CONTACTS
SUBJECTS
VA Podiatry Review Metatarsalgia Pain Balls of Feet Enable Physical
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 57 0000. ref SDS 56 0000.
040502 -
040503 -
040504 -
040505 -
040506 - [On 160118 0124 letter to Doctor Stewart VA General
040507 - Surgery, commended Podiatry Doctor Tang and Doctor
040508 - Hewitson for enabling restoration of former maximum
040509 - extended endurance exercise hiking 11 miles under 170
040510 - minutes required for regressing atherosclerosis plaques.
040511 - ref SDS 62 X64K
040513 - ..
040514 - [On 160121 2128 letter to Doctor Tang and Doctor
040515 - Hewitson asking about following up order 5 weeks ago for
040516 - new inserts. ref SDS 63 A26F
040518 - ..
040519 - [On 160202 1540 reported injury to right knee, very
040520 - painful; Doctor Tang recommended not using adjusted
040521 - orthotic inserts, until meeting with Doctor Hewitson in
040522 - Podiatry Biomechanics can evaluate adjustments to avoid
040523 - right knee injury. ref SDS 65 WG59
040525 - ..
040526 - [On 160325 0443 letter to VA notifies Doctor Tang that
040527 - orthotic inserts ordered by Doctor Hewitson on 151215,
040528 - have been received, so meeting can be scheduled for
040529 - Doctor Hewitson to configure the new inserts,
040530 - ref SDS 67 AK6J, as planned by the doctor during the
040531 - prior meeting on 151215. ref SDS 58 HM8J
040532 -
040533 -
040534 -
040536 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - Meeting Doctor Tang in Podiatry on 140805 1030. ref SDS 36 NU4G
040902 - Progress Notes for meeting on 140805, call for return to clinic after
040903 - receiving FFO. ref SDS 36 IJ4G A few days after meeting on 140805,
040904 - received letter from VA scheduling follow meeting today on 140820
040905 - 1000.
040907 - ..
040908 - On 140828 meeting with Doctor Kevin Daun and later with Doctor Mihara,
040909 - attending developed solution to blister on inside of big toe on left
040910 - foot, ref SDS 44 W74O, that required stopping 11 mile hike after 8
040911 - miles and calling for a ride home, shown in case study on 120101 0900.
040912 - ref SDS 9 BO6F
040914 - ..
040915 - On 140904 0900 meeting with Doctor Cynthia Lieu and Doctor Tang,
040916 - attending. ref SDS 47 AK6J Doctor Tang said orthotics can be trimed
040917 - to fit a smaller shoe size, if necessary; he has scheduled a meeting
040918 - after orthotics inserts are received. ref SDS 47 4M3H
040920 - ..
040921 - On 150115 0845 meeting with Doctor Tang and Doctor Goodman, the doctor
040922 - ordered a 2nd set of orthotic inserts to recover from and prevent
040923 - recurrance of metatarsalgia. ref SDS 52 BG6I
040924 -
040925 -
040926 -
040927 -
040929 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Meeting with Doctor Hewitson was scheduled by Doctor Olalemi in
041302 - Podiary on 151117 1609. ref SDS 57 AK6J He clarified work plan
041303 - prepared by Doctor Tang in the meeting the day before on 151113 1130.
041304 - ref SDS 55 TV7K
041306 - ..
041307 - Doctor Hewitson is a biomechanics specialist in Podiatry.
041309 - ..
041310 - He has done Half Dome 50 times, most recently about 5 years ago.
041311 - Seems to be about 50 years old.
041313 - ..
041314 - This was a fun, informative, helpful meeting. The doctor was training
041315 - about 5 residents, so everyone crowded into the examination room.
041316 - There were 2 women. They took notes, and got started entering
041317 - Progress Notes during the meeting.
041318 -
041319 - [On 160121 2128 letter to Doctor Tang and Doctor Hewitson
041320 - transmitting the record for review and comment as needed.
041321 - ref SDS 63 A25U
041323 - ..
041324 - The doctor worked fast and talked faster. Was concerned several times
041325 - that his detailed explanations of disgnostic conditions, and treatment
041326 - recommendations be included in Progress Notes. The staff assured they
041327 - were getting everything down, including arcane, complicated technical
041328 - terms.
041330 - ..
041331 - After the meeting, went to the cafeteria to write up the record. This
041332 - effort revealed several questions on terminology. Coincidentally on
041333 - leaving the cafeteria, encountered what seemed like the entire crew of
041334 - residents who assisted Doctor Hewitson. One, a woman, clarified
041335 - terminology.
041337 - ..
041338 - During the meeting, the doctor made thorough examination of feet,
041339 - ankles, knees and hips.
041341 - ..
041342 - Examination included walking up and down the hallway about 7 yards, in
041343 - the Podiatry Department. Additionally, the doctor placed his hands to
041344 - position patient in order to sense balance and propoer heel pressure.
041346 - ..
041347 - Doctor Hewitson seemed to explain finding...
041348 -
041349 - 1. Left leg shorter than the right leg, because of injury to
041350 - knee in 1973, it is not locking out fully when walking, as
041351 - the right knee does.
041353 - ..
041354 - He characterized patient's gait shows left foot "early lift
041355 - off."
041356 -
041357 - [On 170929 1010 biomechanics review by Mark Wachter, CEO
041358 - On-the-Run, reported normal gait, possibly indicating
041359 - recovery from prior findings on 151215, of early lift
041360 - off on left foot due to long-standing osteoarthritis in
041361 - left knee - indicating recovery with PRP treatment from
041362 - severe injury decades earlier. ref SDS 70 VW50
041364 - ..
