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:
221024 -
221025 -
221026 -
221027 -
221028 -
221029 -
221030 -
221031 -
221032 -
221033 -
221034 -
221035 -
221036 -
221037 -
221038 -
221039 -
221040 -
2211 -