CONTACTS
SUBJECTS
VA Podiatry Review Metatarsalgia Pain Balls of Feet Enable Physical
1303 -
1303 - ..
1304 - Summary/Objective
1305 -
130501 - Follow up ref SDS 35 0000. ref SDS 33 0000.
130502 -
130503 -
130504 -
130505 -
130506 -
130507 -
130509 - ..
1306 -
1307 -
1308 - Background
1309 -
130901 - Meeting Doctor Tang in Podiatry on 140805 1030. ref SDS 25 NU4G
130902 - Progress Notes for meeting on 140805, call for return to clinic after
130903 - receiving FFO. ref SDS 25 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 29 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 30 318I
130916 - ..
130917 - On 1408, 140827 follow up lab showed WBC 13.8 increased. ref SDS 32
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 33 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 35 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 35 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 37 AK6J
130939 - ..
130940 - On 140911 1529 letter to VA notified Podiatry received Prolab orthotic
130941 - inserts. ref SDS 38 AK6J
130943 - ..
130944 - On 141008 1349 letter to VA submit agenda for meeting on 141009 0900,
130945 - ref SDS 40 AK6J; advised orthotic inserts orderedby VA were not
130946 - received in time for Half Dome, ref SDS 40 ST60; suffered pain that
130947 - prevented reaching top of Half Dome, but likely not related to delay
130948 - receiving VA orthotics. ref SDS 40 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 40 ST68
130953 - Switching inserts between shoes causes debilitating injuries.
130954 - ref SDS 40 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 40 ST92
130958 -
130959 -
130961 - ..
1310 -
1311 -
1312 - 0547
1313 -
131301 - Arrive VA working in ER ground floor, next to ER.
131302 -
131303 -
131305 - ..
1314 -
1315 -
1316 - 0641
1317 -
131701 - Move to Cafateria that opens 0645.
131702 -
131703 - Ordered breakfast...cost $7.06.
131705 - ..
131706 - Posting expense ledger...
131707 -
131710 -
131711 -
131713 - ..
1318 -
1319 -
1320 - 0823
1321 -
132101 - Check in at Module 3...
132102 -
132103 - After checking in for 0900 meeting in Podiatry walked to 2nd floor in
132104 - Building 300, to see Karen in Cardiology, and follow up discussion
132105 - last month on 140805 1030. ref SDS 25 0082
132107 - ..
132108 - Karen is on vacation. There were 2 doctors conversing in an adjacent
132109 - office - one sitting behind his desk, and another dressed in scrubs
132110 - was standing and leaning against the wall immediately in front of the
132111 - desk. Paused briefly, at the doorway. In about 30 seconds, their
132112 - conversation ended, and the doctor standing left the room.
132114 - ..
132115 - Asked the other doctor about ordering a coronary CTA with calcium
132116 - score to test for regression of athersclerosis to evaluate response to
132117 - treatment hiking 300+ miles per month over the past year?
132119 - ..
132120 - The doctor was immediately evasive and defensive in tone and
132121 - appearance, certainly reluctant to engage the issue. This may only
132122 - have reflected not having enough time to think, rushing to get things
132123 - done on hectic schedule.
132125 - ..
132126 - He seemed to say that coronary CT angiogram radiology with calcium
132127 - score can measure the diamter of arteries, but not plaques.
132129 - ..
132130 - Began discussion of well known "Tim Russert" cardiology case reported
132131 - on 131125 0005. ref SDS 4 N73K The doctor said he did not have time
132132 - for discussion, but proposed that performing coronary CTA testing with
132133 - calcium score is not necessary because results do not add value to
132134 - diagnosis and treatment.
132136 - ..
132137 - We chatted briefly as he left his office and started walking down the
132138 - hall. He referred the issue to the attending cardiologist, and did
132139 - not offer authority that testing response to treatment, in this case
132140 - physical activity with extended exercise hiking 300+ miles per week,
132141 - is not standard of care for adjusting treatment in time to be
132142 - effective.
132144 - ..
132145 - The proposition presented today in VA cardiology that standard of care
132146 - testing response to treatment does not add value to diagnosis and
132147 - treatment, is nearly identical to discussions with the VA on 140519.
132148 - 140519 0800, ref SDS 10 SY5G
132150 - ..
132151 - Since the doctor was walking down the hall to his assignment, could
132152 - not correlate reluctance at VA Medical Center in San Francisco to test
132153 - for response to treatment, with research showing that testing with
132154 - coronary CTA and calcium score is standard of care for CABG patients,
132155 - presented in the letter to Doctor Alba on 140626 1652. ref SDS 15 MZ54
132156 -
132157 -
132159 - ..
1322 -
1323 -
1324 - 0837
1325 -
132501 - Returned to Module 3 and waited to be called into Podiatry.
132502 -
132503 -
132505 - ..
1326 -
1327 -
1328 - 0853
1329 -
132901 - Called into Podiatry.
132902 -
132903 - Waited for 20 minutes. Saw Doctor Tang walking through the area. He
132904 - said the letter was received and reviewed, which was sent yesterday
132905 - 141008 1349, ref SDS 40 AK6J, so he is prepared for the meeting.
