CONTACTS
SUBJECTS
VA Podiatry Review Metatarsalgia Pain Balls of Feet Order Custom Ort
1103 -
1103 - ..
1104 - Summary/Objective
1105 -
110501 - Follow up ref SDS 29 0000. ref SDS 28 0000.
110502 -
110503 -
110504 -
110505 -
110506 -
110508 - ..
1106 -
1107 -
1108 - Progress
1109 -
110901 - Testing Standard of Care Evaluate Response to Treatment
110902 - Response to Treatment Testing Standard of Care for Evaluation
110903 - Standard of Care Testing Evaluate Response to Treatment
110904 - Planning EPC and CTA Testing for Regression Atherosclerosis
110905 -
110906 - Follow up ref SDS 29 0082.
110907 -
110908 - Met with Karen in Cardiology on 2nd floor of Building 200.
110910 - ..
110911 - Karen received a copy of the letter to Doctor Tang (with copy to
110912 - Doctor Alba), submitted on 141008 1349. ref SDS 39 AK6J
110914 - ..
110915 - She offered congratulations on hiking Half Dome, despite turning back
110916 - before reaching the top due to feet injuries, reported on 140917 0540,
110917 - ref SDS 38 0001, and cited in the letter to Doctor Tang. ref SDS 39
110918 - ST60 Karen seemed supportive of cardiology patient maintaining
110919 - physical exercise hiking 300+ miles per month with 11 mile daily hikes
110920 - that increase HDL and EPC labs for regression of atherosclerosis, also
110921 - presented in the letter to the VA on 141008, ref SDS 39 ST68, and
110922 - discussed with Karen previously on 140805, ref SDS 29 0082, citing the
110923 - meeting with Doctor Alba on 140519 0800. ref SDS 14 WS4L
110925 - ..
110926 - Karen asked why coronary CTA with calcium score and EPC tests are
110927 - needed to evaluate regression of atherosclerosis? She asked what
110928 - value would be added to diagnosis and treatment from testing coronary
110929 - CTA and calcium score testing?
110931 - ..
110932 - This same question was asked by the doctor in the office next door to
110933 - Karen's last week, when Karen was on vacation during a brief visit to
110934 - the Cardiology Department in conjunction with getting treatment in the
110935 - Podiatry Department on 141009 0900. ref SDS 40 VQ31 Karen's language
110936 - using terms "added value to diagnosis and treatment," were also
110937 - expressed by Doctor Feingold during the meeting on 140519, ref SDS 14
110938 - M16K, and later in Doctor Alba's letter a month later on 140612 1048.
110939 - ref SDS 18 X45G The uniformity of language reflects compliance with
110940 - published policy guidance, rather than reasoned application of
110941 - guidance to particular patient circumstances.
110943 - ..
110944 - We reviewed Karen's comments when we met on 140805, that testing is
110945 - standard of care to assess response to treatment, ref SDS 29 2Y3I,
110946 - shown in analysis of Doctor Alba's letter on 140731 1048, ref SDS 25
110947 - 545J, and citing prior research submitted to the VA on 140626 1652.
110948 - ref SDS 19 MZ33
110950 - ..
110951 - At that time on 140805, Karen planned to continue considering ideas
110952 - and make appropriate inquiries for VA doctors (which are actually
110953 - UCSF) to sign off on ordering EPC and coronary CTA with calcium score,
110954 - which was discussed in the letter to Doctor Alba on 140710 1348.
110955 - ref SDS 14 DX7K
110957 - ..
110958 - History Considering Coronary CTA and EPC Tests
110959 -
110960 - Defer EPC and CTA testing...................... 140731 1048, ref SDS 25 GY4K
110961 - Testing standard of care response to treatment. 140731 1048, ref SDS 25 546K
110962 - VA in loop..................................... 140731 1048, ref SDS 25 545J
110963 - VA again recommend 2nd opinion Doctor Egan..... 140731 1048, ref SDS 25 QU4F
110964 - Doctor Egan did not respond.................... 140731 1048, ref SDS 25 X45G
110965 - Patient requests support Doctor Egan........... 140710 1348, ref SDS 22 DX7K
110966 - VA recommends 2nd opinion from Doctor Egan..... 140703 1938, ref SDS 21 H233
110967 - Request referral for 2nd opinion on CTA........ 140626 1652, ref SDS 19 MY51
110968 - No grounds refuse CTA assess atherosclerosis... 140626 1652, ref SDS 19 MZ33
110969 - CTA for CABG common assess atherosclerosis..... 140626 1652, ref SDS 19 MZ54
110970 - VA no grounds failure order CTA assess plaques. 140612 1048, ref SDS 18 Y68L
110971 - Follow up on ordering CTA atherosclerosis...... 140610 0903, ref SDS 17 LJ61
110972 - Request CTA assess atherosclerosis plaques..... 140529 0942, ref SDS 16 QG38
110973 - Justification coronary CTA order............... 140520 0732, ref SDS 15 VQ48
110974 - Request EPC lab predicate to CTA............... 140515 2043, ref SDS 13 YM61
110975 - Original research on........................... 131125 0005, ref SDS 6 N73K
110977 - ..
