THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: October 20, 2006 04:40 PM Friday;
Millie meeting at Kaiser evaluate treatment plan IBC relapse.
2...Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
3...7 Agenda Issues Overwhelm Case Management Too Complex to Remember
4...Complex Patient History 7 Agenda Issues Overwhelms Case Management
5...Patient History Complex Case Study Needs Careful Review Avoid Mistakes
6...Risk Mangement Complex Patient History Needs Adding Energy for Order
7...Case Study Complexity Patient Hisotry Requires Energy Maintain Order
8...Complex Patient History Tracking 32 Issues
9...Vitals Show Stable Medical Condition
10...CA 15-3 Cancer Marker 56 Rises Slightly from Prior Test on 060928
11...CA 15-3 56 Cancer Marker Test Tomorrow Influence Treatment Decision
12...Esophagitis Not Compared in Current PET Test with Prior Report
13...Left Axillary No Evidence Lymphadenopathy CT Testing 060930
14...Lymphedema Left Arm Lump Complications Cellulitus Hospitalized
15...Cellulitus Hospitalized Lymphedema Left Arm Lump Complications
16...Post Operation Localized Edema Left Axillary Swelling Cellulitus
17...Right Axillary FDG SUV 2.5 Lump Discomfort Not Reported by Patient
18...Left Supraclavicular Examination PET Test Report Finding SUV 4.5
19...Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
20...Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
21...Red Rash Stable Left Breast Slow Response to Treatment
22...Examination Left Breast IBC Inflammation Red Rash Seems to Stable
23...IBC Inflammation Left Breast Red Rash Stable Slow Response Treatment
24...Response to Treatment Slow IBC Inflammation Left Breast Red Rash Stable
25...Distant Metastasis No Evidence Imaging Tests Conflicts Rising CA 15-3
26...Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
27...Slow Response to Treatment Mastectomy Removed Blood Vessels
28...Expectations Recovery Rate Tempered by Mastectomy Surgery
29...Mastectomy Removes Blood Vessels Slows Rate Recovery IBC Relapse
30...Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
31...Biopsy to Determine Biology of IBC and Guide Choice of Treatment
32...Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
33...CT Test 060930 Findings Pulmonary Emboli No Evidence Distant Metastasis
34...Distant Metastasis No Evidence PE Positive Findings CT Test 060930
35...Pulmonary Emboli Findings Distant Metastasis No Evidence CT Test 060930
36...Emotional Trauma Rising Falling Cancer Symptoms
37...Exercise Vigor Strength Engagement Ease Distress Living with Cancer
38...Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
39...Pool Chemotherapy Drugs Available to Treat IBC
40...Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
41...Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
42...Treatment 5th Cycle Continue Taxotere and Capecitabine (Xeloda)
43...5th Cycle Taxotere and Capecitabine (Xeloda) Treatment Continue
44...Taxotere and Capecitabine (Xeloda) 5th-Cycle Treatment Continue
45...Schedule Treatment Continue Prescription Taxotere Capecitabine Xeloda
46...Fatigue Shortness Breath Normal Activity Pulmonary Emboli Symptoms
47...Coumadin Treatment Pulmonary Emboli Symptoms Less Severe Continue
48...Pulmonary Emboli Symptoms Continue Less Severe Coumadin Treatment
49...Comparison CT Test 060930 with Test 041103 Original Diagnosis
50...Notification Patient Medications Coumadin Balance with Xeloda
51...Patient Medications Coumadin Balance with Xeloda Notification
52...Coumadin Balance with Capecitabine (Xeloda) Patient Medications
53...CT Tests for Pulmonary Emboli Different from CT Tests for Cancer
54...Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
55...Heart Disorder Enlarged Right Ventricle Cor Pulmonale How Serious
56...Cor Pulmonale: Heart Disorder From Pulmonary Hypertension How Serious
57...Clincial Examination Stethoscope No Findings Enlarged Right Ventricle
58...Coagulapathy Report Family Genetic Disposition Pulmonary Emboli
59...Hypercoabulable State Work Up Risk Assessment Treatment Guidance
60...Work Plan Received Communications Doctor/Patient Partnership
61...Communications Doctor Submits Work Plan Doctor/Patient Partnership
62...Doctor/Patient Partnership Communications Doctor Submits Work Plan
63...Patient Correspondence No Record Document Management in Medical Chart
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1...Millie asked how serious is her pulmonary emobli condition, and cited
2...Millie asked that Kaiser submit actual measurements? Is the right
3...Kaiser's team care practice may support review by a heart specialist
Meeting Doctor Examination 5th Review Prepare for Treatment #5 After
1903 - ..
1904 - Summary/Objective
190501 - Follow up ref SDS F1 0000. ref SDS E7 0000.
190503 - CA 15-3 increased slightly over the past 3 weeks, ref SDS 0 GJ5M; may
190504 - conflict with CT test on 060930 showing no evidence of metestatic
190505 - disease. ref SDS 0 NG6N Examination found stable, possibly rising IBC
190506 - on left breast. ref SDS 0 XO5L UCSF 2nd opinion discusses verifying
190507 - IBC relapse with measureable disease to participate in drug trials.
190508 - ref SDS 0 CR4O Biopsy to verify IBC was not scheduled. ref SDS 0 KT7J
190509 - The doctor feels complex patient history can be simplified by tracking
190510 - fewer issues. ref SDS 0 MO4K Emotional trauma rises from mounting
190511 - issues and challenges of complex patient history. ref SDS 0 Y642
190512 - Symptoms of pulmonary embolism may be less severe after treatment with
190513 - Coumadin resumed on 061002 following CT test diagnosis of recurrence.
190514 - ref SDS 0 CV5L Failure of the Kaiser computer system to notify team
190515 - care elements of medications changes 3 weeks ago, was corrected today
190516 - by the patient telling the pharmacist, and the pharmacist telling the
190517 - Coagulation Treatment Clinic. ref SDS 0 YQ7L The doctor's list of
190518 - current medications, however, still requires correction. ref SDS 0
190519 - SE86 Disclosure today that CT tests for pulmonary embolism require a
190520 - different order by the doctor from CT tests for cancer, explains why
190521 - tests did not find the problem in 2004, and again this year.
190522 - ref SDS 0 S56G The doctor learned from the patient today that CT test
190523 - on 060930 found heart disorder of enlarged right ventricle, and
190524 - advised that the severity of the problem cannot be obtained from
190525 - Kaiser's analysts. ref SDS 0 VJ4J Research indicates the disorder is
190526 - called Cor Pulmonale. The doctor feels that Millie's symptoms are not
190527 - yet severe. ref SDS 0 ZD9N Examination with stethoscope aligns with
190528 - research on assessing this type of problem, and did not find severe
190529 - symptoms. ref SDS 0 PC6H The doctor received the wrong documents for
190530 - studying Millie's hypercoagulable state for genetic risk of pulmonary
190531 - emboli. The patient is following up for Kaiser to review the scope of
190532 - the problem. ref SDS 0 626L Progress continues strengthening
190533 - communications for doctor patient partnership. ref SDS 0 FE4I
190540 - ..
1908 - Progress
190901 - Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
190903 - Follow up ref SDS F1 SM6M, ref SDS E7 SM6M.
190905 - This is the 5th review meeting to begin the 13th overall, and 5th
190906 - chemotherapy cycle following start of treatments on 060711 for the 3rd
190907 - relapse of IBC. ref SDS C6 SM6M The doctor had a hectic schedule
190908 - today, and was 30 minutes late.
190910 - ..
190911 - Millie submitted ref DIT 1 0001 to the doctor with an agenda to guide
190912 - discussions, ref DIT 1 GF5N, and provided background to support the
190913 - doctor in preparing for the meeting. Prior to starting the meeting,
190914 - Millie listed the agenda on the marking board...
190916 - [On 061110 doctor worked from agenda transferred into
190917 - Kaiser's electronic Medical Chart, so Millie does not write
190918 - the list on the marking board. ref SDS H0 K84N
190920 - 1. CA 15-3 review seems favorable................. ref SDS 0 GJ5M
190921 - 2. Lymphedema worse due to broken finger.......... ref SDS 0 MW8J
190922 - 3. CT test scope for PE LR Axillary............... ref SDS 0 EY5O
190923 - 4. Breast exam IBC biopsy measurable disease...... ref SDS 0 025H
190924 - 5. Treatment plan strategy........................ ref SDS 0 K36G
190925 - 6. Doctor Benz 2nd Opinion trials................. ref SDS 0 KT7J
190926 - 7. Pulmonary emboli how serious................... ref SDS 0 CV5L
190927 - 8. Coumadin dose balance with Xeloda.............. ref SDS 0 YQ7L
190928 - 9. Coagulopathy report family member.............. ref SDS 0 626L
190929 - 10. Hypercoagulable state work up.................. ref SDS 0 ES3X
190931 - ..
190932 - During the meeting, the doctor displayed the agenda submitted with
190933 - Millie's letter on the computer in the examination room. He had used
190934 - Windows XP cut and paste tools to transfer the list from Millie's
190935 - letter into Kaiser's electronic Medical chart. The doctor's notes in
190936 - the Medical Chart list only 7 items of the agenda. ref SDS 0 684G He
190937 - used this list to guide discussions. During the meeting three issues
190938 - were added to reflect lung and hear disorders discovered by recent
190939 - testing. Review on 061012 shows the CT test on 060930 diagnosed
190940 - recurrent pulmonary embolism and a new issue of enlarged right
190941 - ventricle. ref SDS 0 NG6I This change in patient profile requires
190942 - coordination of treatments for cancer. ref SDS 0 YQ7L Therefore the
190943 - original list of 7 issues expanded to 10, as shown. ref SDS 0 NO6O
190945 - ..
190946 - Kaiser's progress using computers to strengthen speed and accuracy of
190947 - communications for better meeting productivity is discussed further
190948 - below. ref SDS 0 FE4I
190950 - ..
190951 - Scheduled next meeting in about 5 weeks after cycle 14 of treatment.
190952 - OA November 10, 2006
Patient History Agenda 7 Issues Too Many Makes Case Management Compl
470401 - ..
470402 - 7 Agenda Issues Overwhelm Case Management Too Complex to Remember
470403 - Complex Patient History 7 Agenda Issues Overwhelms Case Management
470405 - The doctor commented that the agenda listing 7 issues for the meeting
470406 - today makes communication too complex. ref SDS 0 684G He seemed to
470407 - say that half this number simplifies remembering critical details for
470408 - case management covering patient history the past 5 years. The
470409 - doctor's progress notes for the examination today list 4 issues...
470411 - ..
470412 - 11. PE: [Physical Examination]
470414 - 1. CVS: S1, S2 RR
470415 - 2. Chest wall: decreasing lesions on lower chest wall
470416 - 3. Lung: Clear to A & P
470417 - 4. Ext: decreased LUE edema
470419 - ...shown below. ref SDS 0 ZL5W
470421 - ..
