study:            evaluate for djd                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220966 -             ..
220967 -        2.  Clinical History:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220968 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220969 -            69 y.o. male with HAV / bunion , metatarsalgia mtpj's 2-5 both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
220970 -            feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220972 -             ..
220973 -        3.  Performing Location:          SAN FRANCISCO VAMC 4150 CLEMENT STREET, SAN FRANCISCO 94121                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
220974 -            Radiologist:                  GRISWOLD,VIRGINIA J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
220976 -             ..
220977 -        4.  RADIOLOGY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220979 -             ..
220980 -        5.  Report:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220981 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220982 -            4 views right foot weightbearing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220984 -             ..
220985 -        6.  No prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
220987 -             ..
220988 -        7.  Impression:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
220989 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
220990 -            1.  Multiple surgical clips seen on the medial aspect of the ankle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220991 -                region likely related to vascular bypass surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
220993 -                 ..
220994 -            2.  There is a small plantar calcaneal spur and there is a spur at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
220995 -                the Achilles tendon insertion on the posterior margin of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
220996 -                calcaneus. There is also apposition of new bone along the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
220997 -                posterior and the inferior margin of the calcaneus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
220999 -                 ..
221000 -            3.  Hallux valgus of the right great toe with narrowing of the joint                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221001 -                space and irregularity and sclerosis of the head of the first                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
221002 -                metatarsal and base of the proximal phalanx of the great toe.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
221003 -                Prominent styloid process of the fifth metatarsal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
221005 -                 ..
221006 -                Probable small ankle joint effusion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221008 -  ..
221009 - See note above. ref SDS 0 6Y64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
221011 -  ..
221012 - Radiology report continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
221013 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221014 -            4.  Otherwise unremarkable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221016 -                 ..
221017 -            5.  Addendum:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
221019 -                 ..
221020 -            6.  The plantar arch appears high.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
221022 -             ..
221023 -        8.  Primary Diagnostic Code:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
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2211 -