CONTACTS 

SUBJECTS
Meeting Doctor Examination 5th Review Prepare for Treatment #5 After

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS G4 0000. ref SDS F3 0000.
040502 -
040503 - The doctor took proactive measures to change his schedule and meet
040504 - with Millie today, as originally scheduled. ref SDS 0 2Y5M  Relapse of
040505 - Cellulitis on 061112 seems to be under control again. ref SDS 0 MW8J
040506 - Millie suffered another cat bite that may cause a delayed reaction.
040507 - ref SDS 0 ZW6M  The doctor feels that erratic cancer marker CA 15-3
040508 - diagnostics, ref SDS 0 GJ5M, together with similar findings of pockets
040509 - that risist treatment for IBC red rash on the left chest, ref SDS 0
040510 - 025H, indicate that changing treatment may be required.  The cat bite
040511 - a few weeks ago may have caused erratic changes in the cancer marker
040512 - and the rash which could be Cellulitis. ref SDS 0 P66O  The doctor
040513 - wants to meet next week on 061208 to consider a change in strategy.
040514 - ref SDS 0 ZZ9N  Pulmonary embolism symptoms continue of fatigue and
040515 - shortness of breath with normal activity.  Prescription for Procrit
040516 - was not renewed, because hemoglobin blood count increased to the
040517 - normal range. ref SDS 0 CV5L  Doctor plans to order another PET scan
040518 - test to set a baseline for new treatments. ref SDS 0 EY5O  This can
040519 - evaluate esophagitis, and perform analysis to compare with prior CT
040520 - tests to evaluate pulmonary embolism. ref SDS 0 ZY5L
040521 -
040522 -     [On 061203 patient relapses with cellulitis in the left arm, which
040523 -     could be delayed reaction to the cat bite a few weeks ago,
040524 -     ref SDS H0 MF9H, very slight temperature; notify primary care
040525 -     physician. ref SDS H0 5X3N
040527 -      ..
040528 -     [On 061204 patient notifies Kaiser that inflammation has spread
040529 -     from the left chest area infected with IBC across the sternum and
040530 -     slightly onto the right breast. ref SDS H1 AE5I
040531 -
040532 -
040533 -
040534 -
040535 -
040537 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
040902 -
040903 - Follow up ref SDS G4 SM6M, ref SDS F3 SM6M.
040904 -
040905 - This is the 7th review meeting for the 7th chemotherapy cycle, as
040906 - reported in another record today, ref SDS G9 407N, and following start
040907 - of treatments on 060711, ref SDS B9 SM6M, for the 3rd relapse of IBC.
040908 - ref SDS B9 8Y8I  Since there were 8 previous cycles ending as shown on
040909 - 050916, ref SDS 77 407N, today begins the 15th overall treatment with
040910 - this protocol.
040912 -  ..
040913 - The doctor had a hectic schedule today.  He did an outstanding job
040914 - adjusting to correct scheduling snafus, reported below. ref SDS 0 N96O
040915 - The meeting scheduled for 1530 started at 1620.
040917 -  ..
040918 - Since the meeting today was not scheduled, Millie did not submit an
040919 - agenda.  There was not enough time to consider all of the pending
040920 - issues.  The agenda for the previous meeting on 061110, ref SDS G4
040921 - NO6O, supports the meeting today....
040922 -
040923 -    1.  CA 15-3 review seems negative.................. ref SDS 0 GJ5M
040924 -    2.  Lymphedema/Cellulitis treatment effective...... ref SDS 0 MW8J
040925 -    3.  Breast exam IBC biopsy measurable disease...... ref SDS 0 025H
040926 -    4.  Treatment plan strategy........................ ref SDS 0 K36G
040927 -    5.  Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
040928 -    6.  PE symptoms cough clearing throat fatigue...... ref SDS 0 CV5L
040929 -    7.  Esophagitis, heart burn........................ ref SDS 0 JP6K
040930 -    8.  Eyes tearing................................... ref SDS 0 OH6I
040932 -  ..
040933 - The doctor's notes list no agenda, reflecting expedited procedures for
040934 - this unscheduled meeting. ref SDS 0 684G
040936 -  ..
040937 - Kept the schedule to meet next Friday, 061208 to assess change in
040938 - treatment strategy.
040939 -
040940 -
040941 -
040942 -
0410 -

SUBJECTS
Complex Patient History 34 Issues Overwhelms Span of Attention Drive

0603 -
060401 -  ..
060402 - Complex Patient History Knowledge Management Dilemma Issues Grow 34
060403 -
060404 - Follow up ref SDS G4 LU3J, ref SDS F3 PB3H.
060405 -
060406 - Sampling of issues patient history diagnosis and treatment...
060407 -
060408 -    1.  CA 15-3 monitors advance of cancer response to treatment
060409 -    2.  Lymphedema complicated by mastectomy surgery
060410 -    3.  Broken finger from minor fall complicates lymphedema
060411 -    4.  Esophagitis reflux digestion issues
060412 -    5.  Immune system chemotherapy increases risk of infection
060413 -    6.  Chemotherapy increase risk of infection
060414 -    7.  Cat bites increase risk of infection complicates lymphedema
060415 -    8.  Pneumonia chemotherapy increases risk of infection
060416 -    9.  Metastatic cancer increases risk pulmonary embolism
060417 -   10.  Lymphadenopathy left axilla local regional metastasis
060418 -   11.  Lymphadenopathy right axilla distant metastasis
060419 -   12.  Lymphadenopathy left supraclavicular diagnose metastatic cancer
060420 -   13.  Mastectomy surgery impact on cancer treatment and lymphedema
060421 -   14.  Breast cancer secondary IBC 3rd relapse
060422 -   15.  Cancer mutates slow response chemotherapy treatment
060423 -   16.  Blood vessels removed mastectomy slow chemotherapy treatments
060424 -   17.  Treatment options, strategy, planning, schedule
060425 -   18.  Drug trials increase declining pool chemotherapy agents
060426 -   19.  UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
060427 -   20.  Pulmonary embolism blood clots in lungs
060428 -   21.  INR weekly adjustments Coumadin treatment blood clots
060429 -   22.  Enlarged right ventricle heart problem core pulmonale
060430 -   23.  Dizziness symptom enlarged right ventricle cor pulmonale
060431 -   24.  Fatigue shortness breath side effect chemotheapy loss fitness
060432 -   25.  Fatigue shortness breath symptom pulmonary embolism
060433 -   26.  Shortness breath fatigue dizzy symptoms pulmonary embolism
060434 -   27.  Coagulapathy hypercoagulable state work up genetic risks
060435 -   28.  Testing resolution of errors (see Benz 2nd opinion 060821)
060436 -   29.  Testing distant metastatic disease
060437 -   30.  Testing resolution pulmonary emoblism and heart disease
060438 -   31.  Communication hectic schedule not enough time to manage details
060439 -   32.  Emotional stress and well being
060440 -   33.  Cellulitis inflammation temperature 102.6 on chemotherapy
060441 -   34.  Urinary tract bladder infection
060442 -
060443 -
060444 -
060445 -
0605 -