470422 - While the meaning of this scope requires professional training and
470423 - experience, there appears to be significant difference in scope with
470424 - the agenda provided under the doctor/patient partnership model, per
470425 - above. ref SDS 0 NO6O
470427 - [On 070105 doctor frustrated that multiple issues are hard to
470428 - manage; describes focusing on immediate problems rather than
470429 - spending time on issues that are irrelevant to the current
470430 - context. ref SDS H5 794K
470432 - ..
470433 - [On 090529 1751 health care doctors confused by complex
470434 - documentation not maintained in a "well ordered" record.
470435 - ref SDS J5 C25M
470437 - ..
470438 - Review on 990303 shows research by Professor Miller at Harvard found
470439 - that people can manage from memory at most 7 subjects, and beyond 3
470440 - subjects become increasingly overwhelmed by limited span attention
470441 - causing errors to rise, ref SDS 3 5328, unless issues are written down
470442 - and tracked with traceability to original sources, as called out in
470443 - management standards reviewed on 950721. ref SDS 1 1740
470446 - ..
470447 - Patient History Complex Case Study Needs Careful Review Avoid Mistakes
470448 - Risk Mangement Complex Patient History Needs Adding Energy for Order
470449 - Case Study Complexity Patient Hisotry Requires Energy Maintain Order
470451 - Doctors contributing to Millie's care have uniformly noted patient
470452 - history presents many issues in a very complex case...
470454 - 1. Primary Care Physician.............. 020628, ref SDS 13 QB7H
470456 - ..
470457 - 2. Primary Care Physician.............. 020726, ref SDS 16 MO37
470459 - ..
470460 - 3. Surgeon............................. 040429, ref SDS 37 9H7M
470462 - ..
470463 - 4. Primary Care Physician.............. 040517, ref SDS 39 4Q65
470465 - ..
470466 - 5. Doctor Benz......................... 041018, ref SDS 49 QU6F
470468 - ..
470469 - 6. Doctor Kaufman...................... 041104, ref SDS 50 Q59K
470471 - ..
470472 - 7. Primary Care Physician.............. 041130, ref SDS 52 WL9M
470474 - ..
470475 - 8. Surgeon............................. 050324, ref SDS 61 WH5L
470477 - ..
470478 - 9. Doctor Shim......................... 050907, ref SDS 78 AE5P
470480 - ..
470481 - 10. Surgeon............................. 050923, ref SDS 85 NT9G
470483 - ..
470484 - 11. Surgeon............................. 051027, ref SDS 93 HC3L
470486 - ..
470487 - 12. Doctor Grissom...................... 060802, ref SDS D6 IT8P
470489 - ..
470490 - 13. Doctor Benz......................... 060821, ref SDS E6 YK6N
470492 - ..
470493 - 14. Medical issues grow from 32 to
470494 - 45 expanding complexity............. 070525, ref SDS H8 LU3J
470496 - ..
470497 - 15. Kaiser referral for treatment at
470498 - UCSF very complicated............... 070130, ref SDS H7 2X6L
470500 - ..
470501 - 16. Patient has 45 medical issues on
470502 - record of examination at
470503 - Kaiser.............................. 070525, ref SDS H8 LU3J
470505 - ..
470506 - 17. UCSF account manager Bob Schwartz
470507 - noted billing process in this
470508 - case is very
470509 - complex............................. 070823, ref SDS H9 RV6U
470511 - ..
470512 - 18. Kaiser Member Services - billings
470513 - for referral to clinical trial
470514 - complicated by patient history
470515 - and coordination between
470516 - Kaiser, Medicare
470517 - and UCSF............................ 070829, ref SDS I0 RA85
470519 - ..
470520 - 19. UCSF billing impossible for anyone
470521 - to understand correlations with
470522 - services performed
470523 - that justify
470524 - payment............................. 070830, ref SDS I1 U96G
470526 - ..
470527 - 20. Clinical trial director UCSF discloses
470528 - that billing procedures are "muddy"
470529 - very complex........................ 070906, ref SDS I2 I49K
470531 - ..
470532 - 21. Doctor asks how Millie is coping with
470533 - emotional trauma of complexity resolving
470534 - dispute between Kaiser and UCSF for
470535 - payment of care on referral
470536 - by Kaiser to
470537 - UCSF................................ 070921, ref SDS I3 QY9V
470539 - ..
470540 - 22. Doctor orders treatment with pills
470541 - to relieve anxiety and mental health
470542 - referral to cope with emotional trauma
470543 - from Kaiser failure to perform payment
470544 - duty for cancer patient on referral to
470545 - UCSF for essential
470546 - treatment........................... 070921, ref SDS I3 QY45
470548 - ..
470549 - 23. Mental Health Department therapyst
470550 - coping with emotional trauma Millie's
470551 - complex issues very
470552 - difficult........................... 070926, ref SDS I4 QY5I
470554 - ..
470555 - 24. Kaiser failure to pay for Millie's
470556 - treatment at UCSF on clinical trial
470557 - prescribed by the doctor presents
470558 - 16 issues of complex
470559 - analysis............................ 070927, ref SDS I5 WU6M
470561 - ..
470562 - 25. CMS Medicare Kaiser contract manager
470563 - advises Kaiser's failure to pay
470564 - for prescribed treatment presents
470565 - complex issues of law, regulation,
470566 - and health care public
470567 - policy.............................. 071003, ref SDS I6 BZ40
470569 - ..
470570 - 26. Paula with Kaiser's Medical case
470571 - resolution center reported Millie's
470572 - case is very complex and so hard
470573 - to understand....................... 071006, ref SDS I7 EX8K
470575 - ..
470576 - 27. Financial engineering UCSF billing
470577 - irregularities create confusing
470578 - complexity to prevent discovery of
470579 - conflicts with agreement Kaiser
470580 - would pay for treatment on
470581 - referral to UCSF a year
470582 - earlier............................. 071006, ref SDS I7 454M
470584 - ..
470585 - 28. Billings from UCSF increase to $20K per
470586 - annum from another business unit no
470587 - explanation of total charges nor
470588 - correlation with costs paid by clinical
470589 - trial and Kaiser promised a year
470590 - earlier............................. 071006, ref SDS I7 PRWW
470592 - ..
470593 - 29. UCSF customer account representative
470594 - overwhelmed by complexity of problems
470595 - in Millie's case cannot cope with
470596 - emotional trauma communicating; asks
470597 - Kaiser to notify patient not to notify
470598 - UCSF of efforts solving problems
470599 - so that Kaiser can
470600 - send payment to
470601 - UCSF................................ 071009, ref SDS I8 X65I
470603 - ..
470604 - 30. Kaiser representative overwhelmed by
470605 - emotional trauma cannot cope with
470606 - complexity of Millie's case driven
470607 - to misrepresent billing dispute as
470608 - sensitive medical conditions invokes
470609 - HIPPA regulations to prevent protecting
470610 - enfeebled patient from emotionally
470611 - traumatic threats and harrassment
470612 - as Kaiser and UCSF try to solve
470613 - differences........................ 071009, ref SDS I8 JW7M
470615 - ..
470616 - 31. Complex referral coordination confuses
470617 - patient UCSF says blood tests paid for
470618 - clinical trial, but invoices say payment
470619 - denied; patient forced to get lab work
470620 - done at Kaiser to assist Kaiser with
470621 - cost containment, which caused
470622 - confusion at UCSF interpreting
470623 - results at Kaiser for
470624 - treatment at
470625 - UCSF............................... 071024, ref SDS I9 EP5W
470627 - ..
470628 - 32. UCSF Billing irregularities overwhelm
470629 - patient with conflicting confusion to
470630 - extract payment without correlation
470631 - to services in order to cope with
470632 - emotional trauma................... 071026, ref SDS J0 UW5J
470634 - ..
470635 - 33. UCSF emotional demand for payment
470636 - within 1 week to cope with complex
470637 - claim for medical services which
470638 - nobody understands; refuses to
470639 - meet and explain justification
470640 - for charges that conflict
470641 - with patient
470642 - history............................ 071026, ref SDS J0 SU5V
470644 - ..
470645 - 34. UCSF increases emotional trauma
470646 - threatens fragile cancer patient with
470647 - emotional harrassment of collection
470648 - agency action for charges
470649 - that nobody can
470650 - justify............................ 071031, ref SDS J1 P753
470652 - ..
470653 - 35. UCSF increases emotional trauma for
470654 - patient threatens termination fo essential
470655 - treatment because patient is easier
470656 - target for collection than experiencing
470657 - emotional trauma of justifying charges
470658 - and recovery from Kaiser for
470659 - referral........................... 071031, ref SDS J1 PSSQ
470661 - ..
470662 - 36. Patient emotional trauma rises conflicting
470663 - Kaiser report doctor make a "mistake"
470664 - referring Millie to UCSF for treatment
470665 - that has proven effective and following
470666 - pattern and practice of paying for
470667 - effective treatment on clinical trials
470668 - which aligns with EOC contract provisions
470669 - because Kaiser wants to transfer 100% of
470670 - cost for care to others by prescribing
470671 - treatment on clinical trial and
470672 - calling it a self-
470673 - referral........................... 071204, ref SDS J2 TH8L
470675 - ..
470676 - UCSF requests help finding UCSF planning
470677 - for treating Millie's cancer as a chronic
470678 - disease; explains Millie's patient
470679 - profile too complex takes a lot
470680 - time to find critical
470681 - details............................ 090121, ref SDS J3 Y67L
470682 - patient assembles list of UCSF
470683 - treatment planns................... 090121, ref SDS J3 EV53
470685 - ..
470686 - 37. Millie's case more complex than when
470687 - Doctor Benz reviewed the record at UCSF
470688 - on 060821, prevents proactive planning
470689 - for strategy to treat cancer as chronic
470690 - disease in time to be effective
470691 - after hyperthermia
470692 - treatment.......................... 090204, ref SDS J4 278T
470694 - ..
470695 - 38. Complex patient history very confusing
470696 - to primary care physician; difficulty
470697 - creating a well ordered record transforms
470698 - confusing complexity into
470699 - misleading case
470700 - management......................... 090529, ref SDS J5 SZ9J
470702 - ..
470703 - 39. Primary care physician confuses "chemotherapy"
470704 - rejected by patient, with patient request for
470705 - therapy "targeted" to cancer; patient forced
470706 - to enter Hospice to avoid pain of chemotherapy
470707 - defers meeting with doctor until Kaiser
470708 - determines entitlement to standard of
470709 - care recovering from cancer spreading
470710 - caused by UCSF medical mistakes and
470711 - using "targeted" agents that are
470712 - more effective and do not cause
470713 - pain and suffering caused by
470714 - chemotherapy.................... 100630, ref SDS J6 036C
470717 - ..
470718 - Complexity theory reviewed on 040312, ref SDS 31 1D6I, requires adding
470719 - energy for order and structure to discover patterns in Millie's
470720 - patient history listed on 050812 and leading to mastectomy,
470721 - ref SDS 74 6L4M, and for the current period post surgery treating IBC
470722 - relapse, listed in the record on 060722. ref SDS D2 QG5L Accurate
470723 - order, structure, and pattern make complexity predictable to aid
470724 - diagnosis and treatment. When order degrades, entropy increases.