132906 -
132908 - ..
1330 -
1331 -
1332 - 0918
1333 -
133301 - Doctor Tang finished with current customer, and another patient
133302 - entered his office.
133304 - ..
133305 - Receptionist said the doctor may be available for meeting in about 20
133306 - minutes or so.
133308 - ..
133309 - Returned to ER in order to continue work. Receptionist will notify
133310 - when the Doctor is ready for the meeting.
133312 - ..
133313 - While waiting in the ER, asked the receptionist to see Doctor Duan for
133314 - just 1 minute to say thanks for good care on 140828 0833. ref SDS 33
133315 - W74O
133317 - ..
133318 - At that time on 140828, Doctor Duan proposed a bandaging scheme to
133319 - prevent further injury and pain hiking with blister on inside of left
133320 - big toe. ref SDS 33 WA3J
133321 -
133322 -
133323 -
133324 -
133325 -
133327 - ..
1334 -
1335 -
1336 - Progress at 0938
1337 -
133701 - Podiatry Meeting Review Metatarsalgia Orthotic Inserts
133702 -
133703 - Follow up ref SDS 35 AK6J, ref SDS 25 HF6H.
133704 -
133705 - Meeting with Doctor Robert Tang and Priya Patel
133707 - ..
133708 - Doctor Tang advised that he reviewed the letter submitted yesterday
133709 - with the agenda for the meeting today, shown on 141008 1349.
133710 - ref SDS 40 AK6J
133712 - ..
133713 - Issues for meeting...
133714 -
133715 - 1. Orthotic inserts ordered on 140805 size 9, ref SDS 25 1F31,
133716 - presented in the letter to the VA on 140806 1753.
133717 - ref SDS 26 XF77
133718 -
133719 - Prolab inserts were received on 140910, reported to the VA
133720 - in a letter the next day on 140911 (see below). ref SDS 38
133721 - AK6J The letter to the VA yesterday reported VA Prolab
133722 - orthotics significantly reduce metatarsalgia pain compared
133723 - to other measures. ref SDS 40 ST68 On some 11 mile hikes
133724 - there is pain level 0 for nearly the entire route or at
133725 - most pain level 3 for a mile or so, which is easily
133726 - tolerated, especially since the feet now recover well
133727 - overnight, as they did in the past. This enables hiking up
133728 - to 3 days in a row. This level of support may get us close
133729 - to 300 miles per month, which has proven effective
133730 - controlling CVD risk by reducing atherosclerosis, based on
133731 - lipid labs, reported on 140514 (see line 760677.
133732 - ref SDS 8 W25L
133734 - ..
133735 - Doctor Tang removed the Prolab orthotic inserts from the Hoka size 9.5
133736 - shoes worn for the meeting today. He placed them in the Adidas
133737 - Response Cushion shoes size 9 shoes, also brought to the meeting to
133738 - verify the inserts will fit all of the 15 or so size 9 shoes in
133739 - inventory, cited during the meeting on 140805 1030. ref SDS 25 1F65
133741 - ..
133742 - Doctor Tang advised that the Prolab orthotics inserts fit the size 9
133743 - shoes without making any adjustments. This resolves the issue
133744 - discussed during meeting with Doctor Tang on 140904 0900. ref SDS 35
133745 - 4M3H
133747 - ..
133748 - 2. Adjustments causing pain level 5 frequency and degree on
133749 - left foot, compared to right foot usually pain level 0,
133750 - but at most 3.,
133752 - ..
133753 - On some hikes pain level varies between feet from 0 - 3 on
133754 - right foot and 0 - 5 on left foot, and switches between
133755 - feet over course of 11 miles, illustrated by recent hike
133756 - this past Tuesday on 1401008, in case study on 120101 0900,
133757 - ref SDS 2 GQ4G, and per following extract saying...
133759 - ..
133760 - Wore 2nd pair Hoka Stinson Trail shoes with VA Prolab
133761 - orthotic inserts, and Thorlo wool silk socks... to prevent
133762 - metatarsalgia pain and to avoid blisters over 11 mile hike.
133763 - Test failed - starting hike pain level 3 both left and
133764 - right feet until about .3 miles, then dropped to pain 0.
133765 - Over entire route left foot pain rose to 3 then dropped to
133766 - 0; but, pain switched to right foot, then switched back to
133767 - left, similar to hike on 140926, per above. ref SDS 0 UR4K
133768 - There was a stretch of perhaps 5 miles with pain level 0
133769 - both feet. At times pain concentrated in middle 2
133770 - metatarsals, but generally subsided within a few hundred
133771 - feet. Pain occurred more often in left foot, which aligns
133772 - with recent patient history of right foot much less
133773 - frequently painful than left foot. Thus, metatarsalgia was
133774 - less controlled today after a days rest, than has occurred
133775 - in recent weeks hiking 2 - 3 days in a row, e.g., on
133776 - 141003, per above. ref SDS 2 JV6M
133778 - ..
133779 - Doctor Tang asked about differences between use of the left leg/foot
133780 - and right leg/foot during hiking and running?