SUBJECTS
Vitals Obtain from Infusion Clinic Progress Note Meeting Doctor John

0803 -
080401 -  ..
080402 - Vitals Show Stable Medical Condition
080403 -
080404 - Follow up ref SDS G4 KB5L, ref SDS F3 KB5L.
080406 -                           ..
080407 -                          Bld Prssr   Pulse   Temp   Weight  SaO2
080408 -     ..
080409 -    061201 1430............ 123 76     76     97.5
080410 -    061110................. 136 83     73     97.0    150     98%
080411 -    061020 1534............ 140 79     67     99.8    151     97
080412 -    060929 1452............ 141 78     66     98.3
080413 -    060908 1335............ 139 79     73     98.1
080414 -    060814 1610............ 139 80     59     98.2
080415 - *  060808.................
080416 -    060711................. 172 87     54     97.5    147
080417 -    060623................. 141 87     71     98.0    147     99%
080418 -    060428................. 129 73     80     99.4    149     99%
080419 -    060217................. 153 81     61     98.6    150     99%
080420 -
080421 - ...per Doctor's report, shown below, vitals were obtained from the
080422 - record on treatment today in the Infusion Clinic. ref SDS G4 JQ4J
080423 -
080424 -
080425 -
080426 -
080427 -
080428 -
0805 -