041365 - Doctor Hewitson advised that CT scan study of both knees
041366 - and particularly the left knee to appreciate the current
041367 - precise condition is needed to comprehensively prescribe
041368 - care for the feet.
041370 - ..
041371 - He was pleased to learn Orthopedics has ordered CT scan on
041372 - both knees scheduled for tomorrow 151216 1130, to support
041373 - meeting in orthopedics also tomorrw at 1315.
041374 -
041375 - [On 151216 1130 xray studies were performed on left and
041376 - right knee, rather than CT radiology. ref SDS 59 XH9M
041378 - ..
041379 - Doctor Hewitson will review the radiology scan to complete
041380 - diagnosis and work plan in this case.
041382 - ..
041383 - 2. Doctor Hewitson supports using Glucosamine Chondroitin to
041384 - avoid worsening degenerative arthritis in left knee.
041386 - ..
041387 - On 990925, Doctor Boulris in Orthopedics at Kaiser in Walnut Creek
041388 - prescribed/recommended Glucosamine Chondroitin to control pain in left
041389 - knee from degenerative arthritis caused by industrial accident in
041390 - 1973. ref SDS 3 3120
041392 - ..
041393 - On 000124, Doctor Yomamoto, also with Kaiser Orthopedics in Kaiser
041394 - Walnut, was consulted for 2nd opinion. He reported good results from
041395 - personal use taking Glucosamine Chondroitin. ref SDS 4 1680 Patient
041396 - tried Glucosamine Chondroitin, but could not swallow the large pills.
041397 - ref SDS 4 G56N About 5 years later, patient diagnosed with
041398 - constricted swallowing, reported on 050714 1000. ref SDS 6 WE4H This
041399 - malady was later identified as "achalasia," reported on 051202 1430,
041400 - ref SDS 7 5B5K, which explained why swallowing large pills was
041401 - difficult. VA performed Heller Myotomy surgery on 091216, to improve
041402 - swallowing.
041404 - ..
041405 - In the interim, without treatment had to stop playing tennis to avoid
041406 - severe pain to left knee. Concentrated on work which involved sitting
041407 - at a desk 24/7 developing and using the SDS software program for
041408 - management consulting work. Inactivity resulted in CABG x4 on 091022,
041409 - to resolve rising atherosclerosis.
041411 - ..
041412 - In 2003, began hiking Lafayette Reservoir - a 3 mile route with
041413 - continual moderate hills. This was at Millie's request. She was
041414 - diagnosed with IBC (cancer), and her doctor prescribed vigorous
041415 - exercise to maintain WBC for immunity to fight cancer and meet
041416 - criteria for consistent chemotherapy treatments. To facilitate her
041417 - care, joined Millie hiking 1 - 2 laps 3 - 5 times a week (about 80
041418 - miles per month). This was very difficult at first, but eventually
041419 - improved physical conditioning to occassionally do 4 and even 5 laps
041420 - (11 and 14 miles). This effort was not enough to increase HDL 30, and
041421 - so atherosclerosis increased until CABG x4 was performed on 091022.
041422 - However, hiking 80 miles per month did increase atherosclerosis in the
041423 - left knee, causing severe pain, especially going downhill. On 040529,
041424 - knee pain from hiking 80 miles per month was completely resolved, when
041425 - Millie brought home liquid Glucosamine Chondroitin from Costco.
041426 - ref SDS 5 MN9P
041428 - ..
041429 - Hiking increased significantly about 4 years ago to 11 miles per day,
041430 - and in recent months to 15 miles per day. During this 4 year period,
041431 - total hiking reached 10K miles last month, shown by patient history in
041432 - case study on 140101 0600. ref SDS 13 XY4M This occurred with pain
041433 - level 0 in left knee taking Glucosamine Chondroitin liquid before
041434 - starting hikes. Pain does occur on 15 mile hikes in left knee and
041435 - less in right knee. Added 2nd dose of Glucosamine Chondroitin after
041436 - 15 mile hikes. This reduced pain on the longer hikes.
041438 - ..
041439 - It is possible extended endurance hiking the past 4 years, has
041440 - improved moderate degenerative arthritis (osetoarthritis) in left knee
041441 - by wearing down calcium and osterophytes (bone spurs) diagnosed during
041442 - examination in Orthopedics Department at Kaiser in Walnut Creek,
041443 - reported by Doctor Boulris on 990910 1410. ref SDS 2 AV4J ref SDS 2
041444 - AV4J
041445 -
041447 - ..
041448 - 3. Doctor Hewitson advised that injection of hyaluronic acid
041449 - into the left knee joint could provide better solution.
041451 - ..
041452 - Hyaluronic acid injections to recover from degenerative arthritis in
041453 - the left knee were considered among 8 new therapies during meeting at
041454 - Kaiser with Doctor Sylvia Campbell on 990625 0945. ref SDS 1 8966
041455 -
041456 - [...below on 151215 1000 Progress Notes do not seem to
041457 - mention consideration of Hyaluronic acid (Synvisc)
041458 - injections. ref SDS 0 L75O
041460 - ..
041461 - On 990910, record meeting Orthopedics at Kaiser in Walnut Creek
041462 - reports Doctor Boulris recommended against prescribing hyaluronic
041463 - injections with Synvisc for this particular diagnosis of degenerative
041464 - arthritis in the left knee. ref SDS 2 OG61
041465 -
041466 - [On 170123 1530 Eugenia performed injection with Supartz
041467 - (alternate to Synvisc); there was no pain. Procedure was
041468 - simple and fast. ref SDS 68 VG6M
041470 - ..
