Hi, Don here. Welcome to Podiatry Practice
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practice to the $1,000,000 mark and beyond.
My MVP or the most valuable patient of the day was a patient
with a 70 year old female. She had bilateral plantar
fasciitis. She had bilateral Aquinas and I
went through my treatment sheet. So basically I took my treatment
sheet on plantar fasciitis, showed her my little
presentation of what the fascia would look like and, and things
like that. And she ended up doing bilateral
night splint with a foam rolling and morning stretch.
She's going to get bilateral 6 sessions of shockwave on both
sides. And then I scheduled her for
the, the, the orthotics at the third visit.
So this for me, if I could have this all day long, this would be
a good patient. She was motivated, she was
ready. She had been suffering for a
number of months. She had had plantar fasciitis in
the past that got better and she came back because it came back
in her life. And her fascia was about 7mm, so
it was very thick. There's a lot of effusion around
that in the ultrasound. So I think the things that help
the best in terms of this one, we did the X-ray, it didn't help
that much. Showed her the tightness and
she'd already been familiar with the, the night split in the
past. So she, she actually asked for,
can I have one for each side? And then when I went through the
option, she had done well with the cortisone last time.
But I explained that a lot of times cortisone doesn't work as
well when it's very, very thick. And that's where the, the
shockwave would come is becoming better.
So I, I used my treatment sheet. So if you'd like a copy of
these, some people have been asking me for these, shoot me,
shoot me an e-mail, don@podiatrypracticemastery.com.
I can certainly share, share this with you, hopefully work in
your practice. I, I basically print it out and
I, and I flip it around at a clipboard and I go through and I
just check the boxes with the patients.
And it has the, the most common treatments that I use for most
of the conditions. And I just have a kind of a way
of explaining it. Sometimes I use my patient
presentations. Those are those little
PowerPoints. Once again, if you want those,
just ask as well. The PowerPoints I'm using less
and less these days, or I'm reducing the amount of slides
for them. And then also on these sheets,
there is AQR code from my treatment sheets that goes to a
blog post that really reviews everything for the patient.
So it's kind of their their take home as well.
OK, let's go into the rest of the day.
There was a 58 year old female that got 80% better with a
cortisone injection and the night splint and foam roller.
Since she's feeling so much better, I'm not going to see her
back, but I did remind her that many times the cortisone can
wear off in two to three months. And if that happens, she'll come
back and we'll go to the next phase, which is most likely the
the shockwave for her. And the reason this patient got
cortisone was basically because she's had it in the past and she
wanted it. So she came in requesting for
cortisone. I do not do a lot of a lot of
cortisone. You might see a couple today,
but I don't do a lot. I do more of the, the shockwave.
Next patient was a swift #4 so 59 year old female.
So usually with the last shockwave, which is for me the
6th shockwave, and with the last swift, I'll do an office visit.
So these ones, I've been doing an office visit plus that
procedure. That's why that that's the way I
do it. And then they're going to come
back in three months. Usually with shockwave, they
come back in six weeks. Next patient was a 48 year old
female. She had metatarsalgia and she is
a hiker. And I, I talked to her about
correct toes and anatomic shoes. I find for correct toes because
we do have them in their office. I find that if I modify them for
the patients, it increases their compliance of getting the
correct toes and trying them out.
So what I mean by that is a lot of times if you do correct toes,
they're the same price no matter what.
They're $65. And if you the main correction I
have to do is I have to trim out between the 4th and 5th toes.
There's a kind of it pushes over a little toe too much.
And so that's what that's the most common modification.
Sometimes if patients have short toes, you have to trim them back
a little bit so they can fit on. And so doing that modification
helps the patient, but it also increases compliance of them
getting them on the way out. Next patient was a 38 year old
female. This, I guess would be my lowest
value patient of the day. So this patient had an avulsion
last week and the avulsion was very painful for her.
And so she's been taking like Motrin and Tylenol and she came
in and she came in within the global period.
So meaning there was an office visit.
There was really nothing I could do.
And so I was thinking to myself, how could I, how could I fix
this? I I'd like to make a page on
like A blog post kind of talking about this just to put her at
ease because this is, this could have been done via text message,
could have been done via the phone or even just setting the
expectations that the nail avulsion is going to hurt a lot
for her. But they wanted to come back in
these patients. They're also going to be setting
up for shockwave for her. And I've been having this trend
and maybe it's, I'm the trend versus the patients or the
trend, but she has bilateral plantar fasciitis.
And, and I just find that some patients they just want, feel
like they want a deal. So sometimes if one is worse
than the one other one isn't that bad.
I'll, I'll do full session on one and I'll just do a little
bit on the other one for them. I, I just feel like some people,
they just want to feel like they're, I have this patience
that some just always want a deal.
I can tell you in private who who there's a certain
demographic that are these ones. OK, next one.
This was an MVP patient as well. So this patient, he had both
Epat for his his Achilles tendonitis.
So he's epat #4 he's going on vacation.
So I'm going to see him back in about six weeks.
That's why he only did 4, not 6. But he also did Swift.
So he did Shockwave and Swift. This was swift #2 So he still
has one more Swift in about a month.
And so I'll do the the last one at that time.
He has a number of warts that have been there a long time.
And and so this is kind of this is a good patient if I can more
have more of those. Next patient was 71 year old
female for bilateral foot pain. She had left midfoot arthritis
and she had been seen by another, I think he was a PM and
R doctor that does like pain management.
So she had had PRP around her ankle.
She has a lot of midfoot arthritis on the left side and
she is not, she has orthotics. She is not really wanting
surgery, but she wants to be out of pain.
And I was kind of explaining to her about this midfoot
arthritis, which I think is the cause of it.
