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: September 9, 2015 00:20 AM Wednesday;
Rod Welch
VA Podiatry letter resolve severe blister big toe left foot prepare for Half Dome on Sep 16.
1...Summary/Objective
2...Blister Left Foot Resolve in Time for Half Dome
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CONTACTS
SUBJECTS
VA Podiatry Review Metatarsalgia Pain Balls of Feet Enable Physical
1303 -
1303 - ..
1304 - Summary/Objective
1305 -
130501 - Follow up ref SDS 47 0000. ref SDS 43 0000.
130502 -
130503 -
130504 -
130505 -
130507 - ..
1306 -
1307 -
1308 - Background
1309 -
130901 - Meeting Doctor Tang in Podiatry on 140805 1030. ref SDS 27 NU4G
130902 - Progress Notes for meeting on 140805, call for return to clinic after
130903 - receiving FFO. ref SDS 27 IJ4G A few days after meeting on 140805,
130904 - received letter from VA scheduling follow meeting today on 140820
130905 - 1000.
130907 - ..
130908 - Wound on left big toe looked infected, and may account for elevated
130909 - WBC 12.8 on recent lab performed at Martinez VA on 140814 1530,
130910 - ref SDS 31 RP4N
130912 - ..
130913 - On 140819 Doctor Sandhu, Primary Care Martinez VA Clinis examined the
130914 - wound and ordered follow up lab. 140819 0800, ref SDS 32 318I
130916 - ..
130917 - On 1408, 140827 follow up lab showed WBC 13.8 increased. ref SDS 34
130918 - RP4N
130920 - ..
130921 - On 140828 meeting with Doctor Kevin Daun and later with Doctor Mihara,
130922 - attending developed solution to blister on inside of big toe on left
130923 - foot, ref SDS 35 W74O, that required stopping 11 mile hike after 8
130924 - miles and calling for a ride home, shown in case study on 120101 0900.
130925 - ref SDS 2 BO6F
130927 - ..
130928 - On 140904 0900 meeting with Doctor Cynthia Lieu and Doctor Tang,
130929 - attending. ref SDS 37 AK6J Doctor Tang said orthotics can be trimed
130930 - to fit a smaller shoe size, if necessary; he has scheduled a meeting
130931 - after orthotics inserts are received. ref SDS 37 4M3H
130933 - ..
130934 - On 140910 1553 receive Prolab orthotic inserts ordered by VA to
130935 - resolve metatarsalgia pain side effects of endurance exercise physical
130936 - activity treatment to lower CVD risk by reression of atherosclerosis.
130937 - ref SDS 39 AK6J
130939 - ..
130940 - On 140911 1529 letter to VA notified Podiatry received Prolab orthotic
130941 - inserts. ref SDS 40 AK6J
130943 - ..
130944 - On 141008 1349 letter to VA submit agenda for meeting on 141009 0900,
130945 - ref SDS 42 AK6J; advised orthotic inserts orderedby VA were not
130946 - received in time for Half Dome, ref SDS 42 ST60; suffered pain that
130947 - prevented reaching top of Half Dome, but likely not related to delay
130948 - receiving VA orthotics. ref SDS 42 ST60 Advise VA Prolab custom
130949 - orthotic inserts significantly reduce metatarsalgia pain compared to
130950 - other measures. Enables hiking up to 3 days in a row; may support
130951 - hiking 300 miles per month, which has proven effective controlling CVD
130952 - risk by reducing atherosclerosis, based on lipid labs. ref SDS 42 ST68
130953 - Switching inserts between shoes causes debilitating injuries.
130954 - ref SDS 42 ST79 Therefore to maintain level of effort, would like to
130955 - order 3 more sets of VA Prolab orthotics so that all 4 pair of Hoka
130956 - Stinson Trail shoes have separate inserts. If there is a cost
130957 - consideration, I can pay for the work. ref SDS 42 ST92
130959 - ..
130960 - On 141009 0900 meeting with Doctor Tang to review progress wearing
130961 - prescribed Prolab orthotic inserts combined with Thorlo socks and
130962 - ibuprofen medication to prevent metatarsalgia side effects hiking 300
130963 - miles per month for treating cardiovascular disease (CVD). ref SDS 43
130964 - W69H Doctor Tang scheduled another meeting on 150113, to order
130965 - another set of Prolab orthotic inserts. ref SDS 43 KE61
130967 - ..
