041498 - ..
041499 - Close up of right foot shows 11 injections...
041500 -
041501 - 
041503 - ..
041504 - Doctor Tucker used prior protocol applying lidocaine cream, then pain
041505 - numbing spray before injecting treatment sites with lidocaine to
041506 - prevent pain injecting PRP blood plasma.
041508 - ..
041509 - Even with these pain management steps, injections into the ball of the
041510 - right foot treating plantar plate areas, and including into the arch
041511 - of the foot were quite painful, possibly because for this 2nd line of
041512 - care, the doctor made deeper injections, and injected greater amounts
041513 - of PRP blood plasma to advance recovery, given that the 1st treatment
041514 - was only partially successful treating plantar plate tear, as set out
041515 - in the record requesting this 2nd phase of care, reported on 170809
041516 - 1739. ref SDS 20 UO79
041518 - ..
041519 - [On 170817 0836 letter to Doctor Tucker asks about possible
041520 - steps to mitigate pain for future, deep injections.
041521 - ref SDS 21 U449
041528 - ..
041529 - Pain was only at moments of needle penetration, similar to Doctor
041530 - Jessica Della Valle, performing debridement of hematoma 2 years ago,
041531 - on lower left leg suffered hiking Half Dome, and reported at VAMCSF on
041532 - 150923 1530. ref SDS 6 QD5K As with Doctor Della Valle, today,
041533 - encouraged Doctor Tucker to continue with understanding patient has
041534 - total confidence in the procedure, and appreciation for the doctor's
041535 - expertise and consideration for patient comfort balancing benefits of
041536 - treatment.
041537 -
041538 - [On 170817 0836 letter to Doctor Tucker confirms patient
041539 - confidence in the doctor's expertise and efforts to
041540 - minimize pain during injection therapy. ref SDS 21 U453
041542 - ..
041543 - Doctor Tucker advised that regeneration injection treatment can be
041544 - performed in a clinical setting with appropriate monitoring equipment
041545 - for 2 technicians to apply sedation that shields patients from any
041546 - pain. This adds several thousand dollars to the cost of care.
041548 - ..
041549 - If another treatment is needed, then might inquire if arrangements can
041550 - be made for Doctor Tucker to do the work at the VA Medical Center in
041551 - San Francisco. VAMCF is the top research facility in the VA system.
041552 - Conscious sedation would be well supported. Orthopedics and Podiatry
041553 - could benefit. In that case, could be admitted for monitoring and
041554 - pain management overnight, or simply stay onsite in Hoptel, and drive
041555 - home the next day.
041556 -
041558 - ..
041559 - Doctor Tucker took extra time today, between right foot injections,
041560 - allowing patient to recover from acute pain instances. She asked
041561 - about objectives of extended endurance exercise hiking long distances
041562 - at age 72. This may have been simply treatment practice to divert
041563 - attention from pain.
041564 -
041566 - ..
041567 - Feet and Knee Care Enables Hiking for Fun and Good Health
041568 -
041569 - There was discussion that healthy feet, knees and hips enable hiking
041570 - long distances that increase HDL and EPCs, reported in research on
041571 - 131125 0005. ref SDS 3 W76M The record in this case shows extended
041572 - hiking 13,000 miles the past 5 years, elevated HDL 30, at time of CABG
041573 - x4 on 091022, to HDL 73. Some authorities say elevated HDL regresses
041574 - plaque in the circulatory system, and elevated EPC's repair stenosis
041575 - that otherwise causes cardovascular failure, also reported on 131125
041576 - 0005. ref SDS 3 6S7F CCTA radiology study on 151019, showing no
041577 - evidence of cardiovascular blockage/stenosis of any kind, ref SDS 7
041578 - SU62, offers evidentiary support that elevated HDL regressed/cured CVD
041579 - plaque disease, thus optimizing blood vessel diameters. Increased
041580 - diameter of blood vessels increases cognition, improves digestion and
041581 - strengthens immunity. Better blood flow increases nutrients and
041582 - ogygen to cells, preventing vascular senescence, thereby extending
041583 - longevity with physical and mental capacity for a life worth living,
041584 - reported in research on 150406 0740. ref SDS 5 4M82 While research
041585 - continues to understand HDL, EPC and longevity correlations, in the
041586 - meantime the potential for hiking to maintain good mental and physical
041587 - health over extended time by elevating HDL and EPCs induces efforts to
041588 - fix feet and knee problems essential for extended hiking.
041589 -
041590 -
041591 -
041593 - ..
041594 - Follow Up Treatments Might be Needed
041595 - Dressing PRP Injections Final Instructions and Payment
041596 -
041597 - Follow up ref SDS 15 S93J.
041598 -
041599 - Doctor wrapped both feet with loose gause bandages. She explained
041600 - this helps hold injected plazma in place.
041602 - ..
041603 - On standing up from the treatment table, there was considerable pain
041604 - at level 8 or so, in the feet where injections were made.
041606 - ..
041607 - At this time Doctor Tucker examined Books Ghost shoes, and new
041608 - orthotic inserts received from the VA on 170725 1636. ref SDS 14 KD8H
041609 - She clarified advice to consider metatarsalgia bar, presented during
041610 - her call on 170727 1747, ref SDS 16 517O, and later cited in a letter
041611 - on 170809 1710 to Doctor Tang in VAMCSF Podiatry, for adding
041612 - metatarsalgia bar to new orthotic inserts. ref SDS 19 DV95 Doctor
041614 - ..
041615 - The doctor explained the metatarsal bar she has in mind would be added
041616 - to the Brooks Ghost shoes by a shoe cobbler, and not to the orthotic
041617 - inserts.
041619 - ..
041620 - After putting on Brooks Ghost shoes with new orthotic inserts designed
041621 - by Doctor Tang at VAMCSF, and received on 170725 1636, ref SDS 14
041622 - KD8H, pain was considerably less at about level 3. Even so, this
041623 - presented issues for driving 50 miles home to Concord on route 37
041624 - during commute traffic.
041626 - ..
041627 - Doctor Tucker cautioned pain will likely increase as pain-suppression
041628 - effects of lidocaine wear off. She proposed prescribing Tramadol to
041629 - manage pain as lidocaine subsides.
041631 - ..
041632 - We discussed challenges driving 50 miles across highway 37, and during
041633 - heavy commute traffic. This drive could take 2 hours before
041634 - opportunity arose to fill a prescription at Long's Drugs or somewhere.
041635 - Actually, VA might provide Tramadol or equal if Doctor Thuillier or
041636 - Doctor Tang would issue a prescription. The immediate problem is how
041637 - to drive for 2 hours in heavy traffic with mounting pain in the
041638 - offing.
041640 - ..
041641 - Doctor Tucker solved the problem by providing 10 Tramadol pills. She
041642 - also provided a cookie to eat with the medication, rather than take it
041643 - on an empty stomach.
041645 - ..
041646 - Thanked Doctor Tucker for great work.
041647 -
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