SUBJECTS
CA 15-3 67 Erratic Rise After Dramatic Drop to 56 Indicates Slow Res

2303 -
230401 -  ..
230402 - CA 15-3 Cancer Marker 67 Rises from Prior Test on 061110
230403 -
230404 - Follow up ref SDS G4 087J, ref SDS F3 087J.
230405 -
230406 - The test yesterday shows CA 15-3 cancer marker at 67.  There were two
230407 - other tests since the prior meeting on 061110.  The test for a blood
230408 - draw during treatment in the Infusion Clinic 061110 shows a
230409 - significant drop from 61 down to 56.  Another interim test on 061116
230410 - shows a rise to 66; then over the past two weeks there was a rise of
230411 - only 1 tick to 67.
230413 -           ..
230414 -          Test Date                         Date Received
230415 -          061130......... 67 H............. 061201, ref SDS 0 087J
230416 -          061116......... 66 H............. 061201, ref SDS 0 087J
230417 -          061110......... 56 H............. 061201, ref SDS 0 087J
230418 -          061109......... 61 H............. 061110, ref SDS G4 087J
230419 -          061026......... 57 H............. 061110, ref SDS G4 087J
230420 -          061019......... 56 H............. 061020, ref SDS F3 087J
230421 -          060928......... 51 H............. 060929, ref SDS E5 087J
230422 -          060907......... 68 H............. 060929, ref SDS E5 087J
230423 -          060813......... 73 H............. 060817, ref SDS E0 U24M
230424 -          060809......... 87 H............. 060810, ref SDS D8 2N5J
230425 -          060708......... 71 H............. 060711, ref SDS B9 087J
230426 -          060616......... 63 H............. 060623, ref SDS B7 UQ5Q
230427 -          060522......... 59 H............. 060605, ref SDS B2 UQ5Q
230428 -          060501......... 49 H............. 060522, ref SDS A9 MC4F
230429 -          060421......... 44 H............. 060428, ref SDS A2 087J
230430 -          060330......... 40 H............. 060428, ref SDS A2 087J
230431 -          060303......... 36............... 060428, ref SDS A2 087J
230432 -          060210......... 33............... 060217, ref SDS 92 087J
230433 -          060109......... 34............... 060126, ref SDS 91 KV59
230434 -          051223......... 34............... 060106, ref SDS 90 087J
230435 -          051202......... 28............... 060106, ref SDS 90 087J
230436 -          051116......... 31............... 051121, ref SDS 88 087J
230437 -          051109......... 30............... 051121, ref SDS 88 087J
230438 -          051102......... 34............... 051121, ref SDS 88 087J
230439 -          050909......... 45 H............. 051007, ref SDS 82 087J
230440 -          050826......... 45 H............. 050913, ref SDS 76 087J
230441 -          050819......... 45 H............. 050913, ref SDS 76 087J
230442 -          050812......... 39 .............. 050819, ref SDS 69 3K6L
230443 -          050729......... 45 H............. 050819, ref SDS 69 EA5G
230444 -          050708......... 46 H............. 050729, ref SDS 68 087J
230445 -          050701......... 37 .............. 050729, ref SDS 68 087J
230446 -          050617......... 45 H............. 050729, ref SDS 68 087J
230447 -          050527......... 56 H............. 050610, ref SDS 65 087J
230448 -          050512......... 67 H............. 050520, ref SDS 63 087J
230449 -          050506......... 80 H............. 050520, ref SDS 63 087J
230450 -  ..
230451 -          050415.........105 H............. 050422, ref SDS 60 087J
230452 -          050325.........100 H............. 050329, ref SDS 58 087J
230453 -          050318.........101 H............. 050325, ref SDS 57 2N5J
230454 -          050304......... 88 H............. 050311, ref SDS 55 087J
230455 -          050225......... 95 H............. 050308, ref SDS 54 0001
230456 -          050211......... 78 H............. 050214, ref SDS 53 02BB
230457 -          050128......... 67 H............. 050204, ref SDS 51 087J
230458 -          041228......... 56 H............. 041230, ref SDS 50 087J
230459 -          041204......... 43 H............. 041210, ref SDS 49 087J
230460 -          041007......... 39............... 041104, ref SDS 45 087J
230461 -          040923......... 49 H............. 041005, ref SDS 43 087J
230462 -          040908......... 44 H............. 040909, ref SDS 42 087J
230463 -          040825......... 47 H............. 040909, ref SDS 42 087J
230464 -          040811......... 42 H............. 040812, ref SDS 41 087J
230465 -          040728......... 43 H............. 040729, ref SDS 39 2N5J
230466 -          040712......... 47 H............. 040713, ref SDS 38 087J
230467 -          040614......... 55 H............. 040615, ref SDS 37 PX6X
230468 -          040517......... 78 H............. 040601, ref SDS 35 2N5J
230469 -          040311......... 70 H............. 040318, ref SDS 28 SM6M
230470 -          040205......... 60 H............. 040211, ref SDS 26 SM6M
230471 -          031201......... 62 H............. 031205, ref SDS 25 SM6M
230472 -          030912......... 66 H............. 030915, ref SDS 24 SM6M
230473 -          030708......... 68 H............. 030710, ref SDS 23 SM6M
230474 -          030503......... 54 H............. 030508, ref SDS 21 SM6M
230475 -          030403......... 45 H............. 030508, ref SDS 21 SM6M
230476 -          030215......... 46 H............. 030220, ref SDS 20 5E6L
230477 -          030106......... 37 H............. 030109, ref SDS 19 SM6M
230478 -          021202......... 41 H?............ 021204, ref SDS 18 SP5G
230479 -          021111......... 36 H?............ 021113, ref SDS 17 Y65I
230480 -          021023......... 33 H?............ 021023, ref SDS 16 SQ5I
230481 -          020930......... 33 H?..39........ 021002, ref SDS 15 SQ5I
230482 -          020917......... 36 H?............ 020924, ref SDS 14 SQ5I
230483 -          020717......... 59 H?............ 020726, ref SDS 13 YN5K
230484 -          020629......... 75 H ............ 020705, ref SDS 11 UX6I
230485 -          020608........  67 H ............ 020614, ref SDS 9 0001
230486 -          020603........ 108 H ............ 020607, ref SDS 8 X67F
230487 -          020511........ 117 H ............ 020603, ref SDS 7 PJ4J
230488 -          020419......... 81 H ............ 020430, ref SDS 5 7N5H
230489 -          020321......... 85 H ............ 020405, ref SDS 4 6T8K
230490 -
230491 -
230492 -
230493 -
230495 -  ..
2305 -
2306 -
2307 - Analysis
2308 -
230801 - CA 15-3 67 Cancer Marker Falls Significantly Rises Significantly
230802 -
230803 - Follow up ref SDS G4 GJ5M, ref SDS F3 GJ5M.
230804 -
230805 - The doctor started the meeting by holding up the list of changes in
230806 - the CA 15-3 cancer marker, ref SDS 0 087J, to discuss the prospect
230807 - that the current treatment may not be effective.  Several small areas
230808 - of IBC inflammation resist treatment on the left chest per examination
230809 - below. ref SDS 0 025H, aligns with cancer marker increasing and
230810 - decreasing erratically, noted by the doctor today.  Therefore the
230811 - doctor ended treatment with Taxotere and capecitabine today, and plans
230812 - to start a different regimen after the 1st of the year. ref SDS 0 ZZ9N
230814 -  ..
230815 - The doctor seemed to feel this record on CA 15-3 may signal disease
230816 - has mutated, becoming increasingly resistant to the current treatment
230817 - protocol, considered previously on 061110, ref SDS G4 GJ5M, reviewing
230818 - scenario #2 developed on 060808. ref SDS D5 HT5K  Effectiveness of
230819 - treatment protocol has fallen, and/or treatment is not being delivered
230820 - to infected tissue because mastectomy surgery created "pockets of
230821 - resistance" by removing blood vessels with mastectomy surgery on
230822 - 051021, reviewed recently on 061020. ref SDS F3 KU4L
230823 -
230824 -     [On 061208 IBC progresses speading from left to right breast.
230825 -     ref SDS H2 025H
230827 -      ..
230828 -     [On 061230 Kaiser collaboating with UCSF on switching treatments
230829 -     to clinical study drug trial cetuximab carboplatin. ref SDS H4
230830 -     PN5X
230832 -      ..
230833 -     [On 061230 CA 15-3 presented for measurable disease IBC cases.
230834 -     ref SDS H4 PO3V
230836 -  ..
230837 - There might be a possibility that CA 15-3 spiked on 061116 due to the
230838 - cat bite Millie suffered on 061114.  This was reported to Kaiser in a
230839 - letter on 061116, ref SDS G8 MD6R, citing the record on 061115.
230840 - ref SDS G7 0001  Erratic CA 15-3 cancer diagnostics reported today,
230841 - following a cat bite on 061114 follows the prior pattern in 2005 of
230842 - steep changes in the cancer marker after a cat bite on 050212.
230843 - ref SDS 0 8888
230844 -
230845 -     [On 061208 patient's letter to the doctor cites correlation
230846 -     between cat bites, and erratic swings in red rash on left chest,
230847 -     and in CA 15-3 cancer marker test diagnostics. ref SDS H2 GJ5M
230849 -  ..
230850 - The good news is that cancer is not getting worse fast, but seems to
230851 - resist full recovery after 6 cycles, which was achieved last year
230852 - after only 5 cycles, reported on 050727. ref SDS 67 YY7F  Review on
230853 - 060922 presents factors that reconciles differences in the rate of
230854 - recovery. ref SDS E3 GA8H
230855 -
230856 -
230857 -
230858 -
230859 -
2309 -