470725 - Complexity becomes a crushing liabilty that overwhelms span of
470726 - attention, as set out on 040312 reviewing the locality principle that
470727 - guides transformation of information into the power of knowledge for
470728 - controlling the future. ref SDS 31 W46M
Complex Patient History 32 Issues Overwhelms Span of Attention Drive
480401 - ..
480402 - Complex Patient History Tracking 32 Issues
480404 - Sampling of issues patient history diagnosis and treatment...
480406 - 1. CA 15-3 monitors advance of cancer response to treatment
480407 - 2. Lymphedema complicated by mastectomy surgery
480408 - 3. Broken finger from minor fall complicates lymphedema
480409 - 4. Esophagitis reflux digestion issues
480410 - 5. Immune system chemotherapy increases risk of infection
480411 - 6. Chemotherapy increase risk of infection
480412 - 7. Cat bites increase risk of infection complicates lymphedema
480413 - 8. Pneumonia chemotherapy increases risk of infection
480414 - 9. Metastatic cancer increases risk pulmonary embolism
480415 - 10. Lymphadenopathy left axilla local regional metastasis
480416 - 11. Lymphadenopathy right axilla distant metastasis
480417 - 12. Lymphadenopathy left supraclavicular diagnose metastatic cancer
480418 - 13. Mastectomy surgery impact on cancer treatment and lymphedema
480419 - 14. Breast cancer secondary IBC 3rd relapse
480420 - 15. Cancer mutates slow response chemotherapy treatment
480421 - 16. Blood vessels removed mastectomy slow chemotherapy treatments
480422 - 17. Treatment options, strategy, planning, schedule
480423 - 18. Drug trials increase declining pool chemotherapy agents
480424 - 19. UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
480425 - 20. Pulmonary embolism blood clots in lungs
480426 - 21. INR weekly adjustments Coumadin treatment blood clots
480427 - 22. Enlarged right ventricle heart problem core pulmonale
480428 - 23. Dizziness symptom enlarged right ventricle cor pulmonale
480429 - 24. Fatigue shortness breath side effect chemotheapy loss fitness
480430 - 25. Fatigue shortness breath symptom pulmonary embolism
480431 - 26. Shortness breath fatigue dizzy symptoms pulmonary embolism
480432 - 27. Coagulapathy hypercoagulable state work up genetic risks
480433 - 28. Testing resolution of errors (see Benz 2nd opinions)
480434 - 29. Testing distant metastatic disease
480435 - 30. Testing resolution pulmonary emoblism and heart disease
480436 - 31. Communication hectic schedule not enough time to manage details
480437 - 32. Emotional stress and well being
Vitals Obtain from Infusion Clinic Progress Note Meeting Doctor John
500401 - ..
500402 - Vitals Show Stable Medical Condition
500404 - Follow up ref SDS F1 KB5L, ref SDS E7 KB5L.
500406 - ..
500407 - Bld Prssr Pulse Temp Weight SaO2
500408 - ..
500409 - 061020................. 140 79 67 99.8 151 97
500410 - 060929................. 141 78 66 98.3
500411 - 060825................. 139 79 73 98.1
500412 - 060711................. 172 87 54 97.5 147
500413 - 060623................. 141 87 71 98.0 147 99%
500414 - 060428................. 129 73 80 99.4 149 99%
500415 - 060217................. 153 81 61 98.6 150 99%
500417 - ...per Doctor's report, shown below, vitals were obtained from work by
500418 - the Infusion Clinic giving treatment today. ref SDS 0 JQ4J
CA 15-3 56 Rise Slightly from 51 Reverse 2 Months Decline Indicates
600401 - ..
600402 - CA 15-3 Cancer Marker 56 Rises Slightly from Prior Test on 060928
600404 - Follow up ref SDS F1 087J, ref SDS E7 087J.
600406 - The test yesterday shows CA 15-3 cancer marker at 51 has ticked up
600407 - slightly the past 3 weeks during cycle 4...
600409 - ..
600410 - Test Date Date Received
600411 - 061019......... 56 H............. 061020, ref SDS 0 087J
600412 - 060928......... 51 H............. 060929, ref SDS F1 087J
600413 - 060907......... 68 H............. 060929, ref SDS F1 087J
600414 - 060813......... 73 H............. 060817, ref SDS E5 U24M
600415 - 060809......... 87 H............. 060810, ref SDS E3 2N5J
600416 - 060708......... 71 H............. 060711, ref SDS C6 087J
600417 - 060616......... 63 H............. 060623, ref SDS C4 UQ5Q
600418 - 060522......... 59 H............. 060605, ref SDS B9 UQ5Q
600419 - 060501......... 49 H............. 060522, ref SDS B6 MC4F
600420 - 060421......... 44 H............. 060428, ref SDS A8 087J
600421 - 060330......... 40 H............. 060428, ref SDS A8 087J
600422 - 060303......... 36............... 060428, ref SDS A8 087J
600423 - 060210......... 33............... 060217, ref SDS 98 087J
600424 - 060109......... 34............... 060126, ref SDS 97 KV59
600425 - 051223......... 34............... 060106, ref SDS 96 087J
600426 - 051202......... 28............... 060106, ref SDS 96 087J
600427 - 051116......... 31............... 051121, ref SDS 94 087J
600428 - 051109......... 30............... 051121, ref SDS 94 087J
600429 - 051102......... 34............... 051121, ref SDS 94 087J
600430 - 050909......... 45 H............. 051007, ref SDS 87 087J
600431 - 050826......... 45 H............. 050913, ref SDS 81 087J
600432 - 050819......... 45 H............. 050913, ref SDS 81 087J
600433 - 050812......... 39 .............. 050819, ref SDS 74 3K6L
600434 - 050729......... 45 H............. 050819, ref SDS 74 EA5G
600435 - 050708......... 46 H............. 050729, ref SDS 73 087J
600436 - 050701......... 37 .............. 050729, ref SDS 73 087J
600437 - 050617......... 45 H............. 050729, ref SDS 73 087J
600438 - 050527......... 56 H............. 050610, ref SDS 70 087J
600439 - 050512......... 67 H............. 050520, ref SDS 68 087J
600440 - 050506......... 80 H............. 050520, ref SDS 68 087J
600441 - ..
600442 - 050415.........105 H............. 050422, ref SDS 65 087J
600443 - 050325.........100 H............. 050329, ref SDS 63 087J
600444 - 050318.........101 H............. 050325, ref SDS 62 2N5J
600445 - 050304......... 88 H............. 050311, ref SDS 59 087J
600446 - 050225......... 95 H............. 050308, ref SDS 58 0001
600447 - 050211......... 78 H............. 050214, ref SDS 57 02BB
600448 - 050128......... 67 H............. 050204, ref SDS 56 087J
600449 - 041228......... 56 H............. 041230, ref SDS 55 087J
600450 - 041204......... 43 H............. 041210, ref SDS 54 087J
600451 - 041007......... 39............... 041104, ref SDS 50 087J
600452 - 040923......... 49 H............. 041005, ref SDS 48 087J
600453 - 040908......... 44 H............. 040909, ref SDS 47 087J
600454 - 040825......... 47 H............. 040909, ref SDS 47 087J
600455 - 040811......... 42 H............. 040812, ref SDS 46 087J
600456 - 040728......... 43 H............. 040729, ref SDS 44 2N5J
600457 - 040712......... 47 H............. 040713, ref SDS 43 087J
600458 - 040614......... 55 H............. 040615, ref SDS 42 PX6X
600459 - 040517......... 78 H............. 040601, ref SDS 40 2N5J
600460 - 040311......... 70 H............. 040318, ref SDS 32 SM6M
600461 - 040205......... 60 H............. 040211, ref SDS 29 SM6M
600462 - 031201......... 62 H............. 031205, ref SDS 28 SM6M
600463 - 030912......... 66 H............. 030915, ref SDS 27 SM6M
600464 - 030708......... 68 H............. 030710, ref SDS 26 SM6M
600465 - 030503......... 54 H............. 030508, ref SDS 24 SM6M
600466 - 030403......... 45 H............. 030508, ref SDS 24 SM6M
600467 - 030215......... 46 H............. 030220, ref SDS 23 5E6L
600468 - 030106......... 37 H............. 030109, ref SDS 22 SM6M
600469 - 021202......... 41 H?............ 021204, ref SDS 21 SP5G
600470 - 021111......... 36 H?............ 021113, ref SDS 20 Y65I
600471 - 021023......... 33 H?............ 021023, ref SDS 19 SQ5I
600472 - 020930......... 33 H?..39........ 021002, ref SDS 18 SQ5I
600473 - 020917......... 36 H?............ 020924, ref SDS 17 SQ5I
600474 - 020717......... 59 H?............ 020726, ref SDS 16 YN5K
600475 - 020629......... 75 H ............ 020705, ref SDS 14 UX6I
600476 - 020608........ 67 H ............ 020614, ref SDS 12 0001
600477 - 020603........ 108 H ............ 020607, ref SDS 11 X67F
600478 - 020511........ 117 H ............ 020603, ref SDS 10 PJ4J
600479 - 020419......... 81 H ............ 020430, ref SDS 8 7N5H
600480 - 020321......... 85 H ............ 020405, ref SDS 7 6T8K
600486 - ..
6007 - Analysis
600801 - CA 15-3 56 Cancer Marker Test Tomorrow Influence Treatment Decision
600803 - Follow up ref SDS F1 GJ5M, ref SDS E7 GJ5M.
600805 - Slight rise of CA 15-3 cancer marker from 51 to 56, together with
600806 - favorable report from the CT test on 060930, shown by review on 061012
600807 - finding no evidence of distant metastasis, ref SDS F6 2967, taken
600808 - together seems consistent with stable to rising IBC activity on the
600809 - left breast area, reported previously on 060929, ref SDS F1 FQ6G, and
600810 - seen again during examination today, reported below, ref SDS 0 XO5L,
600811 - including doctor's comments noting no evidence of distant metastasis.
600812 - ref SDS 0 YQ6I
600814 - ..
600815 - Effectivenss of chemotherapy protocol may be starting to fail in the
600816 - treatment of cancer cells that infect the red rash area under scenario
600817 - #2, and due to "pockets of resistance," possibly increased by
600818 - mastectomy surgery on 051021 that removed blood vessels, as further
600819 - discussed below. ref SDS 0 725L
600821 - ..
600822 - The doctor feels this record supports continuing current treatment, as
600823 - shown below. ref SDS 0 PF3O
Esophagitis Continued Mild Refulx Treated with Tums Meeting Primary
630401 - ..
630402 - Esophagitis Not Compared in Current PET Test with Prior Report
630404 - Follow up ref SDS F1 JP6K, ref SDS E7 JP6K.