041471 - [On 160101 0700 reporting hiking on 170125, 48 hours after
041472 - 1st treatment with Supratz; seemed to prevent pain right
041473 - knee on 6 mile hike; hours after hike right knee swelled
041474 - and stiff. ref SDS 61 X17O
041475 -
041476 -
041478 - ..
041479 - Research after the meeting with Doctor Hewitson today, found...
041481 - ..
041482 - What Is Synvisc Injections for Knees?
041483 -
041484 -
041485 - http://hyaluronicacidwiki.com/what-is-synvisc-injections-for-knees/
041486 -
041487 - Synvisc is an injection of hyaluronic acid that is derived
041488 - from the combs of chickens. This material is found
041489 - naturally in the human body and used for many purposes.
041490 - One of its main purposes is keeping all of the joints in
041491 - the body cushioned. The cushioning provided by hyaluronic
041492 - acid helps to cut down on friction when you bend your
041493 - joints, so that movement can occur frequently. Natural
041494 - hyaluronic acid in the body works with the cartilage or
041495 - padding between your joints to serve as natural protection
041496 - for the places where your bones meet.
041498 - ..
041499 - If you have osteoarthritis, the cartilage in your joints
041500 - is breaking down. This means that there is more friction
041501 - occurring when you move your joints, which is why you
041502 - develop stiffness and pain in the area. Synvisc injections
041503 - add extra healthy hyaluronic acid to the affected joints,
041504 - providing more lubrication. This in turn reduces the
041505 - friction when you work your joints and cut down on pain.
041506 -
041508 - ..
041509 - Wikipedia - Sodium hyaluronate injections
041510 -
041511 -
041512 - https://en.wikipedia.org/wiki/Sodium_hyaluronate#Medical_uses
041514 - ..
041515 - Sodium hyaluronate for intra-articular injection is used to
041516 - treat knee pain in patients with osteoarthritis who have
041517 - not received relief from other treatments. It is similar
041518 - to the lubricating fluid that occurs naturally in the
041519 - articular capsule of the knee joint. Once injected into
041520 - the joint capsule, it acts as both a shock absorber and a
041521 - lubricant for the joint.[1][2][3] Thus sodium hyaluronate
041522 - is used as a viscosupplement, administered through a series
041523 - of injections into the knee, increasing the viscosity of
041524 - the synovial fluid, which helps lubricate, cushion and
041525 - reduce pain in the joint.[4] It is generally used as a last
041526 - resort before surgery[5] and provides symptomatic relief,
041527 - by recovering the viscoelasticity of the articular fluid,
041528 - and by stimulating new production from synovial fluid.[6]
041529 - Use of sodium hyaluronate may reduce the need for joint
041530 - replacement.[7] Injections appear to increase in
041531 - effectiveness over the course of four weeks, reaching a
041532 - peak at eight weeks and retaining some effectiveness at six
041533 - months, with greater benefit for osteoarthritis than oral
041534 - analgesics.[8] It may also be effective when used with
041535 - other joints.[9]
041537 - ..
041538 - Mechanism of Action...
041539 -
041540 - Sodium hyaluronate functions as a tissue lubricant and is
041541 - thought to play an important role in modulating the
041542 - interactions between adjacent tissues. Sodium hyaluronate
041543 - is a polysaccharide which is distributed widely in the
041544 - extracellular matrix of connective tissue in man. It forms
041545 - a viscoelastic solution in water which makes it suitable
041546 - for aqueous and vitreous humor in ophthalmic surgery.
041547 - Mechanical protection for tissues (iris, retina) and cell
041548 - layers (corneal, endothelium, and epithelium) are provided
041549 - by the high viscosity of the solution. Elasticity of the
041550 - solution assists in absorbing mechanical stress and
041551 - providing a protective buffer for tissues. This
041552 - viscoelasticity enables maintenance of a deep chamber
041553 - during surgical manipulation since the solution does not
041554 - flow out of the open anterior chamber. In facilitating
041555 - wound healing, it is thought that it acts as a protective
041556 - transport vehicle, taking peptide growth factors and other
041557 - structural proteins to a site of action. It is then
041558 - enzymatically degraded and active proteins are released to
041559 - promote tissue repair.[13] Sodium hyaluronate is being used
041560 - intra-articularly to treat osteoarthritis.
041562 - ..
041563 - In this case, there is no pain in the left knee while hiking 11 miles
041564 - per day and when taking liquid Glucosamine Chondroitin immediately
041565 - before these 3 hour exercise episodes. In past few months hiking 15
041566 - miles per day, and taking Glucosamine Chondroitin immediately prior to
041567 - beginning hikes will sometimes feel thickening in left knee about mile
041568 - 9 or 10, possibly because of 2 additional hills on the extended route.
041569 - This is treated by taking a second dose of Glucosamine Chondroitin
041570 - after the 4 hour hikes.
041572 - ..
041573 - Doctor Hewitson comments continue...
041574 -
041575 - 4. Alternatively, Wenzyme Q, and Glucosamine both available in
041576 - liquid form at Costco are as good or better than
041577 - Glucosamine Chondroitin, and cost less.
041578 -
041580 - ..
041581 - 5. Left heel bone joint has 5% flexibility and should have
041582 - 30%, like right heel. The doctor speculates the left heel
041583 - was injured by the same accident in 1973, but was
041584 - overlooked, because of greater focus on the left knee.