SUBJECTS
Digestion Problems Increasing GERD Worse Doctor Plans to Order PET S

2703 -
270401 -  ..
270402 - Digestion Problems Increasing Relatively Infrequent Mild
270403 - Esophagitis Not Compared in Current PET Test with Prior Report
270404 -
270405 - Follow up ref SDS G4 JP6K, ref SDS F3 JP6K.
270406 -
270407 - Millie reported that frequency and severity of indegestion continue to
270408 - increase, since the report on 061110. ref SDS G4 JP6K
270410 -  ..
270411 - Background on PET scan and CT scan tests finding likely esophagitis is
270412 - reviewed on 061110. ref SDS G4 Y46K
270414 -  ..
270415 - Next week on 061208, the doctor plans to order another PET scan test.
270416 - Hopefully this will clarify diagnosis and lead to a treatment plan, as
270417 - shown below. ref SDS 0 EY5O  The doctor's progress report in the
270418 - medical chart reflects these understandings, now noting GERD worse.
270419 - ref SDS 0 1248
270420 -
270421 -     [On 061208 doctor added order for analysis of next PET scan test
270422 -     to compare with prior tests on 060414, and with the CT test on
270423 -     060505 to clarify diagnosis of esophagatis, or other condition
270424 -     causing increased digestion problems. ref SDS H2 5X40
270425 -
270426 -
270427 -
270428 -
270429 -
270430 -
270431 -
2705 -

SUBJECTS
Left Axillary Lymphadenopathy Patient No Complaint of Swelling Disco

4403 -
440401 -  ..
440402 - Cellulitis Complications Lymphedema Cleared Treatment Ends
440403 - Left Axillary No Evidence Lymphadenopathy Cellulitis Treatment Ends
440404 - Lymphedema Left Arm Lump Under Arm Diagnosis Not Cancer
440405 - Post Operation Localized Edema Left Axillary Swelling Reduced
440406 -
440407 - Follow up ref SDS G4 MW8J, ref SDS F3 MW8J.
440409 -  ..
440410 - Patient history of left axillary lymphadenopathy and lymphedema is
440411 - reported on 060106. ref SDS 90 S164
440413 -  ..
440414 - There was no examination today for cancer in left axilla.  The patient
440415 - again made no complaint of lumps or discomfort from swelling under the
440416 - left arm.
440418 -  ..
440419 - Background of lymphedema and complications of Cellulitis is reported
440420 - on 061110. ref SDS G4 TM8O
440422 -  ..
440423 - Examination on 061110 showed the left arm was cleared of Cellulitis
440424 - infmallation. ref SDS G4 A640
440426 -  ..
440427 - Two (3) days later, on 061112 patient relapses, ref SDS G5 HP52, and
440428 - was examined by Doctor Seier at Internal Medicine Clinic, Kaiser in
440429 - Walnut Creek. ref SDS G5 FP67  The doctor prescribed antibiotics for
440430 - another 10 days. ref SDS G5 BX4G  Millie's letter, ref DIP 4 0001, on
440431 - 061113 to Kaiser notified the primary care physician about recurrence,
440432 - and treatment steps. ref SDS G6 5K5G
440434 -  ..
440435 - On 061116 Millie submitted a follow up letter to Kaiser, ref DIP 5
440436 - 0001, notifying the primary care physician that additional treatment
440437 - seems to have Cellulitis inflammation under control. ref SDS G8 6T5L
440439 -  ..
440440 - Millie suffered a cat bite to her right hand on 061114.  A report the
440441 - next day on 061115 shows there was no immediate adverse medical
440442 - reaction, including no elevated temperature. ref SDS G7 0001  Millie
440443 - advised Kaiser about the cat bite in the letter on 061116, ref DIP 5
440444 - JE6G, noting there could be a delayed reaction, ref SDS G8 MD6R, like
440445 - the broken finger on 060914, that was later cited as the cause of
440446 - Cellulitis on 061027. ref SDS F6 V759  Millie has a history of bad
440447 - reaction to cat bites while on chemotherapy.  Last year on 050212 she
440448 - was treated in the emergency room and hospitalized for 4 days.
440449 - ref SDS 52 0001
440451 -  ..
440452 - Measurements before the meeting today of location below elvow 11.25"
440453 - shows lymphedema swelling in left arm stable at elevated levels,
440454 - reported in case study on 060509. ref SDS A7 HO7F
440456 -      ..
440457 -     [On 061203 patient relapses with cellulitis in the left arm, which
440458 -     could be delayed reaction to the cat bite a few weeks ago,
440459 -     ref SDS H0 MF9H, very slight temperature; notify primary care
440460 -     physician. ref SDS H0 5X3N
440462 -  ..
440463 - Since this was a non-scheduled meeting for the purpose of considering
440464 - IBC and pulmonary embolism, the doctor deferred review of this issue
440465 - until the regularly scheduled meeting next week on 061208.
440466 -
440467 -
440468 -
440469 -
440470 -
440471 -
440472 -
4405 -

SUBJECTS
Right Axillary Clinical Examination Finds No Lump Patient Complains

4903 -
490401 -  ..
490402 - Right Axillary FDG SUV 2.5 Lump Discomfort Not Reported by Patient
490403 -
490404 - Follow up ref SDS G4 3D6K, ref SDS F3 3D6K.
490405 -
490406 - Background on patient history of testing for lymphedanopathy in the
490407 - right axilla is reported in the record on 060929. ref SDS E5 3D6K
490409 -  ..
490410 - There was no examination today for cancer in right axilla.  The
490411 - patient made no complaint of lumps or discomfort from swelling under
490412 - the right arm.  This work aligns with CT test on 060930 that found no
490413 - evidence of disease in the right axillary, reported on 061020.
490414 - ref SDS F3 8T4S
490415 -
490416 -      [On 061204 patient notifies Kaiser that inflammation has spread
490417 -      from the left chest area infected with IBC across the sternum and
490418 -      slightly onto the right breast. ref SDS H1 AE5I
490419 -
490420 -
490421 -
490422 -
490423 -
4905 -

SUBJECTS
Left Supraclavicular Neck CT Test Contrast Study on 060505 Finds No

5703 -
570401 -  ..
570402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
570403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
570404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
570405 -
570406 - Follow up ref SDS G4 8R6M, ref SDS F3 8R6M.
570407 -
570408 - Background of image testing, and consideration for radiation treatment
570409 - of left supraclavicular is reported on 060623. ref SDS B7 8R6M
570411 -  ..
570412 - Like the left and right axillary locations, there was no examination
570413 - today for cancer in left supraclavicular region.  The patient made no
570414 - complaint of lumps or discomfort from swelling in this area.  This
570415 - work aligns with CT test on 060930 that found no evidence of disease
570416 - in the left supraclavicular location, reported on 061020. ref SDS F3
570417 - LP5G
570418 -
570419 -
570420 -
570421 -
570422 -
5705 -