630406 - Background on imgaing tests finding "likely" esophagitis is cited in
630407 - the record on 060929, noting continued mild indigestion treated with
630408 - Tums, and occassional serious reflux. ref SDS F1 JP6K
630410 - ..
630411 - There was no discussion of esophagitis today, shown by the doctor's
630412 - record. ref SDS 0 1248
Left Axillary No Evidence Lymphadenopathy Lymphedema Left Arm Lump 2
Left Axillary Lymphadenopathy Patient No Complaint Swelling Discomfo
740501 - ..
740502 - Left Axillary No Evidence Lymphadenopathy CT Testing 060930
740503 - Lymphedema Left Arm Lump Complications Cellulitus Hospitalized
740504 - Cellulitus Hospitalized Lymphedema Left Arm Lump Complications
740505 - Post Operation Localized Edema Left Axillary Swelling Cellulitus
740507 - Follow up ref SDS F1 MW8J, ref SDS E7 MW8J.
740509 - ..
740510 - Patient history of left axillary lymphadenopathy and lymphedema is
740511 - reported on 060106. ref SDS 96 S164
740513 - ..
740514 - Examination today again found no evidence of cancer in left axilla.
740515 - The patient made no complaint of lumps or discomfort from swelling
740516 - under the left arm.
740518 - ..
740519 - CT scan imaging test ordered on 060929 was performed the next day on
740520 - 060930. Review on 061012, ref SDS F6 0Y4N, shows testing found no
740521 - evidence of disease (NED) in the axilla and supraclavicular regions.
740522 - ref SDS F6 2967 This supports prior testing in April and May reviewed
740523 - during the meeting on 060623 that showed no findings of
740524 - lymphadenopathy. ref SDS C4 MW8J
740526 - ..
740527 - Previously, on 060929 the doctor reviewed patient history on 060914
740528 - when Millie fell at the BART station as a result of fatigue, and
740529 - injured the middle index finger on her left hand; since this was the
740530 - side of mastectomy surgery on 051021, lymphedema increased causing the
740531 - left arm to swell. ref SDS F2 ZQ5I Over the next week, swelling
740532 - increased, so on 060922 Millie notified Kaiser of significant
740533 - swelling. ref SDS F3 0D5Y Examination on 060929 showed problem
740534 - persists on the left arm. There was no change to treatment with home
740535 - massage and physical therapy at the Kaiser Lymphedema Clinic.
740536 - ref SDS F1 IW9J
740538 - ..
740539 - Swelling in the left arm, and pain in the left finger worsened under
740540 - the prescribed regimen.
740542 - ..
740543 - After physical therpay for rising lymphedema on 061016, Kaiser xrayed
740544 - the left hand and found Millie's finger was broken in the fall on
740545 - 060914. Kaiser immobilized the left hand and finger with a soft-cast
740546 - to facilitate healing. ref SDS F8 IP5I On 061019 orthopedic doctor
740547 - removed the cast, and prescribed continued exercise to maintain range
740548 - of motion; prognosis is long slow healing process. ref SDS F9 087I
740550 - ..
740551 - The doctor examined Millie's left arm, hand, and finger.
740553 - ..
740554 - Swelling was observed during the meeting today. The doctor feels this
740555 - will decline, as the broken finger heals, and trauma to the left arm
740556 - subsides. Prescribes further treatment in Kaiser Physical Therapy
740557 - Clinic, as shown in doctor's progress notes. ref SDS 0 1248
740559 - ..
740560 - Measurements below elbow shows improvement 11.75" down slightly from
740561 - 12" reported during meeting with physical therapyst on 061016, and
740562 - shown in case study on 060509. ref SDS B4 HO7F
740564 - ..
740565 - [On 061027 Millie hospitalized temperature 102.6, ref SDS G3 HP52,
740566 - severe red rash envelops left arm and shoulder; diagnosis
740567 - cellulitis complications of lymphedema, reaction to tramua from
740568 - fall and breaking finger on 060914. ref SDS G3 V759
740570 - ..
740571 - [On 061101 Millie was released from the hospital with home care
740572 - administering antibiotis for 10 days to treat cellulitis.
740573 - ref SDS G6 0001
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom
790401 - ..
790402 - Right Axillary FDG SUV 2.5 Lump Discomfort Not Reported by Patient
790404 - Follow up ref SDS F1 3D6K, ref SDS E7 3D6K.
790406 - Background on patient history of testing for lymphedanopathy in the
790407 - right axilla is reported in the record on 060929. ref SDS F1 3D6K
790409 - ..
790410 - Examination today again found no evidence of cancer in right axilla.
790411 - The patient made no complaint of lumps or discomfort from swelling
790412 - under the right arm.
790414 - ..
790415 - CT scan imaging test ordered on 060929 was performed the next day on
790416 - 060930. Review on 061012, ref SDS F6 0Y4N, shows testing found no
790417 - evidence of disease (NED) in the axilla and supraclavicular regions.
790418 - ref SDS F6 2967 This supports prior testing in April and May reviewed
790419 - during the meeting on 060623 that showed no findings of
790420 - lymphadenopathy. ref SDS C4 CZ8L
Left Supraclavicular Neck Lymphadenopathy Patient No Complaint Swell
870401 - ..
870402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
870403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
870404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
870406 - Follow up ref SDS F1 8R6M, ref SDS E7 8R6M.
870408 - Background of image testing, and consideration for radiation treatment
870409 - of left supraclivicular is reported on 060623. ref SDS C4 8R6M
870411 - ..
870412 - Examination today again found no evidence of lumpiness in the left
870413 - supraclavicular. The patient made no complaint of lumps or discomfort
870414 - from swelling in this region.
870416 - ..
870417 - On 060929 Doctor Benz 2nd opinion from examination on 060821 notes
870418 - that failure of CT test on 060505 to report findings in left
870419 - supraclavicular where PET test finds nodes progressing in size raises
870420 - concerns, ref SDS F2 WI4I, set out in previous analysis on 060523.
870421 - ref SDS B6 4R82
870423 - ..
870424 - CT scan imaging test ordered on 060929 was performed the next day on
870425 - 060930. Review on 061012, ref SDS F6 0Y4N, shows testing found no
870426 - evidence of disease (NED) in the axilla and supraclavicular regions.
870427 - ref SDS F6 2967 This supports prior testing in April and May reviewed
870428 - during the meeting on 060623 that showed no findings of
870429 - lymphadenopathy. ref SDS C4 K74Y
Examination IBC Red Rash Left Breast Seems Stable Unchanged from 060
A40401 - ..
A40402 - Red Rash Stable Left Breast Slow Response to Treatment
A40403 - Examination Left Breast IBC Inflammation Red Rash Seems to Stable
A40404 - IBC Inflammation Left Breast Red Rash Stable Slow Response Treatment
A40405 - Response to Treatment Slow IBC Inflammation Left Breast Red Rash Stable
A40407 - Follow up ref SDS F1 025H, ref SDS E7 025H.
A40409 - Background on prior relapse examinations is listed on 060711.
A40410 - ref SDS C6 8Y7O
A40412 - ..
A40413 - On 060929 the primary care physician submitted a copy of the 2nd
A40414 - opinion from UCSF, ref SDS F1 624L, following up the meeting with
A40415 - Doctor Benz on 060821. ref SDS E6 0001
A40417 - ..
A40418 - Primary focus today is on pulmonary embolism, see below. ref SDS 0
A40419 - CV5L
A40421 - ..
A40422 - As on 060929, the doctor looked briefly at the red rash on the left
A40423 - breast area, and noted stable to somewhat improved conditions with red
A40424 - rash possibly slightly less or slightly more spread out. Without
A40425 - measurements this issue is indeterminate, because of slow change in
A40426 - the spread and severity of the rash. ref SDS F1 FQ6G
A40428 - ..
A40429 - Observation today shows IBC rash occurs in various "pockets" with
A40430 - varying degrees of intensity above and below the incision line for
A40431 - mastectomy surgery on 051021. Some pockets of rash seem stable,
A40432 - others seem slightly worse, and some may show improvement. Overall
A40433 - there is little change since examination on 060825, ref SDS E7 025H,
A40434 - and including the 2nd opinion from UCSF received on 060929.
A40435 - ref SDS F2 WQ8V After three (3) additional treatments there is no
A40436 - appreciable improvmement of the rash on the left breast from
A40437 - conditions found on 060821 by Doctor Benz. ref SDS E6 KR6I
A40439 - [On 061208 primary care physician observes rash has spread
A40440 - from the left breast to slightly onto the right breast for
A40441 - the first time in 3 years, and so may establish measurable
A40442 - disease to qualify for UCSF drug studies. ref SDS H2 AX6G
A40444 - ..
A40445 - Doctor Benz raises the prospect in his 2nd opinion reviewed on 060929
A40446 - that the rash on the left breast might not be IBC, ref SDS F2 WQ8V,
A40447 - cited in Millie's letter to the primary care physician today.
A40448 - ref DIT 1 9I6O
A40450 - ..
A40451 - During the examination on 060821 the doctor proposed getting a biopsy
A40452 - for "measurable" disease to qualify for drug trials. ref SDS E6 KT7J
A40453 - At that time, on 060821 Doctor Benz seemed to emphasize importance of
A40454 - establishing "measureable disease" to qualify for drug trials.
A40455 - ref SDS E6 W66J Measureable disease was presented again in UCSF's
A40456 - written opinion, reviewed on 060929. ref SDS F2 WQ5T
A40458 - ..
A40459 - Doctor Benz opinion on 060929 raises questions on "measurable
A40460 - disease." ref SDS F2 WQ5T Do we need...
A40462 - 1. biopsy.......................... 060929, ref SDS F2 WY79
A40463 - 2. measurements.................... 060929, ref SDS F2 WQ5T
A40464 - 3. photographs
A40465 - 4. narrative
A40467 - ..
A40468 - Millie's letter to Kaiser today alerted the doctor about these issues,
A40469 - saying in part...
A40471 - ..
A40472 - Conceivably CA 15-3 could be responding to cancer elsewhere
A40473 - that is still too small for image testing to pickup, and the
A40474 - rash is not IBC. That seems very remote. ref DIT 1 8J7K
A40476 - ..
A40477 - Measureable disease could be measuring spread of the rash. You
A40478 - used a tape measure for lymph nodes in my neck. Maybe we can
A40479 - take measurements of the rash. What about photographs?
A40480 - ref DIT 1 4K8F
A40482 - ..
A40483 - The doctor decided not to take measurements, nor to take photographs
A40484 - to create a record of measureable disease.
A40486 - ..
A40487 - Photographs were previously considered to capture a record for
A40488 - evaluating boundaries to perform mastectomy surgery, reported during
A40489 - examination by the surgeon on 050324. ref SDS 61 0347
A40491 - [On 070130 photographs planned to determine measureable
A40492 - disease treating Millie with drug trial in clinical
A40493 - study at UCSF. ref SDS H6 M661
A40496 - ..