133782 - ..
133783 - We reviwed the larger right leg muscle that has persisted since left
133784 - knee surgery OA 1973, and follow up surgery in 1988. In the 1970s,
133785 - protocol for knee surgery was to remove cartilage and the knee was
133786 - placed in a cast for 6 weeks or so. This caused the left leg muscle
133787 - to atrophy. Since then have not been able to rebuild the left leg
133788 - muscle.
133790 - ..
133791 - On daily 11 mile hikes have been trying to emphasize the left leg to
133792 - rebuild the muscle. In particular, about 30% of the route requires
133793 - walking on concrete sidewalks, rather than the softer asphalt of
133794 - street pavement. Over the past 2 years, have adopted the practice of
133795 - using sidewalk construction joints about 4' apart as guidelines for
133796 - emphasizing the left leg.
133798 - ..
133799 - Today, Doctor Tang recommended not consciously favoring the left leg.
133800 - He feels this may help relieve increased metatarsalgia pain levels in
133801 - the left foot.
133802 -
133804 - ..
133805 - 3. Sore big toe left foot, treated in ER on 140828 0833.
133806 - ref SDS 33 WS3H Hiking Half Dome had to turn back before
133807 - reaching top despite applying bandage, reported on 140917
133808 - 0540. ref SDS 39 U342
133810 - ..
133811 - Doctor Tang said that the VA can treat the blistered tissue similar to
133812 - prior work in the ER, to relieve further pain, as occurred hiking Half
133813 - Dome on on recent hike Tuesday, 141007, shown in case study on 120101
133814 - 0900. ref SDS 2 GQ4G
133816 - ..
133817 - Pryia used a scapal to cut away crusted skin that has not healed well,
133818 - this continued and hopefully completed prior work in the ER on 140828
133819 - 0833. ref SDS 33 WS3H
133820 -
133821 - [On 141021 1411 VA was able to provide additional care in
133822 - Podiatry to further resolve blister problems that got
133823 - progressively worse as hiking increased following
133824 - recovery from metatasalgia. ref SDS 41 DR9G
133826 - ..
133827 - [On 151113 1130 meeting Doctor Tang in Podiatry
133828 - Department; examination shows Geri-Hydrolac 12 (Ammonium
133829 - Lactate 12%), and Burt's Bees foot lotion recommended in
133830 - Cardiology Department not completely successful
133831 - preventing blisters on big toes both feet caused by
133832 - dehydration due to frequent urination caused by
133833 - Omeprazole (PPI) 20 mg and statin treatments with
133834 - Avorstatin 10 mg and Ezetimibe 10 mg taken daily.
133835 - ref SDS 42 AW6H
133836 -
133838 - ..
133839 - 4. Review imlementation of Doctor Tang's prescription to
133840 - reduce hiking presented during the meeting at VA on 140805
133841 - 1030, ref SDS 25 1E65, and discussed in the letter
133842 - yesterday on goals for endurance training to level that
133843 - reduces atherosclerosis, shown on 141008 1349. ref SDS 40
133844 - ST68
133846 - ..
133847 - Mileage 2014
133848 -
133849 - 130902....Aug................. 297 4916 ...... ref SDS 2 554N
133850 - 130929....Sep................. 225 4305 ...... ref SDS 2 419J
133851 - 131103....Oct................. 373 5757 ...... ref SDS 2 6F9N
133852 - 131201....Nov................. 172 2899 ...... ref SDS 2 XRPV
133853 - 131229....Dec................. 234 3324 ...... ref SDS 2 XXQY
133854 - 140202....Jan................. 347 5393 ...... ref SDS 2 YWST
133855 - 140302....Feb................. 234 3681 ...... ref SDS 2 PYWS
133856 - 140330....Mar................. 207 3313 ...... ref SDS 2 RXPR
133857 - 140427....Apr................. 310 4402 ...... ref SDS 2 RXVV
133858 - 140601....May................. 322 5338 ...... ref SDS 2 SXWV
133859 - 140629....Jun................. 156 2337 ...... ref SDS 2 ZW4N
133860 - 140803....Jul................. 81 1023 ...... ref SDS 2 I37G
133861 - 140831....Aug................. 140 1998 ...... ref SDS 2 236I
133862 - 140928....Sep................. 136 2855 ...... ref SDS 2 XWUY
133864 - ..
133865 - During the meeting today, Doctor Tang indicated reduced hiking shown
133866 - in Jul, Aug, and Sep aligns with prescription for recovering from
133867 - metatarsalgia presented during the meeting on 140805 1030. ref SDS 25
133868 - 1E65
133870 - ..
133871 - 5. Order 3 more Prolab custom orthotic inserts presented in
133872 - the letter to Doctor Tang yesterday on 141008 1349.
133873 - ref SDS 40 ST92
133875 - ..
133876 - Doctor Tang scheduled follow up meeting on 150113, to order another
133877 - set of Prolab orthotic inserts.
133878 -
133879 -
133880 -
133881 -
133882 -
133883 -
133884 -
133885 -
133886 -
133887 -
133888 -
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1339 -