SUBJECTS
Examination IBC Red Rash Left Breast Worse Increased Erythema Lower

7203 -
720401 -  ..
720402 - Pockets of Resistance to Treatment of IBC Red Rash Left Breast
720403 - IBC Red Rash Left Breast Stable Not Responding to Treatment
720404 - Red Rash Stable Left Breast Rising CA 15-3 No Response to Treatment
720405 - Examination Left Breast IBC Inflammation Red Rash Seems Stable Rising
720406 -
720407 - Follow up ref SDS G4 025H, ref SDS F3 025H.
720408 -
720409 - Background on prior relapse examinations is listed on 060711.
720410 - ref SDS B9 8Y7O
720412 -  ..
720413 - The doctor examined Millie's left breast area showing IBC red rash
720414 - seems worse, as indicated might be occurring during examination on
720415 - 061020, ref SDS F3 XO5L, and again last month on 061110. ref SDS G4
720416 - RU6J, when the doctor reported condition is not improved, i.e., no
720417 - evident recovery, citing "pockets of resistance" to the current
720418 - treatment protocol. ref SDS G4 569G
720420 -  ..
720421 - Worsening IBC and rising CA 15-3 cancer marker cited today, per above,
720422 - ref SDS 0 GJ5M, indicate progression of disease that requires changing
720423 - treatments.
720425 -         ..
720426 -        [...below, Medical Chart doctor's progress notes describe
720427 -        "increased erythema on lower chest wall." ref SDS 0 ZL5W
720429 -         ..
720430 -        [On 061204 patient notifies Kaiser that IBC may have spread
720431 -        from left chest area to the right breast may require biopsy to
720432 -        verify, since it could be cellulitis. ref SDS H1 I93X
720434 -  ..
720435 - The problem to solve was described in the record on 061110 saying in
720436 - part that IBC may not be responding to systemic treatment under
720437 - scenario #2 presented in the record on 060808. ref SDS D5 HT5K  On
720438 - 050311 the doctor presented a theory that "pockets" of cancer resist
720439 - treatment with chemotherapy, and so must be removed with surgery.
720440 - ref SDS 55 PA4N  This may be occurring due to cancer mutating, and
720441 - compounded by mastectomy surgery that removed blood vessels, which
720442 - normally deliver treatment to infected tissue, discussed further
720443 - below. ref SDS G4 EH3F
720445 -  ..
720446 - The doctor apologized for scheduling mixup and computer problems that
720447 - almost prevented meeting today, per below. ref SDS 0 N96O  He
720448 - explained urgency that rising cancer marker and worsening IBC rash
720449 - signal Millie has suffered a 4th relapse.  Cancer gets worse and
720450 - harder to treat with each relapse, so timely change to a new treatment
720451 - is critical.  He wants to meet again next week on 061208 to schedule
720452 - another PET scan test for a new baseline to change treatment, per
720453 - review of strategy below. ref SDS 0 ZZ9H
720454 -
720455 -        {...below Medical Chart work plan schedules meeting next week
720456 -        on 061208 to consider prescribing treatment with either
720457 -        Navelbine or Genzar. ref SDS 0 125V
720459 -  ..
720460 - 7indings today of 4th relapse of cancer, and 3rd relapse of IBC extend
720461 - case study on 060711 reporting Millie's 3rd relapse. ref SDS B9 8Y8I
720462 -
720463 -        1.  Lymph node biopsy positive start
720464 -            bevacizumab Taxotere.............. 040318, ref SDS 28 8R6M
720465 -        2.  Cancer marker IBC increase end
720466 -            bevacizumab Taxotere due to
720467 -            pulmonary embolism................ 041210, ref SDS 49 025H
720468 -        3.  Cancer marker IBC recurs 9 months
720469 -            months after mastectomy........... 060711, ref SDS B9 025H
720470 -        4.  Cancer marker IBC worsens end
720471 -            capeticabine Taxotere............. 061201, ref SDS 0 RU6J
720473 -  ..
720474 - Millie is worried about starting a new treatment, going through all
720475 - the preparation, and tolerating severe side effects of Kaiser's only
720476 - remaining 2 treatments, discussed below, ref SDS 0 ZZ9N, and then just
720477 - to fail again and again.
720478 -
720479 -               [On 070105 Kaiser advises Millie of referral to UCSF for
720480 -               treatment with cetuximab carboplatin clinical trial as
720481 -               the best course to care for her complex patient profile.
720482 -               ref SDS H5 PK7L
720484 -                ..
720485 -               [On 080306 0830 Millie suffers 4th relapse of IBC with
720486 -               progression of disease. ref SDS H7 459G
720488 -  ..
720489 - Millie asked about possibility that rather than progression of cancer,
720490 - could a recent cat bite on 061114 have caused complications of
720491 - Cellulitis in the left chest area, as well as in the left arm (see
720492 - above, ref SDS 0 ZW6M), and per analysis of erratic CA 15-3 cancer
720493 - marker, also above, that shows a similar pattern of dramatic change in
720494 - both directions following a cat bite on 050212. ref SDS 0 P66O
720496 -  ..
720497 - The doctor noted that wihout timely change in treatment beginning
720498 - today, Millie will suffer rapid decline in less than a year.  He said
720499 - that many patients get frightened and decide to end treatments, when
720500 - cancer suddenly gets worse, because going through more meetings and
720501 - tests to change treatments can be very discouraging.  The doctor
720502 - emphasized that Millie seems stronger and more emotionally stable than
720503 - most patients suffering a 4th relapse. ref SDS 0 H54F
720505 -                ..
720506 -               [On 090213 case study patient advised to get affairs in
720507 -               order for life ending in months. ref SDS I2 L19H
720509 -  ..
720510 - He feels Millie's survival and quality of life can be extended by
720511 - acting quickly today on details for her next treatment.  That's why he
720512 - went to all of the trouble today getting everyone to work around
720513 - Kaiser policies to correct scheduling mistakes and computer problems,
720514 - explained below. ref SDS 0 N96O  The doctor indicated that Millie's
720515 - patient history shows physical resiliance, strong will to live, and
720516 - ability to contribute through an effective doctor/patient partnership
720517 - that makes treatment effective.  The key is timely action to prevent
720518 - relapse from losing local control.
720520 -  ..
720521 - Millie thanked the doctor for clarifying a very confusing and
720522 - emotionally traumtic subject.
720524 -         ..
720525 -        [On 061204 patient reports to Kaiser that IBC red rash has
720526 -        worsened, possibily spreading to the right breast, ref SDS H1
720527 -        I93X; later in the day the rash seemed to subside, suggesting
720528 -        possible effects of cat bite, ref SDS H1 PQ7U; another letter
720529 -        reported this dramatic change to the doctor. ref SDS H1 2P8U
720530 -
720531 -
720532 -
720533 -
7206 -