110978 - Today, we recalled again meeting with Doctor Shunk in Karen's office
110979 - on 131121. At that time, we discussed testing for regression of
110980 - atherosclerosis. ref SDS 5 MS7G Doctor Shunk cautioned against doing
110981 - an invasive procedure, like the angiogram study, ref SDS 5 8D6N, which
110982 - he performed on 091021, ref SDS 1 7L43, and which then led to CABG +4
110983 - the next day, performed by Doctor Tseng, and her team on 091022.
110984 - ref SDS 2 PQWU
110986 - ..
110987 - Karen asked why coronary CTA with calcium score and EPC tests are
110988 - needed to evaluate regression of atherosclerosis?
110990 - ..
110991 - Explained testing can show treatment has caused regression of
110992 - atherosclerosis hiking 300 miles per month for 6 months up until end
110993 - of June...
110995 - ..
110996 - Mileage 2014
110997 -
110998 - 130902....Aug................. 297 4916 ...... ref SDS 3 554N
110999 - 130929....Sep................. 225 4305 ...... ref SDS 3 419J
111000 - 131103....Oct................. 373 5757 ...... ref SDS 3 6F9N
111001 - 131201....Nov................. 172 2899 ...... ref SDS 3 XRPV
111002 - 131229....Dec................. 234 3324 ...... ref SDS 3 XXQY
111003 - 140202....Jan................. 347 5393 ...... ref SDS 3 YWST
111004 - 140302....Feb................. 234 3681 ...... ref SDS 3 PYWS
111005 - 140330....Mar................. 207 3313 ...... ref SDS 3 RXPR
111006 - 140427....Apr................. 310 4402 ...... ref SDS 3 RXVV
111007 - 140601....May................. 322 5338 ...... ref SDS 3 SXWV
111008 - 140629....Jun................. 156 2337 ...... ref SDS 3 ZW4N
111009 - 140803....Jul................. 81 1023 ...... ref SDS 3 I37G
111010 - 140831....Aug................. 140 1998 ...... ref SDS 3 236I
111011 - 140928....Sep................. 136 2855 ...... ref SDS 3 XWUY
111013 - ..
111014 - Karen observed that cardiology urges patients to maintain physical
111015 - activity walking 20 miles per week, about 80 miles per month. She
111016 - made a joke that hiking 300 miles per month may reflect mere masculine
111017 - impulse. She feels that regardless of patient motivations, walking
111018 - and running are innately healthy, noted as well by research on 131125
111019 - 0005. ref SDS 6 8X4N
111021 - ..
111022 - Karen recalled tests show extended endurance training hiking 300 miles
111023 - per month over the past year has significantly improved patient lipid
111024 - profile, shown in labs on 140514 0950. ref SDS 12 W25L
111026 - ..
111027 - Mentioned research on 131125, also indicates extended endurance
111028 - exercise, e.g., hiking 300 miles per month, induces regression of
111029 - atherosclerosis, which reduces CVD risk. ref SDS 6 XY7L However,
111030 - besides favorable response to treatment, hiking 300 miles per month
111031 - also caused significant side effects, reported to Doctor Alba in the
111032 - meeting at the VA on 140519 0800. ref SDS 14 CC8O
111034 - ..
111035 - At that time on 140519, the VA medical team considered that if
111036 - coronary CTA calcium score testing show significant regression of
111037 - atherosclerosis has occurred, in the same way lipid labs have
111038 - dramatically improved, then this evidence of response to treatment
111039 - could allow treatment to be reduced as no longer necessary at the
111040 - current level. Reducing treatment would reduce severe adverse side
111041 - effects. ref SDS 14 635O
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