And she has the bone marrow edema.
And so I talked to her, probably the best thing for her if she's
not wanting to do an AFO, she's not wanting to do any big
surgical procedures, but she wants to be in less pain and not
wear like a walking boot all the time.
I talked about doing shockwave to help with the bone marrow
edema. So doing focused only shockwave
3 to 6 sessions once a year that can help that bone marrow edema
and help her pain along with the orthotics that she's wearing.
The current orthotics aren't contouring very high to her
arch. And so she, I told her she might
need a newer pair that'll contour a little bit higher to
take some more of the stress up that mid midfoot.
OK. And next patient was a bilateral
insertional Achilles tendonitis. So they did #2 out of 6 for
Shockwave. So they are starting to feel
better. She's, she's pleased with this
number 3. This one was a 50 year old
female with #3 out of 6 for right plantar fasciitis.
And she has a little bit of pain on the left second met head.
So I did a like. So I did, for example, I would
do 1500 on the right plantar fascia and then another 500 on
the left second mad head. I didn't charge for the other
one. And the, I think the bilateral
Achilles, I think I told you, I told, I talked about this last
week, But so this one, I, she has it on both kind of like the
insertional and she only wanted me to do one side and I just
couldn't in good conscience only do one side.
So I'm adding on the second side.
So I might be doing the, the like hurting myself in terms of
financially, things like that, but I'm, I'm still, I want
patients to get better and I just didn't feel comfortable
only doing one if both of them are really hurting her just
because of price. So she's paying for one doesn't
take me much more time. I know there are some doctors
that I've talked to, they just have like a time slot.
And so you do as much as you can in that time slot.
And so, you know, yes, you put a little bit more wear and tear on
the on the machine, but I think it's better for the patient all
around. Next patient was Q Tenza number
six. This gentleman has had six.
He's like the the guy that has the most Q Tenzes in, in my
practice. He is doing well.
He tends to have less pain when he's walking barefoot.
He has he's just feeling better, less pain at night and things
like that. For the Q 10s, I'm still
struggling a little bit with mod Med in terms of billing because
there's some that are buying bill and there's others that we
they get them from the through the pharmacy, the specialty
pharmacy. So I'm still trying to figure
out the different codes to make it easier for my note taking.
I still have to edit, like edit the billing component of that
next patient was a 67 year old that is a thick second toe.
So they had kind of a thickened toenail with a hammer toe, a
second hammer toe causing the thickness and the nails were a
little bit hard to trim. So I, I debrided those
debridement, did the hammertoe kind of office visit and I
recommended Kara nail gel. So I think Kara nail gel works
really well for thickened toenails for patients.
They're maybe not on a call icotic, but they're just
thickened. Next was a patient, 48 year old
female that has left second Med head pain, got X-rays, got an
ultrasound. She thought she needed
orthotics. She thought, well, I need an
orthotic like adjustment for my neuroma.
But really I think she has some type of a over over use injury
on the second metatarsal. I didn't put her in a Cam boot
and I'm going to see her back in a few weeks to see how that
feels. Next patient was a 71 year old
that just had thick second toenails.
Once again divided those. Next was a 76 year old male that
had X-rays. He was post fifth met head
resection. He he'll see one of my
colleagues because I'll be on vacation for the next follow up
for suture removal. He's doing well.
Next was a 70 year old female I talked about in the beginning
for the bilateral plantar fasciitis.
She did the night splint in the bilateral shockwave.
Those will be set up for her. Carrie Flex was done for a 30
year old female. I just did 1 nail for her.
Another patient that came in and also a 55 year old that did
Carrie Flex on 2 nails. I had a interesting patient.
I don't have these that many. This is a 45 year old guy.
He had a superficial white onicomycosis.
So I was able with like a curette just to scrape it off.
And so it didn't really penetrate that deep.
So I recommended him formula seven that we have in the office
for that. And there was another patient
She actually came in she I've been treating her for for with
Kanthorid and her warts She's using, she was using Aldera and
she asked me to prescribe something I've never prescribed
before. Maybe you have, I just haven't.
It's podophyllox, which is I guess a topical porphylin and I
think in my can through that, I think it might have that in
there as well as one of the other ingredients.
But she asked to prescribe. That's why I prescribe that
today for her. I've never done that before.
I'd like to know anyone else use that you find it beneficial
topically for patients? It might be something like we
would typically do in the office, I'm guessing.
So it might be kind of caustic. So I don't know if it'll like
take the place of what I put on like the canther that I put on.
Next patient was a 58 year old female.
She's going to be going on vacation and she had like a
subluxing peroneals. She'd come back after a Cam
wearing a Cam boot. She's going to be doing physical
therapy and if it's not getting better, we're going to do an MRI
and another similar patient. She had a left peroneal pain.
She had previously had plantar fascial pain.
Now she has kind of pain in the peroneals and I did an injection
because she's going that's one's going on vacation.
So I did it right around the peroneal tendon region where
there was an effusion in the in that area on ultrasound.
And then finally, there's a little girl, 21 year old.
She had an this kind of a digiti quini varus, the under lapping
5th toes. She had hiked a lot.
She had one of these calluses. So I trimmed down the calluses
there. She had them on the first met
head or I'm sorry, the IPJ Hallux talked about the anatomy
and I for her, I'm I'm going to recommend the correct toes.
So I modified her correct toes and she's going to try those for
a couple months and I gave her some shoe recommendations.
So that was the day and I'll talk to you until the next one.
I am, if anyone's kind of following me every day, you
might be a little break between some episodes, going on vacation
for a little bit to Brazil, and I'll tell you about that maybe
when I'm on the road. Or I might try to do some other
podcasts about different topics in the interim here.