SUBJECTS
Eyes Tearing Increasing Side Effect Taxotere Capecitabine (Xeloda) C

7503 -
750401 -  ..
750402 - Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
750403 -
750404 - Millie reported increased tearing in her eyes, also, reported last
750405 - week during treatment in the Infusion Clinic. ref SDS G9 HM9G  There
750406 - is no evident impact on vision, and no pain.  It is a nusiance to be
750407 - continually wiping her eyes, so that her face is not covered with
750408 - tears.
750410 -  ..
750411 - The doctor suggested that Millie contact Kaiser's eye clinic for an
750412 - examination.
750414 -  ..
750415 - He indicated that changing treatment discussed today, per Work Up
750416 - Strategy Treatment Options, below, ref SDS 0 K36G, may end or at least
750417 - reduce this problem.
750418 -
750419 -
750420 -
750421 -
750422 -
7505 -

SUBJECTS
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea

8103 -
810401 -  ..
810402 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
810403 - Slow Response to Treatment Mastectomy Removed Blood Vessels
810404 - Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
810405 - Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
810406 -
810407 - Follow up ref SDS G4 EH3F, ref SDS F3 EH3F.
810408 -
810409 - Background on slow response to treatment and impending progression of
810410 - disease due to mastectomy surgery on 051021 was reviewed in the record
810411 - for the meeting on 061020, ref SDS F3 EH3F, and again on 061110.
810412 - ref SDS G4 EH3F
810414 -  ..
810415 - This issue seems to be recognized in the doctor's review today of
810416 - treatment strategy, shown below. ref SDS 0 K36G
810417 -
810418 -
810419 -
8105 -

SUBJECTS
Biopsy Left Breast Investigate for Mutated Cancer IBC Red Rash Statu

8703 -
870401 -  ..
870402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
870403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
870404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
870405 -
870406 - Follow up ref SDS G4 KT7J, ref SDS F3 KT7J.
870407 -
870408 - Can a biopsy contribute to patient work up for developing a strategy
870409 - and treatment plan, discussed on 060711, ref SDS B9 K36G, and more
870410 - recently on 061020? ref SDS F3 KH6H  Further review on 061110 presents
870411 - objectives and rationale based on evidence of cancer mutating for
870412 - biopsy of IBC red rash on left breast. ref SDS G4 448F
870413 -
870414 -        [On 061204 patient notifies Kaiser that IBC may have spread
870415 -        from left chest area to the right breast may require biopsy to
870416 -        verify, since it could be cellulitis. ref SDS H1 I93X
870418 -         ..
870419 -        [On 090204 2nd opinion discusses testing tissue to develop best
870420 -        agent for treating cancer. ref SDS I0 9K9W
870421 -
870422 -
870423 -
870424 -
870425 -
870426 -
8705 -

SUBJECTS
PET Scan Test Planning Order 061208 Baseline New Treatment Strategy

9403 -
940401 -  ..
940402 - PET CT Image Testing Distant Metastasis Risks Secondary Cancer
940403 - IBC Test Distant Metastasis Discouraged Avoid Risk Secondary Cancer
940404 - Radiation Image Tests PET CT Limit to Reduce Risk Secondary Cancer
940405 - Risk Secondary Cancer Exposure Radiation Image Testing CT PET Scan
940406 -
940407 - Follow up ref SDS G4 EY5O, ref SDS F3 EY5O.
940408 -
940409 - Doctor plans to place an order during the meeting next week on 061208
940410 - for a PET scan test to evaluate cancer, and set a baseline for
940411 - changing treatment protocols, per review of strategy today, shown
940412 - below. ref SDS 0 K36G
940413 -
940414 -     [On 061208 doctor ordered PET scan test for setting a baseline to
940415 -     evaluate changing chemotherapy treatments. ref SDS H2 EY5O
940417 -  ..
940418 - This test can resolve issues pending from previous tests cited on
940419 - 061110 to compare findings of pulmonary embolism in tests on 041103
940420 - and on 060930, including severity of enlarged right ventricle.
940421 - ref SDS G4 EY5O
940422 -
940423 -    [On 061208 doctor ordered PET scan test to set new baseline for
940424 -    changing chemotherapy to treat IBC; and added to the order request
940425 -    for analysis of pulmonary embolism, and enlarged right ventricle
940426 -    by comparing and contrasting with prior CT tests on 041103 and on
940427 -    060930, even though CT scan tests are a better diagnostic for this
940428 -    comparison. ref SDS H2 ZY5L
940430 -  ..
940431 - With rising symptoms of esophagitis reported the past few months, this
940432 - test can correlate with the PET test on 060120, and the CT test on
940433 - 060505 which both seemed to make findings that relate to esophagitis,
940434 - per discussion above. ref SDS 0 JP6K
940435 -
940436 -
940437 -
940438 -
940439 -
9405 -

SUBJECTS
Emotional Trauma Increases 4 New Issues Cellulitis Relapse Erratic C

9903 -
990401 -  ..
990402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
990403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
990404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
990405 -
990406 - Follow up ref SDS G4 Y642, ref SDS F3 Y642.
990407 -
990408 - Proactive medical management initiating review of treatment protocol
990409 - today is a big relief, reported below. ref SDS 0 ZZ9H
990411 -  ..
990412 - Emotional stress increased from growing list of 10 pending medical
990413 - issues reported on 061020. ref SDS F3 Y642  Following new issues
990414 - increase trauma from doubt and worry...
990416 -             ..
990417 -        1.  Erratic CA 15-3 cancer marker
990418 -            noted by the doctor
990419 -            today.............................. 061201, ref SDS 0 GJ5M
990421 -             ..
990422 -        2.  IBC rash big swings in severity on
990423 -            left breast, with considerations
990424 -            to replace treatment
990425 -            protocol........................... 061201, ref SDS 0 RU7M
990427 -             ..
990428 -        3.  Cellulitis relapse following end
990429 -            of treatment, and possibly delayed
990430 -            reaction to cat
990431 -            bite............................... 061201, ref SDS 0 MD5N
990433 -             ..
990434 -        4.  Pulmonary embolism stable to
990435 -            worsening symptoms after 2 months
990436 -            treatment.......................... 061201, ref SDS 0 2P8H
990437 -
990438 -
990439 -
990440 -
990441 -
990442 -
9905 -

