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