A40497 - Distant Metastasis No Evidence Imaging Tests Conflicts Rising CA 15-3
A40499 - The doctor indicated that imaging tests, most recently on 060930, show
A40500 - no evidence of distant metastasis, which aligns with review on 061012.
A40501 - ref SDS F6 2967
A40503 - ..
A40504 - One possibility is that sudden rise of CA 15-3 means that IBC is
A40505 - rising on the left breast area, though at this time not significantly
A40506 - enough to recognize by observation, per analysis of the cancer marker,
A40507 - shown above. ref SDS 0 GJ5M
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea
AA0401 - ..
AA0402 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
AA0403 - Slow Response to Treatment Mastectomy Removed Blood Vessels
AA0404 - Expectations Recovery Rate Tempered by Mastectomy Surgery
AA0405 - Mastectomy Removes Blood Vessels Slows Rate Recovery IBC Relapse
AA0407 - Follow up ref SDS F1 EH3F, ref SDS E7 G57I.
AA0409 - Background of mastectomy surgery performed on 051021 with impacts on
AA0410 - expectations for recovery from IBC red rash is reported on 060929,
AA0411 - ref SDS F1 EH3F Case study on 041210 originally considered mastectomy
AA0412 - surgery for Millie. ref SDS 54 657F Recent 2nd opinion meeting at
AA0413 - UCSF on 060821 requested review of effects from surgery that removed
AA0414 - blood vessels on effectiveness of systemic chemotherapy treatments
AA0415 - delivered through the blood system. ref SDS E6 NN3H
AA0417 - ..
AA0418 - Analysis on 060922 cites mastectomy removing blood vessels as possible
AA0419 - reason for delayed response to treatment this year compared to much
AA0420 - faster response in 2005. ref SDS E9 ML3I
AA0422 - ..
AA0423 - Sudden rise of CA 15-3 cancer marker, ref SDS 0 GJ5M, together with
AA0424 - stable to expanding IBC red rash on the left chest reported today,
AA0425 - ref SDS 0 XO5L, may relate to concerns presented by primary care
AA0426 - physician on 050311 that "pockets of resistance" to chemotherapy
AA0427 - treatment cause slow recovery, ref SDS 60 NT5O, supported later by 2nd
AA0428 - opinion consultation with Doctor Bailey on 051011. ref SDS 88 G65S
AA0429 - Additionally, cancer may be growing that is inherently resistant to
AA0430 - the current treatment using Taxotere and capecitabine (Xeloda), under
AA0431 - scenario #2 explained on 060808. ref SDS E0 HT5K
AA0433 - [On 051027 Millie asks about slow recovery from IBC caused by
AA0434 - mastectomy surgery removing blood vessels needed to deliver
AA0435 - treatment. ref SDS G2 MS3Y
Biopsy Left Breast Investigate for Mutated Cancer IBC Red Rash Statu
AG0401 - ..
AG0402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
AG0403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
AG0404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
AG0406 - Follow up ref SDS F1 KT7J, ref SDS E7 KT7J.
AG0408 - Can a biopsy contribute to patient work up for developing a strategy
AG0409 - and treatment plan, discussed on 060711? ref SDS C6 K36G
AG0411 - ..
AG0412 - Review on 060929 of UCSF 2nd opinion prepared by Doctor Benz from
AG0413 - examination on 060821 finds red rash on left breast area previously
AG0414 - found by biopsy on 040419 to be IBC, and later found to be clear of
AG0415 - IBC disease by biopsy on 051021 has, however, not established as
AG0416 - recurrent IBC by biopsy this year in 2006, ref SDS F2 WY79; caution
AG0417 - presented in the Benz examination resisting association of red rash
AG0418 - lesions and inflammation on the left breast area with IBC disease, and
AG0419 - in relation to rising CA 15-3 cancer marker, doctor indicates there
AG0420 - may be wide spread distant metastasis too small for recognition by
AG0421 - image testing and currently being treated systemcially with
AG0422 - chemotherapy. ref SDS F2 WQ8V
AG0424 - ..
AG0425 - Slow response to treatment may warrant investigation with biopsy for
AG0426 - consideration of status change flowing from possible cancer mutation
AG0427 - that resists current treatment under scenario #2 developed on 060808,
AG0428 - ref SDS E0 HT5K, and citing analysis on 030606 presented by the
AG0429 - primary care physician. ref SDS 25 N27L
AG0431 - ..
AG0432 - With a hectic schedule today, ref SDS 0 SM6M, the primary care
AG0433 - physician did not have time to review this issue.
IBC Imaging Tests CT Scan 060930 Investigate Symptoms Pulmonary Embo
AN0401 - ..
AN0402 - CT Test 060930 Findings Pulmonary Emboli No Evidence Distant Metastasis
AN0403 - Distant Metastasis No Evidence PE Positive Findings CT Test 060930
AN0404 - Pulmonary Emboli Findings Distant Metastasis No Evidence CT Test 060930
AN0406 - Follow up ref SDS F1 EY5O, ref SDS E7 EY5O.
AN0408 - On 060929 the doctor ordered a CT test primarily to evaluate pulmonary
AN0409 - embolism. ref SDS F1 J446
AN0411 - ..
AN0412 - The test was performed on an expedited basis the next day on 060930.
AN0413 - ref SDS F3 MI5I A few days later, the doctor called on 061002 and
AN0414 - reported the test was positive for pulmonary embolism recurrence. The
AN0415 - doctor prescirbed treatments with Coumadin to resume, ref SDS F4 MI5I,
AN0416 - which were previously stopped on 061007. ref SDS 87 GC6K
AN0418 - ..
AN0419 - Review of test results on 061012 shows findings of pulmonary embolism,
AN0420 - ref SDS F6 294Q, with complications of enlarged right ventricle,
AN0421 - ref SDS F6 7E5L, discussed below. ref SDS 0 SM41
AN0423 - ..
AN0424 - Review on 061012 further shows that the pathology report for the CT
AN0425 - test on 060930 does not compare with the prior test on 041103 that
AN0426 - originally diagnosed pulmonary embolism. ref SDS F6 2935 This
AN0427 - conflicts with the doctor's order for a comparison, reported on
AN0428 - 060929. ref SDS F1 DY5M Millie's letter to Kaiser on 061013 asks how
AN0429 - to get the comparison ordered by the doctor for effective trend
AN0430 - analysis. ref SDS F7 I75V
AN0432 - [On 061208 doctor ordered PET scan test to set new baseline for
AN0433 - changing chemotherapy to treat IBC; and added to the order
AN0434 - request for analysis of pulmonary embolism, and enlarged right
AN0435 - ventricle by comparing and contrasting with prior CT tests on
AN0436 - 041103 and on 060930, even though CT scan tests are a better
AN0437 - diagnostic for this comparison. ref SDS H2 ZY5L
AN0439 - ..
AN0440 - The doctor had a hectic schedule today, ref SDS 0 SM6M, so there was
AN0441 - not enough time during the meeting to compare findings between the
AN0442 - reports, as set out on 061012. ref SDS F6 7E7G
AN0444 - [...see below, pulmonary embolism review discusses comparing
AN0445 - current condition with original diagnosis on 041103.
AN0446 - ref SDS 0 385I
AN0448 - ..
AN0449 - The primary care physician concurred with review on 061012 that the CT
AN0450 - test on 060930 found no evidence of distant metastasis, ref SDS F6
AN0451 - 1Y8G, also cited above. ref SDS 0 YQ6I
AN0453 - ..
AN0454 - The doctor also noted today that the protocol for the test to evaluate
AN0455 - pulmonary embolism is different from CT tests normally done to
AN0456 - evaluate progression of metastatic cancer, as explained further below.
AN0457 - ref SDS 0 S56G
AN0459 - [On 061110 CT tests for pulmoanry embolism are more rigorous
AN0460 - than tests normally performed to evaluate progression of
AN0461 - metastatic cancer, ref SDS H0 MX4H, and so the test on 060930
AN0462 - is nominally more reliable than normal in finding no evidence
AN0463 - of distant metastasis, per above. ref SDS 0 NG6N
Emotional Trauma Discovery Pulmonary Emboli Many Other Issues Cause
AW0401 - ..
AW0402 - Emotional Trauma Rising Falling Cancer Symptoms
AW0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
AW0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
AW0406 - Follow up ref SDS F1 Y642, ref SDS E7 Y642.
AW0408 - Emotional roller coaster of good news mixed with concern from mounting
AW0409 - medical issues listed above, ref SDS 0 PB3H, increases stress because
AW0410 - limited time prevents timely consideration due a hectic schedule.
AW0411 - ref SDS 0 SM6M
AW0413 - ..
AW0414 - The growing gap between problems and time for review increases trauma
AW0415 - from emotional stress, including...
AW0417 - 1. CT test showing no evidence distant metastasis, nor
AW0418 - findings of cancer of any kind presents a big relief.
AW0419 - ref SDS 0 EY5O Conflict with slow recovery left breast
AW0420 - IBC, ref SDS 0 XO5L, with rising CA 15-3 cancer marker,
AW0421 - ref SDS 0 087J, causes doubt, worry, stress.
AW0423 - ..
AW0424 - 2. Knowledge Management dilemma of complexity from expanding
AW0425 - medical issues, ref SDS 0 PB3H, that overwhelm span of
AW0426 - attention, and give rise to desire to simplify analysis by
AW0427 - ignoring issues that exceed span of attention. ref SDS 0
AW0428 - MO4K
AW0430 - ..
AW0431 - 3. Pulmonary embolism recurrence diagnosed on 061002, after
AW0432 - being removed from treatment on 061007, creates doubt and
AW0433 - worry, reviewed below. ref SDS 0 SM41
AW0435 - ..
AW0436 - 4. Heart disorder discovered by accident complication of
AW0437 - enlarged right ventricle without notice from Kaiser, and
AW0438 - without assessment of severity. ref SDS 0 VD44
AW0440 - ..
AW0441 - 5. Slow response to treatment for IBC cancer left breast
AW0442 - compared to prior rapid recovery with the same treatment in
AW0443 - 2005, reviewed above. ref SDS 0 XO5L
AW0445 - ..
AW0446 - 6. Challenge medical practice develop patient work up with
AW0447 - pool of treatments, strategy, and planning for applying
AW0448 - treatments creates stress about future prospects.
AW0449 - ref SDS 0 K36G
AW0451 - ..
AW0452 - 7. Lymphedema rising left arm, pulmonary emboli, side effects
AW0453 - chemotherapy prevent normal exercise to relieve stress and
AW0454 - increase fitness. ref SDS 0 EP5N
AW0456 - ..
AW0457 - 8. Biopsy for IBC, 2nd opinion cites patient history using
AW0458 - biopsy for diagnosis, and no biopsy to confirm current
AW0459 - condition. ref SDS 0 KT7J
AW0461 - ..
AW0462 - 9. Communication problems within the team care model to verify
AW0463 - medications are correctly coordinated for effectiveness and
AW0464 - to prevent harmful conflicts in treatment, ref SDS 0 YQ7L
AW0466 - ..