SUBJECTS
Strategy Treatment Plan IBC 3rd Relapse Scope Chemotherapy Drug Agen

A503 -
A50401 -  ..
A50402 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
A50403 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
A50404 -
A50405 - Follow up ref SDS G4 K36G, ref SDS F3 K36G.
A50406 -
A50407 - Background on requirements and challenge performing requirements for
A50408 - planning and proactive management in time for action to be effective
A50409 - is reported on 060825. ref SDS E2 K36G
A50411 -  ..
A50412 - Millie's letter, ref DIP 1 ZL6L, to Kaiser on 061027 asks for review
A50413 - of treatment strategy to address slow response to treatment.
A50414 - ref SDS F5 KJ7K
A50416 -  ..
A50417 - The doctor began the meeting today by holding up patient history on CA
A50418 - 15-3 cancer marker, reported above. ref SDS 0 GJ5M  Examination
A50419 - showing stable to worse IBC rash may indicate scenario #2 for reasons
A50420 - cited above. ref SDS 0 P66G
A50421 -
A50423 -  ..
A50424 - Capecitabine Taxotere Ends Progression of Cancer
A50425 - Navelbine Gemzar Switching Treatments Strategy Review
A50426 - Gemzar Navelbine Switching Treatments Strategy Review
A50427 -
A50428 - Millie asked about the next treatment, since the doctor indicated
A50429 - initially that the cancer marker indicates progression is occuring
A50430 - with capecitabine and Taxotere, per above? ref SDS 0 GJ5M
A50432 -  ..
A50433 - The doctor proposed switching treatment from Taxotere and capecitabine
A50434 - (Xeloda) to chemotherapy agents reviewed on 060711, either Navelbine,
A50435 - ref SDS B9 S07M, or to Gemzar. ref SDS B9 576N  Doctor Benz proposed
A50436 - Gemzar be given in combination with Taxotere, similar to capecitabine,
A50437 - in a 2nd opinion received from UCSF on 041117. ref SDS 46 OU6S
A50439 -  ..
A50440 - The doctor seemed to indicate today that Navelbine and Gemzar are the
A50441 - only remaining chemotherapy agents Kaiser has to treat Millie's
A50442 - advancing IBC complicated by delayed diagnosis for 18 months, reported
A50443 - on 040614. ref SDS 36 6T5G  On 041130 the doctor advised there are a
A50444 - limited number of drugs for treating Millie's complex patient profile,
A50445 - ref SDS 47 763L, with triple negative status shown by original biopsy
A50446 - on 020321. ref SDS 3 LA7O  At that time, on 041130 he explained that
A50447 - drug trials expand the list of chemotherapies that may help Millie.
A50448 - ref SDS 47 028N   He noted again today that since subsequent
A50449 - confirmation on 060711 from retesting the biopsy on 040419 showed that
A50450 - ER/PR/HER2 remain negative, ref SDS B9 SW7O, this severely reduces
A50451 - treatments that can help Millie.
A50453 -  ..
A50454 - Millie asked about side effects.
A50456 -  ..
A50457 - The doctor explained that Gemzar and Navelbine have been available for
A50458 - about 10 years.  Side effects are on the order of capecitabine.  The
A50459 - doctor will moderate side effects by controlling the dose, as was done
A50460 - with capecitabine, reported on 050516. ref SDS 62 AQ6G
A50461 -
A50462 -        {...below Medical Chart work plan schedules meeting next week
A50463 -        on 061208 to consider prescribing treatment with either
A50464 -        Navelbine or Genzar. ref SDS 0 125V
A50466 -         ..
A50467 -        [On 061208 the doctor plans to treat Millie with Navelbine
A50468 -        beginning on 070105. ref SDS H2 RW5I
A50470 -         ..
A50471 -        [On 061208 Navelbine given weekly has severe side effects,
A50472 -        ref SDS H2 P04F, which reduce ability to tolerate treatments
A50473 -        sufficient to prevent cancer from cascading out of control.
A50474 -        ref SDS H2 3B4N; patient profile requires research for
A50475 -        effective solution. ref SDS H2 VD5G
A50477 -         ..
A50478 -        [On 061208 Kaiser research finds no drug trials available at
A50479 -        Kaiser to treat Millie's complex patient profile. ref SDS H2
A50480 -        P24L
A50482 -         ..
A50483 -        [On 061208 Kaiser performing due diligence to investigate
A50484 -        clinical trial treatments for Millie at UCSF. ref SDS H2 P256
A50486 -         ..
A50487 -        [On 061230 Kaiser makes arrangements for treating Millie in
A50488 -        clinical trial at UCSF. ref SDS H4 3X6K
A50490 -         ..
A50491 -        [On 070105 Kaiser advises Millie of referral to UCSF for
A50492 -        treatment with cetuximab carboplatin clinical trial as the best
A50493 -        course to care for her complex patient profile. ref SDS H5 PK7L
A50495 -         ..
A50496 -        [On 070510 woman on clinical study treatment with cetuximab and
A50497 -        carboplatin for 10 months was switched to Gemzar when disease
A50498 -        progressed. ref SDS H6 5P88
A50500 -  ..
A50501 - Doctor discussed plans to order PET scan test for a baseline to
A50502 - evaluate treatments; fits new strategy to change treatment protocols.
A50503 - ref SDS 0 EY5O
A50505 -  ..
A50506 - Progress today developing a work plan helps relieve emotional stress,
A50507 - per above. ref SDS 0 Y642
A50509 -  ..
A50510 - More recently, on 060929 Doctor Benz again recommended consideration
A50511 - of Gemzar, however, in combination with capecitabine, rather than with
A50512 - Taxotere, ref SDS E6 WR3Y, as originally proposed on 061117.
A50514 -  ..
A50515 - Surgery to treat "pockets of resistance" to chemotherapy was mentioned
A50516 - only briefly today.  Analysis of background in the record on 061110
A50517 - was not discussed. ref SDS G4 RU81
A50518 -
A50519 -
A50520 -
A50521 -
A50522 -
A506 -