130968 - On 141017 1422 received call from Podiatry Department at the VA
130969 - Medical Center in San Francisco, and was told meeting scheduled with
130970 - Doctor Tang on 150113 0800 has been cancelled and scheduled for 2
130971 - days later on 150115 0845 - did not enter this call in SDS.
130973 - ..
130974 - On 150113 1049 submitted letter to Doctor Tang in Podiatry Department
130975 - at the VA Medical Center in San Francisco, and reporting progress
130976 - recovering from metatarsalgia side effects hiking 300 miles per month
130977 - for recovering from CVD. ref SDS 46 AK6J Presented agenda for next
130978 - meeting on 151015 0845. ref SDS 46 F531
130980 - ..
130981 - On 150115 meeting with Doctor Tang in Podiatry VA Medical Center in
130982 - San Francisco. ref SDS 47 9Y5J
130983 -
130984 -
130985 -
130987 - ..
1310 -
1311 -
1312 - Progress at 0900
1313 -
131301 - Blister Left Foot Resolve in Time for Half Dome
131302 -
131303 - Follow up ref SDS 47 AK6J, ref SDS 43 AK6J.
131304 -
131305 - Sent letter to Doctor Tang in Podiatry with copy to Doctor Rao in
131306 - Medical Practice for Primary Care, and saying...
131307 -
131308 - 1. Subject: Treatment Blister Inside Right Foot
131309 - Date: 2015-09-09 01:09
131315 - ..
131316 - 2. Dear Doctor Tang and Doctor Rao,
131318 - ..
131319 - 3. Following up the letter on 150728, submitting the agenda for
131320 - meeting with Doctor Rao, ref SDS 49 VY6H, there is very good
131321 - news. Only one issue needs medical attention in order to hike
131322 - Half Dome next Wednesday on 150916.
131324 - ..
131325 - 4. The letter on 150728, asked Doctor Rao to examine feet to
131326 - resolve dehydration. ref SDS 49 W894 The next day, Doctor Rao
131327 - made the examination on 150729. Progress Notes do not report
131328 - severe cracked, peeling and bleeding feet due to dehydration
131329 - from excessive urination 20+ times per day, ref SDS 50 299K,
131330 - (see case study on 140101 for condition a week later on 150809
131331 - (see line 104734... ...[reporting continuing symptoms with
131332 - photographs of feet injuries. ref SDS 6 GH3G...]
131334 - ..
131335 - 5. Case study on patient history of daily diet, exercise,
131336 - medication and vitals further shows Atorvastatin and Ezetimibe
131337 - were paused on 150809 in order to stop frequent urination that
131338 - causes dehydration injuries, including to the feet observed by
131339 - Doctor Rao on 150729. Ten days later on 150819, also paused
131340 - Omeprazole, based on patient history showing 80 MG per day also
131341 - contributes to dehydration (see line 105017...
131342 -
131343 - http://www.welchco.com/sd/08/00101/02/14/01/01/060002.HTM#4Q5F
131345 - ..
131346 - 6. After 3 weeks pausing medications resolved dehydration in sufficient degree to continue extended endurance exercise hiking 11 miles per day. That is the good news.
131348 - ..
131349 - 7. There remains a single blister on the inside of the right foot below the big toe (see attached picture taken today). At this time it does not hurt to hike, but the bubble gets bigger everyday. Seems like if I let it go, there will be a big mess in another few days. Training could be paused to allow the blister to resolve with continued decline of dehydration, since both feet are now near normal. However, I need to continue training for Half Dome, and to be ready hiking 18 miles next Wednesday. Even if I stop altogether, will the thing heal by next Wednesday?
131351 - ..
131352 - 8. Can the VA provide a remedy, e.g., cut the blister open to drain, and then somehow bandage the wound sufficiently to heal by next Wednesday? I could probably cut it open as well, but am uncertain how to fashion a bandage. Have used Lambswool the past few months to prevent blisters (see attached pictures). Now that dehydration has subsided, this is no longer needed.
131354 - ..
131355 - 9. Accordingly, please advise if you feel it would be helpful to come into the Medical Center for a solution in time to do Half Dome next week. Any suggestions on personal remedies are greatly appreciated. I appreciate this is an exigent request, which may not be susceptible to immediate attention given other demands on the VA.
131357 - ..
131358 - 10. As always, I remain grateful for outstanding care by the VA medical team.
131360 - ..
131361 - 11. Very best regards,
131363 - ..