AW0467 - 10. Discovery that CT tests require a special specification to
AW0468 - examine pulmonary embolism. ref SDS 0 S56G
AW0470 - ..
AW0471 - 11. Failure of imaging tests to make correct comparisons
AW0472 - ordered by the doctor. ref SDS 0 NG5O
AW0474 - ..
AW0475 - All of these events during the past treatment cycle create emotional
AW0476 - sieches of hope, worry and stress about prospects of getting well to
AW0477 - restore fitness for emotional and physical strength to have a normal
AW0478 - life again.
AW0480 - [On 061027 Millie letter advises Kaiser that pulmonary
AW0481 - embolism symptoms continue fatigue, shortness of breath;
AW0482 - Millie asks about prognosis for getting back in the gym
AW0483 - to improve fitness, which previously were attributed to
AW0484 - symptoms for pulmonary embolism. ref SDS G2 K24K
Strategy Treatment Plan IBC 3rd Relapse Scope Chemotherapy Drug Agen
B10401 - ..
B10402 - Pool Chemotherapy Drugs Available to Treat IBC
B10403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
B10404 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
B10406 - Follow up ref SDS F1 K36G, ref SDS E7 K36G.
B10408 - Background on requirements and challenge performing requirements for
B10409 - planning and proactive management in time for action to be effective
B10410 - is reported on 060825. ref SDS E7 K36G
Treatment IBC 5th Cycle for 3rd Relapse Continue Chemotherapy Agents
B60401 - ..
B60402 - Treatment 5th Cycle Continue Taxotere and Capecitabine (Xeloda)
B60403 - 5th Cycle Taxotere and Capecitabine (Xeloda) Treatment Continue
B60404 - Taxotere and Capecitabine (Xeloda) 5th-Cycle Treatment Continue
B60406 - Follow up ref SDS F1 PF3O, ref SDS E7 PF3O.
B60408 - The doctor proposed continuing current treatment with Taxotere and
B60409 - capecitabine (Xeldoa).
B60411 - ..
B60412 - No ideas and no research were presented for consideration to improve
B60413 - the rate of recovery for IBC on the left breast, which has shown no
B60414 - improvement for several cycles, per above, ref SDS 0 XO5L, and as
B60415 - noted in the doctor's treatment plan, see below. ref SDS 0 125V
Schedule Treatment 061110 on Friday for 6th Cycle Taxotere Capecitab
B80401 - ..
B80402 - Schedule Treatment Continue Prescription Taxotere Capecitabine Xeloda
B80404 - Follow up ref SDS F1 N96O, ref SDS E7 N96O.
B80406 - The doctor scheduled the next meeting for 061110, after chemotherapy
B80407 - treatment.
Pulmonary Emboli Diagnosis CT Test 060930 Blood Clots Lungs Treatmen
BM0401 - ..
BM0402 - Fatigue Shortness Breath Normal Activity Pulmonary Emboli Symptoms
BM0403 - Coumadin Treatment Pulmonary Emboli Symptoms Less Severe Continue
BM0404 - Pulmonary Emboli Symptoms Continue Less Severe Coumadin Treatment
BM0406 - Follow up ref SDS F1 CV5L, ref SDS E7 CV5L.
BM0408 - On 060929 Millie reported side effects of chemotherapy to staff in the
BM0409 - Infusion Clinic, including shortness of breath, and fatigue doing
BM0410 - routine physicial tasks like climbing the stairs at home, and working
BM0411 - out at the gym. ref SDS F0 XP42 This was further reported to the
BM0412 - primary care physician in another meeting later that afternoon on
BM0413 - 060929. ref SDS F1 B56N
BM0415 - ..
BM0416 - At that time, on 060929, the doctor ordered a CT test for pulmonary
BM0417 - embolism to compare with a prior test on 041103, that discovered
BM0418 - initial pulmonary emboli, reported on 041104. ref SDS F1 DY8L The
BM0419 - test was scheduled for the next 10 days in time for review in the
BM0420 - meeting today. ref SDS F1 435I
BM0422 - ..
BM0423 - The next day, on 040930 Millie was called and asked to come in for the
BM0424 - CT test later that same day on an expedited basis. ref SDS F3 MI5I
BM0426 - ..
BM0427 - On 061002 the primary care physician called and left a message that CT
BM0428 - test findings show pulmonary emboli, ref SDS F4 MI5I; Millie resumed
BM0429 - treatment with coumadin, previously ended on 051007. ref SDS F4 GO3J
BM0431 - ..
BM0432 - Millie now seems less fatigued and suffers less shortness of breath
BM0433 - after starting treatments for pulmonary emboli on 061002; however,
BM0434 - symptoms have continued. The doctor feels continuing treatment with
BM0435 - coumadin (warfarin) will yield further improvement.
BM0437 - [On 061027 Millie letter advises Kaiser that pulmonary embolism
BM0438 - symptoms continue fatigue, shortness of breath; Millie asks
BM0439 - about prognosis for getting back in the gym to improve fitness,
BM0440 - which previously were attributed to symptoms for pulmonary
BM0441 - embolism. ref SDS G2 0C4I
BM0443 - ..
BM0444 - Millie thanked the doctor for proactive management discovering
BM0445 - pulmonary embolism in time to avoid serious complications, reported on
BM0446 - 060722, ref SDS D1 346F, and as reported in her letter on 061002
BM0447 - notifying Kaiser that instructions for treatment were followed to
BM0448 - begin taking coumadin. ref SDS F4 HU6K
BM0451 - ..
BM0452 - Comparison CT Test 060930 with Test 041103 Original Diagnosis
BM0454 - Millie asked about follow up with the Imaging department to perform
BM0455 - the comparison ordered by the doctor on 060929 for the CT test?
BM0457 - ..
BM0458 - The doctor did not recall getting Millie's letter on 061013,
BM0459 - ref SDS F7 I75V, asking about failure of the CT test report to make
BM0460 - the comparison ordered by the doctor on 060929, ref SDS F1 DY8L, and
BM0461 - as reported on 061012 reviewing the CT test. ref SDS F6 2935
BM0463 - ..
BM0464 - Since the doctor's schedule was hectic today, ref SDS 0 SM6M, there
BM0465 - was not enough time to review preliminary comparison begun on 061012
BM0466 - for diagnosis and treatment considerations. ref SDS F6 7E7G
BM0468 - [On 061110 hectic schedule again, doctor did not have time to
BM0469 - review comparison of test reports. ref SDS H0 HB3K
Coumadin Medication Notification Mistakes Computer Access Pulmonary
C90401 - ..
C90402 - Notification Patient Medications Coumadin Balance with Xeloda
C90403 - Patient Medications Coumadin Balance with Xeloda Notification
C90404 - Coumadin Balance with Capecitabine (Xeloda) Patient Medications
C90406 - Millie reported discussions earlier today with the Oncology pharmacist
C90407 - about notifying the Coagulation Control Clinic that she is being
C90408 - treated with capecitabine (Xeloda). ref SDS G0 S69H The pharmacist
C90409 - was concerned that capecitiabine treatments prescribed for cancer by
C90410 - the doctor on 060711, ref SDS C6 PF3O, require adjustments to Coumadin
C90411 - treatments for pulmonary emboli, prescribed by the doctor a few weeks
C90412 - ago on 061002. ref SDS F4 MI5I
C90414 - ..
C90415 - Millie asked if the the Coagulation Treatment Clinic was notified that
C90416 - current medications include capecitabine (Xeloda), when Coumadin was
C90417 - prescribed on 061002?
C90419 - [On 061208 doctor prescribes Diflucan antibiotics and expects
C90420 - this will be entered in Kaiser's computer to notify everyone to
C90421 - avoid conflicts in treatments. ref SDS H2 C75F
C90423 - ..
C90424 - [On 061214 treatment mistake pulmonary embolism warfarin
C90425 - (Coumadin) conflicts with Doflucan; blood test INR rises 6.4
C90426 - danger zone for hemoraging; blood clot coagulation treatment
C90427 - paused for 3 days; INR update test advanced. ref SDS H3 HF4O
C90429 - ..
C90430 - The doctor explained that he helped develop a system about 10 years
C90431 - ago for patient medications to be accessible on Kaiser's computers.
C90432 - He was therefore surprised to hear today that the Oncology Pharmacy
C90433 - here in Kaiser's Walunt Creek hospital, and the Coagulation Control
C90434 - Clinic in Martinez were not aware of Millie's treatments, since they
C90435 - all have access to the same data on Kaiser's computer system.
C90437 - [On 061112 Doctor Seier found patient history on 061027 prepared
C90438 - by lead ER physician, and this assisted diagnosis and treatment
C90439 - for cellulitis relapse on 061112 ref SDS H1 XS5J; patient history
C90440 - of other doctors treating Millie for cellulitis beginning on
C90441 - 061027 under Kaiser's team care practice was not available.
C90442 - ref SDS H1 5L6H
C90444 - ..
C90445 - [On 061024 case study medical practice computer access limited
C90446 - even with everything on the computer, people can't find details
C90447 - stored in parts of the computer (software modules) that are not
C90448 - frequently used. ref SDS G1 JD9L
C90450 - ..
C90451 - While we talked, the doctor displayed Millie's medications on the
C90452 - computer screen to demonstrate that access is fast and easy. This
C90453 - took about 10 seconds or so. He feels it should not be necessary for
C90454 - the patient to notify the Coagulation Treatment Clinic to make
C90455 - adjustments for Coumadin treatments with capecitiabine (Xeloda). The
C90456 - doctor also feels that the Oncology Pharmacy down the hall from the
C90457 - examination room should equally be aware of Millie's treatments. He
C90458 - was pleased to learn the Pharmacist took proactive action to notify
C90459 - the Coagulation Treatment Clinic, and that the Clinic updated Millie's
C90460 - records in time to make the proper adjustments in her treatments,
C90461 - reported earlier today, as well. ref SDS G0 VE57 The doctor was
C90462 - frustrated that the pharmacist had to expressly notify the Coagulation
C90463 - Clinic, since balancing treatments is the responsibility of the
C90464 - attending physician, and, when the prescription for coumadin was made
C90465 - on 061002, ref SDS F4 MI5I, the doctor was counting on fast and easy
C90466 - access to medications using Kaiser's computer system, for the
C90467 - Coagulation Treatment Clinic to make adjustments, without express
C90468 - notice from the doctor, the patient, or the Oncology Pharmacy
C90469 - department.
C90471 - ..