041585 -
041586 - [...below on 151215 1000 review of Doctor Hewitson
041587 - Progress Notes say in part Lesser Dorsiflexion ankle
041588 - joint:5 degrees short of 90 R, 5+ degrees short of 90.
041589 - ref SDS 0 7R8L
041590 -
041592 - ..
041593 - 6. The doctor modified the Prolab orthotic inserts applied
041594 - with Hoka Stinson Lite shoes size 10 worn today, and for
041595 - the purpose of improving routine walking gait.
041597 - ..
041598 - Prolab orthotic inserts were ordered by Doctor Tang during
041599 - the first meeting on 140805. ref SDS 36 1F31 They were
041600 - received on 140910. ref SDS 50 AK6J On 150115 0845 Doctor
041601 - Tang ordered 2nd pair Prolab orthotic inserts, ref SDS 52
041602 - BG6I; they were received on 150207. ref SDS 53 AK6J Today,
041603 - not sure which pair were modified by Doctor Hewitson to
041604 - experiment for providing better support.
041606 - ..
041607 - Observation of further walking tests, and placing the
041608 - doctor's hands on the patient's hips while standing to
041609 - evaluate body alignment, indicated to Doctor Hewitson that
041610 - this initial modification did not correct defect in walking
041611 - gait, so he removed that modification and instead raised
041612 - the heel of the left orthotic.
041613 -
041614 - [On 160202 1540 reported injury to right knee, very
041615 - painful; Doctor Tang recommended not using adjusted
041616 - orthotic inserts, until meeting with Doctor Hewitson in
041617 - Podiatry Biomechanics can evaluate adjustments to avoid
041618 - right knee injury. ref SDS 65 WG59
041620 - ..
041621 - Actual changes to orthotic inserts by observation seem to
041622 - be...
041623 -
041624 - 1. Left orthotic has .25" pad across full width of
041625 - heel.
041626 -
041627 - 2. Right orthotic has .25" pad across half width of
041628 - heel.
041630 - ..
041631 - Observation of further walking tests, and further testing
041632 - body alignment with hands on the patient while standing,
041633 - satisfied Doctor Hewitson this change improved patient
041634 - balance and gait to help prevent further injuries.
041636 - ..
041637 - Modifications to 1 of 2 pair orthotic inserts performed and
041638 - tested today, per above, ref SDS 0 NC7M, seem to slant feet
041639 - causing slight sliding sensation off the side of both
041640 - shoes. This may in turn cause slight horizontal pressure
041641 - on knees. Any additional pressure on the knees will only
041642 - occur every other day, since the 2 pair of inserts are
041643 - rotated every day between 5 pair of Hoka Stinson Lite shoes
041644 - for 11-mile hikes
041645 -
041646 - [On 160202 1540 reported injury to right knee, very
041647 - painful; Doctor Tang recommended not using adjusted
041648 - orthotic inserts, until meeting with Doctor Hewitson in
041649 - Podiatry Biomechanics can evaluate adjustments to avoid
041650 - right knee injury. ref SDS 65 WG59
041652 - ..
041653 - Doctor Hewitson said to bring in the other pair of orthotic
041654 - inserts on the next meeting in Podiatry for adding
041655 - modifications that make both pair the same.
041656 -
041657 - [...below on 151215 1000 Progress Notes explain
041658 - modifications to orthotics - Improved gait by decreasing
041659 - early heel off L, increased L knee extension, and
041660 - decreased R recurvatum. ref SDS 0 ZA9I
041662 - ..
041663 - [On 140101 0600 case study reporting on 151222,
041664 - developed new blister on left side little toe left foot,
041665 - possibly related to changed orthotics. ref SDS 15 IE9O
041666 -
041668 - ..
041669 - 7. Doctor Hewitson and his team made molds to make new
041670 - orthodic inserts. They will be shipped in a few weeks.
041672 - ..
041673 - When new orthotics ordered today, are received, notify VA
041674 - to schedule follow with Doctor Hewitson to review
041675 - effectiveness, and to make modifications as needed, and as
041676 - done today to the existing orthotic inserts ordered
041677 - originally by Doctor Tang on 140805 and received 4 weeks
041678 - later on 140910. 140910 1553, ref SDS 50 AK6J The 2nd set
041679 - of orthotics were ordered on 150115 0845, ref SDS 52 BG6I,
041680 - and received 3 weeks later on 150207 0845. ref SDS 53 AK6J
041681 -
041682 - [...below on 151215 1000 Progress Notes confirm follow
041683 - up meeting will occur after receiving orthotic inserts.
041684 - ref SDS 0 PK6L
041686 - ..
041687 - [...below on 151215 1000 at 1642 received telephone
041688 - message on returning home saying to call Podiatry to
041689 - schedule next meeting; seems conflicting with work plan
041690 - to wait until after receiving new orhotic inserts to
041691 - schedule the next meeting, so that the inserts can be
041692 - evaluated and modified as needed. ref SDS 0 5O4M
041694 - ..
041695 - [On 151218 0813 meeting with clerk in Module 3 found the
041696 - next meeting with Podiatry Biomechanics will occur after
041697 - receiving orthotic inserts, and so the call on 151216,
041698 - was a mistake. ref SDS 60 L66I
041700 - ..
041701 - [On 160121 2128 letter to Doctor Tang and Doctor
041702 - Hewitson asking about following up order 5 weeks ago for
041703 - new inserts. ref SDS 63 A26F
041705 - ..