131364 - 12. Rod
131365 - ...0144
131366 - 925 849 4745
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131379 -
131381 - ..
131382 - 13. On 2015-07-28 23:17, Rod Welch wrote:
131383 - > Dear Doctor Rao,
131384 - >
131385 - > Thanks for ordering a complete lab, requested in the letter on
131386 - > 150720. Decided not to order NMR lipids this cycle, because
131387 - > injuries prevented doubling out the past 4 days, planned to get
131388 - > the lab numbers in line. Did a double last Thursday, then had to
131389 - > stand down until yesterday. That lap was difficult due to heat
131390 - > and pain level 7-8 the last 4 miles.
131391 - >
131392 - > Earlier today, talked to Doctor Tang from Podiatry in the lunch
131393 - > line at the cafeteria. Explained recurring side effects that
131394 - > have made maintaining treatment difficult for several weeks. He
131395 - > requested a letter setting out scope of injuries. Tomorrow,
131396 - > would like Medical Practice to examine the feet and report in
131397 - > Progress Notes current status.
131398 - >
131399 - > On the plus side have ordered 6 pair of new Hoka shoes keep the
131400 - > feet from sliding side to side that causes and compounds
131401 - > injuries. Doctor Tang mentioned that hiking 2200 miles with 4
131402 - > pair of Hokas is about the limit, so it is time for replacement.
131403 - > You can get a sense of the problem reviewing patient history in
131404 - > case study on 140101, glancing through a few reports...
131405 - >
131406 - > http://www.welchco.com/sd/08/00101/02/14/01/01/060002.HTM#HN5N
131407 - >
131408 - > Also attached is an updated spreadsheet summarizing treatment
131409 - > with endurance exercise correlated to lab results.
131410 - >
131411 - > As you can see, despite reduced treatment due to side effects,
131412 - > the medical team has done outstanding work yielding one of the
131413 - > best labs in patient history with TG 54 and HDL 65. Remain
131414 - > committed to increase HDL above 70 and reduce LDL-P below 700
131415 - > with resolution of side effects so treatment can increase.
131416 - >
131417 - > Look forward to hearing your ideas during the meeting tomorrow on
131418 - > CCTA testing for tolerance to increase PPI rather than undergo
131419 - > surgery to correct fundoplication, discussed with Doctor Stewart
131420 - > in General Surgery on 150623, cited in the letter on 150720
131421 - > (shown below).
131422 - >
131423 - > Next step is recovery then Half Dome on 150616, with the Rim
131424 - > Trail and Mt Diablo hikes to train up.
131425 - >
131426 - > Best,
131427 - >
131428 - > Rod
131429 - >
131430 - > *************************
131431 - >
131432 - >>> Date: 2015-07-20 00:52
131433 - >>> Subject: Lab order for Meeting Jul 29 0830
131434 - >>>
131435 - >>> Rod Welch wrote:
131436 - >>>> Dear Doctor Rao,
131437 - >>>>
131438 - >>>> Thanks for timely action updating the order for Ezetimibe
131439 - >>>> treatment, and synchronizing with Atorvastatin.
131440 - >>>>
131441 - >>>> We have a meeting scheduled in 10 days on 150729. Would like to
131442 - >>>> get a blood draw later this week, Thursday or Friday, so
131443 - >>>> there is
131444 - >>>> time to review results and prepare for meeting. Will order NMR
131445 - >>>> lipids from Labcorp/Liposcience the same day, and submit results
131446 - >>>> OA 150727, with agenda for meeting on the 29th.
131447 - >>>>
131448 - >>>> Several events may influence your care in my case.
131449 - >>>>
131450 - >>>> Primary Care in the Martinez VA Clinic has cancelled 3 meetings,
131451 - >>>> most recently on 150721. There has been no official
131452 - >>>> explanation,
131453 - >>>> but succeeding cancellations the past 4 months may relate to
131454 - >>>> physician health.
131455 - >>>>
131456 - >>>> Accordingly, can you inquire about my switching primary care to
131457 - >>>> your office at the MP Clinic in San Francisco?
131458 - >>>>
131459 - >>>> On a related matter, during a meeting last month on 150623,
131460 - >>>> Doctor Stewart in General Surgery said she supports ordering
131461 - >>>> coronary CT angiography in my case, and defers to "primary."
131462 - >>>> (see Progress Notes at line 360741)...