C90472 - Since the doctor was behind schedule, ref SDS 0 SM6M, there was not
C90473 - enough time today to review comments by the pharmacist, ref SDS G0
C90474 - RS6H, and by Debbie in the Infusion Clinic on weaknesses in Kaiser's
C90475 - computer system, ref SDS G0 TR53, which can be corrected with feedback
C90476 - loops to verify accuracy of daily communications. Feedback is part of
C90477 - "intelligence" support explained in POIMS, ref OF 3 0367, and is
C90478 - further explained in NWO. ref OF 10 0936 Even though people resist
C90479 - investing time for feedback, in part because feedback sometimes
C90480 - creates controversy, also explained in NWO, ref OF 14 2670, accuracy
C90481 - is critical in medical practice, noted on 040402, ref SDS 33 6E4K, as
C90482 - well as engineering, law, and most other fields, shown by reporting on
C90483 - 990912. ref SDS 5 0001
C90485 - ..
C90486 - The fact that access to part of Kaiser's computer system is fast and
C90487 - easy for one practitioner, does not make this so for others who mostly
C90488 - use different parts of the software, as Debbie noted earlier today.
C90489 - ref SDS G0 P18K The history of difficult access to computers delaying
C90490 - case management and reducing productivity is reported on 060711.
C90491 - ref SDS C6 5Y5J
C90493 - [...below, doctor's progress notes list of current medications
C90494 - is incorrect, omits Coumadin prescribed on 061002. ref SDS 0
C90495 - SE86
C90497 - ..
C90498 - [On 061024 Coagulation Treatment Clinic uses software that
C90499 - requires accessing another part of Kaiser's computer system to
C90500 - coordinate patient treatments; such access requires training,
C90501 - and time for performance; therefore direct notice from the
C90502 - doctor and support staff in Oncology Pharmacy, as occurred
C90503 - today, reported in another record, ref SDS G0 VE57, and also by
C90504 - the patient, as encouraged by the pharmacist, also, in another
C90505 - record, ref SDS G0 S69H, assists the Coagulation Treatment
C90506 - Clinic in making an accurate and effective balance of
C90507 - treatments for pulmonary embolism with chemotherapy treatments
C90508 - for cancer using capecitabine (Xeloda) in this case.
C90509 - ref SDS G1 TZ4I
C90511 - ..
C90512 - [On 061024 case study medical practice computer access limited
C90513 - even with everything on the computer, people can't find details
C90514 - stored in parts of the computer (software modules) that are not
C90515 - frequently used. ref SDS G1 JD9L
C90517 - ..
C90518 - [On 061110 doctor's list of current medications incorrect not
C90519 - listing Coumadin, and also does not list antibiotics for
C90520 - cellulitis, Lovenox, also, for PE, Procrit is not listed for
C90521 - anemia (low energy) to redress low blood counts for hemoglobin,
C90522 - Tums is not listed for GERD. ref SDS H0 SE86
C90524 - ..
C90525 - [On 061208 doctor prescribes Diflucan antibiotics and expects
C90526 - this will be entered in Kaiser's computer to notify everyone to
C90527 - avoid conflicts in treatments. ref SDS H2 C75F
C90529 - ..
C90530 - [On 061214 treatment mistake pulmonary embolism warfarin
C90531 - (Coumadin) conflicts with Doflucan; blood test INR rises 6.4
C90532 - danger zone for hemoraging; blood clot coagulation treatment
C90533 - paused for 3 days; INR update test advanced. ref SDS H3 HF4O
CT Test Pulmonary Embolism Different from CT Tests for Cancer Explai
CI0401 - ..
CI0402 - CT Tests for Pulmonary Emboli Different from CT Tests for Cancer
CI0404 - The letter submitting the agenda for the meeting today, also asked the
CI0405 - doctor whether CT tests are different for pulmonary embolism?
CI0406 - ref DIT 1 WI8L
CI0408 - ..
CI0409 - During the meeting this afternoon, the doctor explained that CT scan
CI0410 - tests for pulmonary emboli are different from CT tests for other
CI0411 - issues, for example in Millie's case evauating distant metastasis. He
CI0412 - described thin slice CT scans find pulmonary embolism. This helps
CI0413 - explain why CT scan tests did not identify pulmonary embolism from
CI0414 - 040517 and until 041104. ref SDS 50 RZ4I
CI0416 - [On 061110 CT tests for pulmoanry embolism are more rigorous
CI0417 - than tests normally performed to evaluate progression of
CI0418 - metastatic cancer, ref SDS H0 MX4H, and so the test on 060930
CI0419 - is nominally more reliable than normal in finding no evidence
CI0420 - of distant metastasis, per above. ref SDS 0 NG6N
CI0422 - ..
CI0423 - Using tests with similar names that have different performance, and
CI0424 - require additional steps and commands to order using the computer
CI0425 - system, compounds the "wicked problem" diagnosing pulmonary embolism
CI0426 - for professionals and patients alike, reviewed on 060722. ref SDS D1
CI0427 - 346F When some parts of the computer system are used frequently, and
CI0428 - other parts are used only rarely, people forget the commands, and
CI0429 - forget to invest time performing rarely used functions. Limited time
CI0430 - drives people to believe the lessor test that is fast and easy to
CI0431 - order with familiar skills is satisfactory, especially since there is
CI0432 - an explanation for symptoms other than pulmonary embolism.
CI0434 - ..
CI0435 - Disclosure today that the computer system requires different ordering
CI0436 - steps for CT scans to test for pulmonary embolism explains why 2 tests
CI0437 - in 2004 failed to report blood clots until 041104, ref SDS 50 Q54K,
CI0438 - and again this year in 2006 multiple CT scans did not report pulmonary
CI0439 - embolism, which leads practitioners to diagnose rising clincial
CI0440 - symptoms as loss of fitness from accumulation of chemotherapy side
CI0441 - effects, as reviewed on 060722. ref SDS D1 WF5H
CI0443 - ..
CI0444 - The dilemma discussed with the primary care physician on 040909 seems
CI0445 - resolved by new information today. At that time, persistant symptoms
CI0446 - escaped correct diagnosis because numerous CT scan tests failed to
CI0447 - diagnose pulmonary embolism. ref SDS 47 RZ4I This problem was
CI0448 - repeated a month later at Kaiser on 041005. ref SDS 48 OG3I
CI0450 - ..
CI0451 - [On 061024 case study medical practice computer access limited
CI0452 - even with everything on the computer, people can't find details
CI0453 - stored in parts of the computer (software modules) that are not
CI0454 - frequently used. ref SDS G1 JD9L
Enlarged Right Ventricle CT Test 060930 Doctor Does Not Remember See
DF0401 - ..
DF0402 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
DF0404 - Follow up ref SDS F6 7E5L.
DF0406 - Millie asked how serious is her pulmonary emobli condition, and cited
DF0407 - her letter to Kaiser on 061013, ref SDS F7 US6H, commenting on the CT
DF0408 - test on 060930, which was reviewed on 061012, ref SDS F6 7E5L, and
DF0409 - Millie further asked about resuming routine exercise at the gym.
DF0411 - ..
DF0412 - The doctor did not recall the letter on 061013, and did not offer an
DF0413 - estimate on when Millie can be return to the gym to restore physical
DF0414 - and emotional fitness, also, reviewed above. ref SDS 0 Y642
DF0416 - [On 061027 Millie letter advises Kaiser that pulmonary
DF0417 - embolism symptoms continue fatigue, shortness of breath;
DF0418 - Millie asks about prognosis for getting back in the gym to
DF0419 - improve fitness, which previously were attributed to
DF0420 - symptoms for pulmonary embolism. ref SDS G2 MS5P
DF0422 - ..
DF0423 - The doctor requested clarification of "serious"?
DF0425 - ..
DF0426 - Millie cited the pathology report that the right ventrical is enlarged
DF0427 - compared to the left ventrical, but does not say how much larger, nor
DF0428 - otherwise present severity, as shown in the record on 061012.
DF0429 - ref SDS F6 7E5L For example, the report does say that the main
DF0430 - pulmonary artery is near the upper limit of normal, which suggests
DF0431 - prospective problems. ref SDS F6 294V
DF0433 - [On 061108 Millie experiences continued symptoms pulmonary
DF0434 - embolism, shortness of breath, fatigue, cough clearing throat.
DF0435 - ref SDS G9 VR6F
DF0437 - ..
DF0438 - The doctor did not remember reading the CT test finding of enlarged
DF0439 - right ventricle. He asked where the issue is presented in the CT test
DF0440 - findings?
DF0442 - ..
DF0443 - Case study on 060428 indicates difficulty doctors have with a hectic
DF0444 - schedule, as occurred today, per above, ref SDS 0 SM6M, allocating
DF0445 - time to read complex medical test findings. Limited time prevents
DF0446 - doctors from performing test analyst's recommendations to correlate
DF0447 - clinically with patient history for discovering symptomatic trends
DF0448 - that enable proactive case management; there is only enough time to
DF0449 - read summaries that present the gist of findings. ref SDS A9 VG5L
DF0450 - Reflects more recent study on 060809 demonstrating Kaiser's strong
DF0451 - reputation for doctor patient partnership through effective
DF0452 - communications. ref SDS E2 K65G
DF0454 - ..
DF0455 - Millie asked the doctor to display the report on the computer screen
DF0456 - there in the examination room. She scrolled through the report to the
DF0457 - paragraph on right ventrical enlargement, reported on 061012.
DF0458 - ref SDS F6 7E5L
DF0460 - [On 061024 case study medical practice computer access limited
DF0461 - even with everything on the computer, people can't find details
DF0462 - stored in parts of the computer (software modules) that are not
DF0463 - frequently used. ref SDS G1 JD9L
DF0465 - ..
DF0466 - Millie asked that Kaiser submit actual measurements? Is the right
DF0467 - ventrical 10% larger, 50%, 100% larger, as an indication of
DF0468 - seriousness of the problem reported by Kaiser? The analyst should
DF0469 - further comment on seriousness of pulmonary embolism, for example,
DF0470 - compared to the prior problem reported on 041103, and in compliance
DF0471 - with the doctor's order for the CT test, as reviewed on 061012.
DF0472 - ref SDS F6 2935
DF0474 - [On 061110 hectic schedule Kaiser has not had enough time to
DF0475 - determine how much the right ventricle is enlarged. ref SDS H0
DF0476 - WT5N
Heart Disorder Cor Pulmonale From Pulmonary Hypertension Article Mer
DO0401 - ..
DO0402 - Heart Disorder Enlarged Right Ventricle Cor Pulmonale How Serious
DO0403 - Cor Pulmonale: Heart Disorder From Pulmonary Hypertension How Serious
DO0405 - Follow up ref SDS F6 IM5J.
DO0407 - Research on 061012 associates enlarged right ventricle with Cor
DO0408 - Pulmonale that can lead to heart failure and death. ref SDS F6 IM5J
DO0410 - ..
DO0411 - The doctor seemed to indicate that the enlarged right ventrical is not
DO0412 - a factor in Millie's diagnosis for pulmonary embolism. He cited
DO0413 - language in the report that describes
DO0415 - There are filling defects within the subsegemental branches
DO0416 - of the right lower lobe pulmonary arteries. ref SDS F6 M435
DO0418 - ...as the controlling conditions for pulmonary embolism. There seemed
DO0419 - to be reluctance about contacting the Medical Imaging Department for
DO0420 - clarification of the CT test report.