041706 - [On 160122 1158 letter from Doctor Tang saying he will
041707 - notify Doctor Hewitson to investigate delayed delivery
041708 - of orthotics, ref SDS 64 M16H, which were ordered on
041709 - 151215 1000. ref SDS 0 HM8J
041711 - ..
041712 - [On 160203 1326 received orthotic inserts ordered by
041713 - Doctor Hewitson today. ref SDS 66 GW7M
041715 - ..
041716 - [On 160325 0443 letter to VA notifies Doctor Tang that
041717 - orthotic inserts ordered by Doctor Hewitson on 151215,
041718 - have been received, so meeting can be scheduled for
041719 - Doctor Hewitson to configure the new inserts,
041720 - ref SDS 67 AK6J, as planned by the doctor during the
041721 - prior meeting on 151215. ref SDS 58 HM8J
041723 - ..
041724 - [On 170309 0739 letter from Doctor Tang advises solution
041725 - to current metatarsalgia pain may be to order new
041726 - orthotic inserts. ref SDS 69 RV5L
041728 - ..
041729 - 8. Doctor Hewitson said again to bring 2nd set of orthotic
041730 - Prolab inserts (originally ordered by Doctor Tang on 150115
041731 - and received on 150207, ref SDS 53 AK6J) for the follow up
041732 - meeting, so they can be modified to conform with changes to
041733 - the orthodics performed today during the examination, per
041734 - above. ref SDS 0 9B6I
041735 -
041737 - ..
041738 - 9. Both feet dehydrated - Doctor Hewitson diagnosed dry,
041739 - cracking, peeling, scaly feet (he used a medical term
041740 - possibly...
041742 - ..
041743 - Keratolysis exfoliativa
041744 -
041745 - https://en.wikipedia.org/wiki/Keratolysis_exfoliativa#Causes
041747 - ..
041748 - Wikipedia explains it is characterized by dry skin and
041749 - superficial, air-filled blisters. These blisters can be
041750 - peeled off very easily and will leave reddish, tender
041751 - areas. The loss of this horny layer of the skin, which
041752 - protects the underlying layers, leaves the skin more
041753 - vulnerable to dryness and cracking.
041755 - ..
041756 - Doctor Hewitson recommends solution of 50/50 water and
041757 - vinegar, soak feet twice a week for 20 minutes. Use pumice
041758 - stone to peel off dried skin.
041759 -
041760 - [...below on 151215 1000 Progress Notes show term
041761 - "hyperkeratotic" which may be related to "keratolysis
041762 - exfoliativa" that seems to encompass the feet condition,
041763 - and with instructions to soak feet; there is no evident
041764 - finding nor diagnosis of dehydrated or dry feet reported
041765 - to the doctor today. ref SDS 0 D663
041767 - ..
041768 - [On 140101 0600 case study reporting on 151222, begin
041769 - prescription soak feet twice per week for 20 minutes 50%
041770 - water 50% vinegar. ref SDS 14 IE9O
041772 - ..
041773 - [On 140101 0600 case study reporting on 160103 hike 11
041774 - mile route, feet were best condition in several years.
041775 - ref SDS 15 YRVW
041777 - ..
041778 - [On 160118 0124 letter to Doctor Stewart VA General
041779 - Surgery, commended Podiatry Doctor Tang and Doctor
041780 - Hewitson for enabling restoration of former maximum
041781 - extended endurance exercise hiking 11 miles under 170
041782 - minutes required for regressing atherosclerosis plaques,
041783 - and because feet in best condition in over 2 years.
041785 - ..
041786 - [On 160222 shown in case study on 140101 report soaking
041787 - feet protocol recommended by Doctor Hewitson resulted
041788 - in easily removing severe calluses big toes both feet.
041789 - ref SDS 16 B17I
041791 - ..
041792 - 10. Uric acid to keep moisture in the feet.
041794 - ..
041795 - Thanked the doctor and residents for excellent meeting.
041796 -
041797 -
041798 -
041799 -
041800 -
041802 - ..
0419 -
0420 -
0421 - 1642
0422 -
042201 - There is a message on the landline saying...
042202 -
042203 - VAMCSF Podiatry Clinic called at 1512, and said to call Podiatry
042204 - at 415 379 5673 to schedule a meeting.
042206 - ..
042207 - This notice appears conflicting with Doctor Hewitson work plan for
042208 - scheduling next meeting after receiving new orthotic inserts, which
042209 - the doctor ordered earlier today, per above. ref SDS 0 HM8J
042211 - ..
042212 - This message is shown in Progress Notes, per below. ref SDS 0 GP8F
042213 -
042214 - [On 151218 0813 meeting with clerk in Module 3 found the
042215 - next meeting with Podiatry Biomechanics will occur after
042216 - receiving orthotic inserts, and so the call on 151216, was
042217 - a mistake. ref SDS 60 L66I
042218 -
042219 -
042220 -
0423 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Medical Chart Progress Notes for Podiatry Biomechanics Meeting 151215
050403 - Progress Notes Podiatry Biomechanics Meeting 151215 with Doctor Hewitson
050404 - Doctor Hewitson Progress Notes Podiatry Biomechanics Meeting 151215
050405 -
050406 - Stored Progress Notes are one entry of several files stored on CD
050407 - received from VA on 151218, and includes Podiatry meeting on 151215
050408 - 1000; Doctor Hewitson entered his Progress Notes at 1025...
050409 -
050410 - F:\05\00003\SM\CC\AGMJ\20151215-102500\w0144_welch_12 15 15.pdf
050412 - ..