131463 - >>>>
131464 - >>>> http://www.welchco.com/sd/08/00101/02/15/06/23/130003.HTM#UM4O
131465 - >>>>
131466 - >>>> The meeting with Doctor Stewart was requested to review findings
131467 - >>>> on 140509, by Doctor Lee at the GI Clinic in San Francisco,
131468 - >>>> where
131469 - >>>> Progress Notes report ulceration of LESV and hiatal hernia on
131470 - >>>> 140509, indicating loosening of Dor fundoplication (see Progress
131471 - >>>> Notes beginning line 520702 para 1 and 2...
131472 - >>>>
131473 - >>>> http://www.welchco.com/sd/08/00101/02/14/05/09/090019.HTM#PXXY
131474 - >>>>
131475 - >>>> Photographs taken by Doctor Lee during EGD dilation procedures
131476 - >>>> beginning on 140509 thru most recent procedure on 150421,
131477 - >>>> seem to
131478 - >>>> show fundoplication has changed.
131479 - >>>>
131480 - >>>> Doctor Stewart constructed Dor fundoplication on 091216,
131481 - >>>> intended
131482 - >>>> to prevent acid from washing back into the esophagus after
131483 - >>>> Heller
131484 - >>>> Myotomy surgery that permanently opens LESV to aid swallowing,
131485 - >>>> thus helping to resolve achalasia, as planned in the meeting
131486 - >>>> with
131487 - >>>> Doctor Stewart a few weeks after CABG, which was performed on
131488 - >>>> 091022.
131489 - >>>>
131490 - >>>> At that time, on 091030, Doctor Mark Ratcliff, then Chief of
131491 - >>>> Surgery arranged a meeting with Doctor Stewart to solve
131492 - >>>> achalasia. The cardio thoracic surgery team was concerned
131493 - >>>> better
131494 - >>>> swallowing was essential to heal from heart surgery. Later that
131495 - >>>> day, Doctor Stewart presented experience resolving achalasia
131496 - >>>> with
131497 - >>>> Heller Myotomy surgery and proposed preventing acid from washing
131498 - >>>> back into the esophagus by constructing a "flap," later
131499 - >>>> identified as a "wrap" and more recently Dor fundoplication (see
131500 - >>>> line 044232...
131501 - >>>>
131502 - >>>> http://www.welchco.com/sd/08/00101/02/09/10/30/081036.HTM#OY64
131503 - >>>>
131504 - >>>> Based on best evidence available on 091030, approved Heller
131505 - >>>> Myotomy surgery with Dor fundoplication to prevent ulceration of
131506 - >>>> LESV and hiatal hernia. The work was performed on 091216.
131507 - >>>>
131508 - >>>> At this time, there are 2 solutions to current symptoms. Doctor
131509 - >>>> Stewart feels redoing Dor fundoplication is high risk. She
131510 - >>>> proposes reliance on proton pump inhibitor (PPI) medication, in
131511 - >>>> this case Omeprazole.
131512 - >>>>
131513 - >>>> There is evidence that increasing PPI reduces ulceration of
131514 - >>>> LESV,
131515 - >>>> reported in EGD dilation procedure on 150421.
131516 - >>>>
131517 - >>>> PPI however increases risk of myocardial infarction up to 21%,
131518 - >>>> reported in recent study published last month on 150610, and
131519 - >>>> citing damage to endothelial lining of blood vessels, see review
131520 - >>>> the next day on 150611...
131521 - >>>>
131522 - >>>> http://www.welchco.com/sd/08/00101/02/15/06/11/071336.HTM#ZB4J
131523 - >>>>
131524 - >>>> Since elevated HDL and EPCs repair endothelial linings, reliance
131525 - >>>> on PPI may be well tolerated in this case, where HDL has been
131526 - >>>> elevated the past year or so under your care.
131527 - >>>>
131528 - >>>> Accordingly, coronary CT angiography with calcium score can
131529 - >>>> yield
131530 - >>>> test evidence patient can tolerate continuing and perhaps
131531 - >>>> increasing PPI treatment, as needed to manage symptoms of
131532 - >>>> fundoplication issues reported by Doctor Lee beginning on
131533 - >>>> 140509.
131534 - >>>>
131535 - >>>> Looking forward to meeting next week.
131536 - >>>>
131537 - >>>> Please confirm labs have been ordered.
131538 - >>>>
131539 - >>>> Sincerely,
131540 - >>>>
131541 - >>>> Rod
131542 - >>>> ...0144
131543 - >>>> 925 849 4745
131544 - >>>>
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