DO0422 - [On 061228 letter from doctor says Cor Pulmonale
DO0423 - enlarged right ventricle most likely due to pulmonary
DO0424 - embolism, clarifying understandings today. ref SDS H4
DO0425 - JU7L
DO0427 - ..
DO0428 - Millie's patient history over many months of slight dizziness and
DO0429 - lightheadedness showing in the record on 061012 correlation with
DO0430 - symptoms of enlarged right ventricle, ref SDS F6 IR46, was not
DO0431 - discussed today.
DO0433 - ..
DO0434 - The doctor said that patients with severe pulmonary embolism have
DO0435 - symptoms of severe distress, such as pain in the lower legs, and
DO0436 - swelled veins, which demonstrate severe pulmonary embolism.
DO0437 - Thankfully, Millie has not had these conditions.
DO0439 - [On 061110 doctor cites So2 blood test 98% shows good cardio
DO0440 - pulmonary performance, indicating enlarged right ventricle not
DO0441 - impacting patient health. ref SDS H0 HT3M
DO0443 - ..
DO0444 - Since the doctor's schedule was hectic today, there was not enough
DO0445 - time to review research on 061012 that seems to indicate an enlarged
DO0446 - right ventrical can cause heart failure and is associated with
DO0447 - pulmonary embolism. ref SDS F6 L35J
DO0449 - ..
DO0450 - As well, there no review of experience in the Oncology Department
DO0451 - working with heart disorders.
DO0453 - ..
DO0454 - Kaiser's team care practice may support review by a heart specialist
DO0455 - for heart disorders, including enlarged right ventricle.
Examination Clinical Findings Correlate with Research Stethoscope No
E00401 - ..
E00402 - Clincial Examination Stethoscope No Findings Enlarged Right Ventricle
E00404 - The doctor examined Millie with a stethescope, as called out in
E00405 - research for clinical assesment, also, reported 061012, ref SDS F6
E00406 - IR5T, and he seemed satisfied that the enlarged right ventricle does
E00407 - not present a serious enough problem to consider directed treatment,
E00408 - or further investigation, and that continuing with coumadin is the
E00409 - best course. The doctor did not report hearing characteristic heart
E00410 - sounds for enlarged right ventricle, possibly indicating a moderate to
E00411 - minimal problem, or that sounds for this problem are unfamiliar.
E00413 - ..
E00414 - [On 061108 Millie experiencing symptoms that may be related to
E00415 - enlarged right ventricle. ref SDS G9 VR6F
Pulmonary Emboli Coagulapathy Report Family History Blood Clots Gene
E50401 - ..
E50402 - Coagulapathy Report Family Genetic Disposition Pulmonary Emboli
E50403 - Hypercoabulable State Work Up Risk Assessment Treatment Guidance
E50405 - The doctor advised that he received a document faxed from the doctor
E50406 - treating Millie's family member; however, it listed only medications
E50407 - prescribed for pulmonary emboli, and did not present the coagulapathy
E50408 - study that describes underlying family genetic disposition, as
E50409 - requested during the meeting on 060929. ref SDS F1 QT6N
E50411 - ..
E50412 - Millie asked if Kaiser still needs the coagulapathy study in light of
E50413 - her diagnosis and treatment for pulmonary embolism, reported by the
E50414 - doctor on 061002? ref SDS F4 0001
E50416 - ..
E50417 - The primary care physician indicated he would like to have the study,
E50418 - if it is not too much trouble. Previously, on 050922 Doctor Bailey
E50419 - recommended in a 2nd opinion that Kaiser perform a hypercoagulable
E50420 - state work up. Millie's family history of blood clot issues, and now
E50421 - her own recurrence increases risks of blood related treatment which
E50422 - can be aided with full understanding of family history for
E50423 - hypercoagulable state, as reviewed on 060929. ref SDS F1 9U4G
E50425 - [On 061027 Millie hospitalized 102.6 temperature, cellulitis
E50426 - complications from lymphedema, and pulmonary emboli. ref SDS G3
E50427 - PP9Q
E50429 - ..
E50430 - [On 061030 called and confirmed request for coagulapathey report.
E50431 - ref SDS G4 IM90
E50433 - ..
E50434 - [On 061031 letter requesting coagulapathy report. ref SDS G5 FW8M
E50436 - ..
E50437 - [On 061102 coagulapathy report received on family history;
E50438 - indicates possible finding Millie has increased genetic risk
E50439 - for blood clots, including pulmonary embolism. ref SDS G7
E50440 - KJ3H
E50442 - ..
E50443 - [On 061103 coagulapathy report submitted to doctor at Kaiser
E50444 - through the advice nurse. ref SDS G8 VR6F
E50446 - ..
E50447 - [On 061110 primary care physician received the coagulapathy
E50448 - report on first-degree relative submitted today on 061103,
E50449 - ref SDS G8 VR6F; the paragraph on risks and follow up to
E50450 - treat pulmonary emboli, ref SDS G8 N18S, was highlighted in
E50451 - the doctor's printed version, ref SDS H0 N18S; the doctor
E50452 - advised that the report shows positive findings for
E50453 - acquired rather than inherited DNA genetic risk for blood
E50454 - clots, and in this case pulmonary emboli, ref SDS H0 626L;
E50455 - the doctor recommended against further measures to evaluate
E50456 - patient profile, including defer hypercoagulable state work
E50457 - up, and indicated no adjustments required in diagnosis and
E50458 - treatment. ref SDS H0 JT6N
Work Plan Doctor Submits Doctor/Patient Partnership Communications I
EA0401 - ..
EA0402 - Work Plan Received Communications Doctor/Patient Partnership
EA0403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
EA0404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
EA0406 - Follow up ref SDS F1 FE4I, ref SDS E7 FE4I.
EA0408 - ..
EA0409 - The doctor's initiative today incorporating the agenda from Millie's
EA0410 - letter into Kaiser's electronic Medical Chart, per above, ref SDS 0
EA0411 - NO6O, facilitated discussions for comprehensive care. ref SDS 0 684G
EA0412 - Collaboration to save time and avoid mistakes applies Kaiser's policy
EA0413 - of leveraging medical capabilities with a doctor/patient partnership
EA0414 - model, reported on 990625. ref SDS 4 4185
EA0416 - ..
EA0417 - [On 061110 doctor worked from agenda transferred into
EA0418 - Kaiser's electronic Medical Chart, so Millie does not write
EA0419 - the list on the marking board. ref SDS H0 K84N
EA0421 - ..
EA0422 - Doctor's Progress Notes in the medical chart were submitted at the
EA0423 - conclusion of the meeting, and received via email, continuing
EA0424 - efficiencies begun on 060711. ref SDS C6 FE4I Kaiser's email
EA0425 - correspondence system can be transferred with cut and paste into SDS
EA0426 - for intelligence support, explained in NWO. ref OF 13 A56M This is a
EA0427 - big improvement on prior practice of not getting any feedback, or
EA0428 - getting printed documents that require typing everything for command
EA0429 - and control of the record with precision access using connections to
EA0430 - chronology in the organic structure of context required for effective
EA0431 - case management.
EA0433 - ..
EA0434 - Vitals and other aspects of the medical chart were again omitted from
EA0435 - the Kaiser's letter submitted to the patient, continuing the problem
EA0436 - reported on 060929. ref SDS F1 1153 This was discussed today. The
EA0437 - problem is lack of experience using Kaiser's computer system. Getting
EA0438 - certain technical details from paragraphs 1 - 6, which were provided
EA0439 - in the record for meeting with the backup doctor on 060808,
EA0440 - ref SDS E0 D64Q, requires using other parts of Kaiser's computer
EA0441 - program. This takes training and assistance from another doctor, a
EA0442 - technician, or nurse. Since the doctor was already 30 minutes late to
EA0443 - the meeting, ref SDS 0 SM6M, adding time into the work flow for
EA0444 - technical support disrupts the doctor's meeting, disrupts the train of
EA0445 - thought, and dialog, and for an unknown amount of time. Finding
EA0446 - someone who is skilled and available for technical assistance where
EA0447 - there are a lot patients waiting for medical attention, therefore,
EA0448 - makes Knowledge Management seem like unnecessary overkill.
EA0450 - [On 061024 case study medical practice computer access
EA0451 - limited even with everything on the computer, people can't
EA0452 - find details stored in parts of the computer (software
EA0453 - modules) that are not frequently used. ref SDS G1 JD9L
EA0455 - ..
EA0456 - [On 061214 treatment mistake pulmonary embolism warfarin
EA0457 - (Coumadin) conflicts with prescription for Diflucan; blood
EA0458 - test INR rises 6.4 danger zone for hemoraging; blood clot
EA0459 - coagulation treatment paused for 3 days; INR update test
EA0460 - advanced. ref SDS H3 HF4O
EA0462 - ..
EA0463 - Lack of familiarity with different parts of Kaiser's medical chart
EA0464 - computer system was discussed by...
EA0466 - Infusion Clinic........................... 061020, ref SDS G0 TR53
EA0467 - Oncology Pharmacy......................... 061020, ref SDS G0 RS6H
EA0468 - Oncology Clinic........................... 061020, ref SDS 0 YQ7L
EA0469 - Coagulation Treatment Clinic.............. 061026, ref SDS G1 TZ4I
EA0471 - ..
EA0472 - A work around for vitals is drawing the data from the report created
EA0473 - for chemotherapy treatment in the Infusion clinic that is captured
EA0474 - just prior to meeting with the doctor.
EA0477 - ..
EA0478 - Patient Correspondence No Record Document Management in Medical Chart
EA0480 - The doctor does not mention in the Progress Note receiving patient's
EA0481 - correspondence into the medical chart...
EA0483 - 1. Letter commending Kaiser and Arlette
EA0484 - for saving time and money assembling
EA0485 - thorough and orderly packet of patient
EA0486 - medical history to facilitate 2nd
EA0487 - opinion review by UCSF which earned
EA0488 - $200 credit (30% reduction) on
EA0489 - cost for 2nd opinion.................. 061011, ref SDS F5 WW4Q
EA0491 - ..
EA0492 - 2. Letter asking about severity of
EA0493 - pulmonary embolism, and other
EA0494 - issues from CT test on 060930
EA0495 - submitted on 061012 and received
EA0496 - by the patient........................ 061013, ref SDS F7 UR7K
EA0498 - ..
EA0499 - 3. Letter submitting agenda, and with
EA0500 - context on critical issues............ 061020, ref SDS 0 NO6O
EA0502 - ..
EA0503 - Progress continues toward good management using the doctor patient
EA0504 - partnership for timely review of patient history, called out in
EA0505 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 4 TD5S, and
EA0506 - recently reported on 060106. ref SDS 96 FE4I
EA0508 - 1. 10/20/2006 04:40 PM
EA0510 - Wcr-ONnc2 > Main Campus
EA0513 - ..
EA0514 - 2. Your primary care clinician is listed as...