050413 - Following VA entry has a different format in not starting with Local
050414 - Title heading...
050415 -
050416 - Consult Request
050417 -
050418 - Current PC Provider: OBRIEN,LYNN M
050420 - ..
050421 - Current PC Team: NP RESIDENT MP F3
050422 - Current Pat. Status: Outpatient
050423 - Primary Eligibility: NSC, VA PENSION(VERIFIED)
050424 - Patient Type: NSC VETERAN
050425 - OEF/OIF: NO
050427 - ..
050428 - Order Information
050429 - To Service: PROSTHETICS REQUEST
050430 - From Service: PODIATRY-BIOMECHANICS
050431 - Requesting Provider: HEWITSON,JOSEPH
050433 - ..
050434 - Service is to be rendered on an OUTPATIENT basis
050436 - ..
050437 - Place: Consultant's choice
050438 - Urgency: Routine
050439 - Earliest Appr. Date:
050440 - Orderable Item: PROSTHETICS REQUEST
050441 - Consult: Consult Request
050443 - ..
050444 - Provisional Diagnosis: Pain in unspecified Foot(ICD-10-CM
050445 - M79.673)
050447 - ..
050448 - Reason For Request:
050449 - FFO
050451 - ..
050452 - Medical Justification: Foot pain secondary to metatarsalgia
050453 - b/l
050455 - ..
050456 - Patient has received appropriate training for this device:
050457 - Yes
050459 - ..
050460 - Issuing Instructions:
050461 - [ ] Mail to Veteran CPRS address (Cannot deliver to PO Box
050462 - address)
050463 - [X] Ward/Clinic personnel will pick up to deliver to Veteran
050464 - [ ] Veteran to pick up device (for Prosthetic & Orthotic Lab
050465 - requests only)
050466 - [ ] Delivery locations if other than CPRS address of record
050468 - ..
050469 - Patient Info:
050470 - Patient Weight: 187.9 lb [85.4 kg] (12/11/2015 08:18)
050471 - Patient Heitht: 64.5 in [163.8 cm] (09/23/2015 15:32)
050473 - ..
050474 - Inter-facility Information
050475 - This is not an inter-facility consult request.
050477 - ..
050478 - Status: PENDING
050479 - Last Action: ADDED COMMENT
050481 - ..
050482 - Facility
050483 - Last Action Date/Time/Zone Responsible Person Entered By
050484 - CPRS RELEASED ORDER 12/15/15 10:54 HEWITSON, JOSEPH HEWITSON, JOSEPH
050486 - ..
050487 - ADDED COMMENT 12/18/15 07:59 STEELE,LESLEY STEELE,LESLEY
050489 - ..
050490 - Mr Welch at desk unclear re V/M. Notes state he will RTC after
050491 - inserts are received. He agreed to make an appt when he
050492 - receives the inserts.
050494 - ..
050495 - Note: TIME ZONE is local if not indicated
050496 - No local TIU results or Medicine results available for this
050497 - consult
050498 -
050499 - =========================== END ==============================
050500 -
050502 - ..
050503 - Current PC Provider: OBRIEN,LYNN M
050504 - Current PC Team: NP RESIDENT MP F3
050505 - Current Pat. Status: Outpatient
050506 - Primary Eligibility: NSC, VA PENSION(VERIFIED)
050507 - Patient Type: NSC VETERAN
050508 - OEF/OIF: NO
050510 - ..
050511 - Order Information
050512 - To Service: PODIATRIC SURGERY OUTPT
050513 - From Service: PODIATRY-BIOMECHANICS
050514 - Requesting Provider: HEWITSON,JOSEPH
050516 - ..
050517 - Service is to be rendered on an OUTPATIENT basis
050519 - ..
050520 - Place: Consultant's choice
050521 - Urgency: Routine
050522 - Earliest Appr. Date: Dec 15, 2015
050523 - Orderable Item: PODIATRIC SURGERY OUTPT
050524 - Consult: Consult Request
050526 - ..
050527 - Reason For Request:
050529 - ..
050530 - If this is an emergency consult, please page the Podiatric
050531 - Surgery on call physician. If this is an IN-PATIENT consult,
050532 - please STOP and call the Podiatric Surgery on call physician
050533 - and enter an INPATIENT CONSULT.
050535 - ..
050536 - Consults are appropriate for patients needing podiatric
050537 - evaluation/treatment who have not responded adequately to conservative
050538 - management. CONSULTS SHOULD NOT BE ENTERED FOR PATIENT NEEDING FOLLOW-UP
050539 - FOR A CONDITION TREATED BY PODIATRIC SURGERY WITHIN THE PAST 2 YEARS.
050540 - THESE PATIENTS SHOULD SCHEDULE AN APPOINTMENT BY CONTACTING THE OUTPATIENT
050541 - CLINIC MODULE 3 AT (415) 379-5673.
050543 - ..
050544 - Please refer patients to the appropriate podiatric surgery clinic by
050545 - selecting one of the following locations:
050546 - VASF Medical Center
050548 - ..
050549 - Is patient Diabetic: No
050551 - ..
050552 - Please indicate the reason for your request by selecting one
050553 - of the following options:
050554 - [ ] Routine Foot Care/Nail Care Clinic
050556 - ..
050557 - [ ] Foot Surgery - including structural deformities, bunions,
050558 - hammertoes, boney deformities, soft tissue lesions, surgical debridement,
050559 - reconstructive foot surgery, and/or diabetic limb salvage.
050561 - ..
050562 - [ ] Treatment of acute/chronic conditions of the foot - foot
050563 - pain, trauma, fractures, infection, paronychia, etc.
050565 - ..
050566 - *** [X] Biomechanics evaluation for orthotics, braces, AFO, etc.
050568 - ..
050569 - [ ] Wound care - diabetic neuropathic foot ulcers, infected or
050570 - non-healing foot or lower extremity wounds.
050571 - [ ] Other (please explain):
050573 - ..
050574 - Frequency and Duration of Treatment/Procedure:
050575 -
050576 - ===================================
050578 - ..
050579 - Primary Eligibility:
050580 - NSC, VA PENSION
050582 - ..
050583 - Service Connected for:
050584 - No current Service Connected data found in computer.
050586 - ..
050587 - Inter-facility Information
050588 - This is not an inter-facility consult request.
050590 - ..
050591 - Status: COMPLETE
050592 - Last Action: ADDED COMMENT
050594 - ..
050595 - Facility
050596 - Activity Date/Time/Zone Responsible Person Entered By
050598 - ..
050599 - CPRS RELEASED ORDER 12/15/15 10:25 HEWITSON,JOSEPH HEWITSON,JOSEPH
050600 - PRINTED TO CBA-12 12/15/15 10:25
050601 - COMPLETE/UPDATE 12/15/15 10:54 HEWITSON,JOSEPH HEWITSON,JOSEPH
050602 - Note# 23038117
050604 - ..
050605 - ADDED COMMENT 12/15/15 15:12 GLORIA,CARLOS M GLORIA,CARLOS M
050606 - unable to reach pt. lm to call and make appmt. bio
050608 - ..
050609 - Note: TIME ZONE is local if not indicated
050610 -
050611 - ----------------------------------------------------------
050613 - ..
050614 - LOCAL TITLE: PODIATRY BIOLMECHANICAL CLINIC CONSULT NOTE
050615 - STANDARD TITLE: PODIATRY CONSULT
050616 - DATE OF NOTE: DEC 15, 2015@10:25 ENTRY DATE: DEC 15, 2015@10:25:38
050617 - AUTHOR: HEWITSON,JOSEPH EXP COSIGNER:
050618 - URGENCY: STATUS: COMPLETED
050620 - ..
050621 - The supervising practitioner of record for this patient care
050622 - encounter is Dr Hewitson. A total of 60 minutes were spent
050623 - face to face with the patient and >50% of the time was spend on
050624 - counseling and/or coordination of care. Current medications
050625 - reviewed with patient/caregiver and reconciliation of
050626 - medications related to today's visit completed, including
050627 - non-VA medications and discrepancies, if identified, were
050628 - addressed. Medication changes and the importance of medication
050629 - management were reviewed with the patient/caregiver today based
050630 - on individual needs. Patient/caregiver acknowledged
050631 - understanding of instructions as stated. An updated list of
050632 - reconciled medications has been provided to the
050633 - patient/caregiver.
050634 - S:
050636 - ..
050637 - 70 y/o male presents to clinic complaining of metatarsalgia
050638 - b/l. The patient presented to clinic wearing Hoka shoes with
050639 - FFO. The patient states that he recieved his current orthotics
050640 - in August 2014 from Dr Tang. The patient claims to be very
050641 - active and states that he frequently hikes 10-15 miles. The
050642 - patient has a hx of left knee pain after falling in 1970. The
050643 - patient states that he has undergone multiple left knee
050644 - surgeries and now has DJD. The patient states that he takes
050645 - Ibuprofen and glucosamine chondroitin to help with the pain.
050646 - The patient states that he has recently begun taking CoEnzyme
050647 - Q. The patient states that he will be getting a CT scan of his
050648 - knee in a few days and will be consulting with an orthopedic.
050650 - ..
050651 - DJD seems like "degenerative joint disease" originally diagnosed by
050652 - Doctor Boulris in Orthopedics at Kaiser in Walnut Creek, on 990910
050653 - 1410. ref SDS 2 OE68
050655 - ..
050656 - This summary of patient history is generally correct. Might clarify
050657 - that patient fell 40' into pump station in summer of 1974. Ibuprofen
050658 - only taken to prevent pain from metatarsalgia, begun last year in
050659 - August after Doctor Tang prescribed this solution during meeting on
050660 - 140805. Began taking Glucosamine Chondroitin in liquid form during
050661 - 2004, when Millie found it at Costco. It was originally prescribed by
050662 - Doctor Boulris at Kaiser Orthopedics in September 1999, to relieve
050663 - pain on left knee, diagnosed from xray as severe degenerative
050664 - arthritis. Delay taking Glucosamine Chondroitin occurred because
050665 - could not swallow large pills, due to swallowing problems, later
050666 - diagnosed as achalasia in July 2005 at the VA.
050668 - ..
050669 - Progress Notes continue...
050670 -
050671 - O:
050673 - ..
050674 - -Open Kinetic Chain-
050675 - Greater Functional LLD: R>L
050676 - Lesser Internal Hip ROM: L 15-, R 15+
050677 - Greater Hyperextension/recurvatum knee:None
050678 - Tibial Bowing: present b/l
050679 - Lesser Dorsiflexion ankle joint:5 degrees short of 90 R, 5+
050680 - degrees short of 90
050682 - ..
050683 - This seems to align with understandings on left ankle issues, per
050684 - discussion with Doctor Hewitson, above. ref SDS 0 MG5O
050686 - ..
050687 - Progress Notes continue
050688 -
050689 - L
050691 - ..
050692 - Lesser ROM STJ:5 L, 10+ R
050693 - Calcaneus Compensated/Uncompensated:Uncompensated RF varus
050694 - Retrocalcaneal exostoses: Present b/l
050695 - MTJ/MPJ Spurring:
050696 - Reduction of Supinatus:
050697 - FF Valgus/Varus:
050698 - MPJ ROM:
050699 - PF nodules:
050700 - Flexor stabilization:
050701 - Extensor substitution:
050703 - ..
050704 - -Closed Kinetic Chain (Static)-Performed in current FFO
050705 - Shoulder CW/CCW:CCW
050706 - ASIS Down/forward:R
050707 - PSIS Decanting:L
050708 - Hips CW/CCW:CCW
050709 - Greater genu recurvatum:R>L
050710 - Ski jump early heel-off:
050711 - Ski jump maximally pronated:
050712 - Hubshure greater resistance:
050713 - Bowstringing plantar fascia:
050715 - ..
050716 - -Closed Kinetic Chain (Dynamic)-Performed in current FFO
050717 - Shoulders CW/CCW:
050718 - Hips CW/CCW:CCW
050719 - Anteverted hip:Right
050720 - Greater recurvatum:Recurvatum right, flexed left
050721 - Pronation sooner/longer:
050722 - Abductory twist:
050723 - Flexor stabilization:
050724 - Extensor substitution:
050725 - Propulsive/apropulsive:Early heel off L
050726 - Abduction (toes):
050728 - ..
050729 - -Shoe evaluation-
050730 - -Greater breakdown of the right shoe Size:
050731 - Inverted/everted:
050732 - Greater medial pronatory breakdown:
050733 - FF varus
050735 - ..
050736 - A:
050737 - Foot pain secondary to metatarsalgia b/l Good biomechanical
050738 - effect with orthotic modifications which included 1/4" lift of
050739 - the left and inversion of the right
050741 - ..
050742 - This explaination seems referenced to the design of Prolab orthotic
050743 - inserts.
050745 - ..
050746 - Progress Notes continue...
050747 -
050748 - P:
050749 - -Recommended possible Vitamin C, and glucosamine (without
050750 - chondroitin) supplements
050752 - ..
050753 - Progress Notes seem to omit recommendation to consider Hyaluronic acid
050754 - (Synvisc) injections into the left knee, as per discussion during the
050755 - meeting, above. ref SDS 0 RI6H
050757 - ..
050758 - Progress Notes continue
050759 -
050760 - -Instructed patient to soak feet in 50/50 water vinegar
050761 - solution for 20 minutes twice a week and to scrub
050762 - hyperkeratotic tissue with a pumice stone.
050764 - ..
050765 - Cannot see in Progress Notes finding of dehydrated, dry, cracking feet
050766 - that was reported to the doctor and examined by the doctor during the
050767 - meeting, per above, ref SDS 0 MG6U, and which will be treated by
050768 - soaking feet, as instructed in this section.
050770 - ..
050771 - During the meeting today, Doctor Hewitson recognized dehydration
050772 - causing feet to peel, crack, and bleed. He used a term, possibly
050773 - "Keratolysis exfoliativa" which research may be related to
050774 - "hyperkeratotic" used in this section of Progress Notes, per above.
050775 - ref SDS 0 MG6U
050776 -
050777 - [On 140101 0600 case study reporting on 151222, begin
050778 - prescription soak feet twice per week for 20 minutes 50%
050779 - water 50% vinegar. ref SDS 14 IE9O
050781 - ..
050782 - [On 160118 0124 letter to Doctor Stewart VA General
050783 - Surgery, commended Podiatry Doctor Tang and Doctor
050784 - Hewitson for enabling restoration of former maximum
050785 - extended endurance exercise hiking 11 miles under 170
050786 - minutes required for regressing atherosclerosis plaques.
050787 - ref SDS 62 X64K
050789 - ..
050790 - Progress Notes continue
050791 -
050792 - -Casted for FFO
050793 -
050794 - -Modified current pair of FFO. Improved gait by decreasing
050795 - early heel off L, increased L knee extension, and decreased R
050796 - recurvatum.
050798 - ..
050799 - This aligns with discussions and walking tests performed during the
050800 - meeting, per above. ref SDS 0 9B6I
050801 -
050802 - [On 140101 0600 case study reporting on 151222, after 11
050803 - mile hike, developed new blister on left side little toe
050804 - left foot, possibly related to changed to orthotics.
050805 - ref SDS 15 IE9O Also experience left hip pain during
050806 - hike. ref SDS 13 SZ6H
050808 - ..
050809 - Progress Notes continue
050810 -
050811 - -Patient will RTC when new FFO are ready for pickup.
050813 - ..
050814 - Aligns with work plan presented by the doctor at the end of the
050815 - meeting. Should receive next set of orthotic inserts in 3 - 4 weeks
050816 - based on prior VA practice, per above. ref SDS 0 HM8J
050817 -
050818 - [On 160121 2128 letter to Doctor Tang and Doctor
050819 - Hewitson asking about following up order 5 weeks ago for
050820 - new inserts. ref SDS 63 A26F
050821 -
050822 -
050823 -
050824 - /es/ JOSEPH HEWITSON
050825 - joseph hewitson dpm
050826 - Signed: 12/15/2015 10:54
050827 -
050828 - =========================== END ==============================
050829 -
050830 -
050831 -
050832 -
050833 -
050834 -
050835 -
050836 -
050837 -
050838 -
050839 -
050840 -
0509 -