SUBJECTS
Treatment IBC 7th Relapse Continue Chemotherapy Agents Taxotere Cape

AA03 -
AA0401 -  ..
AA0402 - Treatment Continue 7th Cycle Taxotere and Capecitabine (Xeloda)
AA0403 - 7th Cycle Taxotere and Capecitabine (Xeloda) Treatment Continue
AA0404 - Taxotere and Capecitabine (Xeloda) 7th-Cycle Treatment Continue
AA0405 -
AA0406 - Follow up ref SDS G4 PF3O, ref SDS F3 PF3O.
AA0407 -
AA0408 - The doctor approved treatment today with Taxotere and capecitabine
AA0409 - (Xeloda) for the 7th cycle already begun today in the Infusion Clinic.
AA0410 - ref SDS G9 SG8I
AA0412 -  ..
AA0413 - Despite hectic schedule, noted above, ref SDS 0 2Y5M, the doctor began
AA0414 - consideration of ideas, research, and strategy, as noted above,
AA0415 - ref SDS 0 K36G, to improve the rate of recovery for IBC on the left
AA0416 - breast, which has shown no improvement for several cycles, per above.
AA0417 - ref SDS 0 025H
AA0418 -
AA0419 -
AA0420 -
AA0421 -
AA0422 -
AA05 -

SUBJECTS
Schedule Meeting 061208 Review Treatment Strategy Changes Because Ta

B803 -
B80401 -  ..
B80402 - Schedule New Treatment End Taxotere Capecitabine
B80403 - Medical Necessity Priority Policy Procedure Case Study
B80404 - Policy Procedure Subordinate Medical Necessity Case Study
B80405 - Case Study Policy Procedure Subordinate Patient Medical Necessity
B80406 -
B80407 - Follow up ref SDS G4 N96O, ref SDS F3 N96O.
B80408 -
B80409 - The doctor took immediate action today working around Kaiser policies
B80410 - for medical necessity to enable Millie's care in time to be effective
B80411 - recovering from 4th relapse, per above. ref SDS 0 H54F  This required
B80412 - correcting a scheduling mistake compounded by problems with Kaiser's
B80413 - computer system.
B80415 -  ..
B80416 - Doctor Discretion Medical Necessity Deference Over Policy Procedure
B80417 - Case Study Deference Doctor Discretion Medical Necessity Over Policy
B80418 - Medical Necessity Doctor Discretion Deference Over Policy Procedure
B80419 - Policy Procedure Subordinate Medical Necessity Doctor Discretion
B80420 -
B80421 - Millie's patient history shows Kaiser has routinely applied policy and
B80422 - procedure with deference to doctor's discretion treating medical
B80423 - necessity in time to be effective...
B80424 -
B80425 -        1.  Surgery post-op quarterly follow up
B80426 -            policy to assess complications from
B80427 -            breast cancer was not performed (due
B80428 -            to computer glitch) during 2002 and
B80429 -            2003; biopsy in 2004 diagnosed IBC
B80430 -            which appears to have begun
B80431 -            in 2002.......................... 040419, ref SDS 31 XU75
B80433 -             ..
B80434 -        2.  Time Out policy to evaluate risks
B80435 -            and benefits of invasive surgery
B80436 -            was omitted for medical
B80437 -            necessity........................ 050913, ref SDS 76 5T5N
B80439 -             ..
B80440 -        3.  Pulmonary embolism Kaiser policy that
B80441 -            cancer patients are treated for life;
B80442 -            treatment was ended for medical
B80443 -            necessity........................ 051007, ref SDS 82 XN7K
B80445 -             ..
B80446 -        4.  Surgeon's report complying with Kaiser
B80447 -            policy to document necessity for invasive
B80448 -            surgery performing mastectomy was
B80449 -            omitted from medical
B80450 -            chart............................ 051021, ref SDS 85 QV4H
B80452 -             ..
B80453 -        5.  Treatment denied applying policy
B80454 -            on low blood counts.............. 060810, ref SDS D8 5K4F
B80455 -            even though primary care
B80456 -            physician routinely approves
B80457 -            treatment with low blood
B80458 -            counts........................... 060810, ref SDS D8 HV45
B80460 -             ..
B80461 -        6.  Medications Kaiser policy to evaluate
B80462 -            harmful conflicts is responsibility
B80463 -            of prescribing physician and
B80464 -            pharmacy......................... 061020, ref SDS F2 RT3K
B80465 -            difficult to implement due to
B80466 -            expanding complexity of medications
B80467 -            and constantly changing computer
B80468 -            systems.......................... 061020, ref SDS F2 TR47
B80469 -            primary care doctor cites
B80470 -            reliance on Kaiser computer system
B80471 -            to manage conflicts
B80472 -            between prescribed
B80473 -            medications...................... 061020, ref SDS F3 YQ7L
B80474 -            doctor/patient partnership
B80475 -            enabled collaboration to provide
B80476 -            timely changes to patient
B80477 -            medications...................... 061020, ref SDS F2 VE57
B80479 -             ..
B80480 -        7.  Medications Kaiser policy evaluate
B80481 -            harmful conflicts another mistake
B80482 -            pulmonary embolism warfarin (Coumadin)
B80483 -            conflicts with Doflucan; blood test INR
B80484 -            rises 6.4 danger zone for hemoraging;
B80485 -            blood clot coagulation treatment
B80486 -            paused for 3 days; INR update
B80487 -            test advanced.................... 061214,ref SDS H3 HF4O
B80489 -             ..
B80490 -        8.  Surgery Kaiser policy for "Time Out"
B80491 -            evaluate benefits and risks of
B80492 -            mastectomy was not performed; patient
B80493 -            suffers continual Cellulitis and
B80494 -            lymphedema attributed to removal
B80495 -            of lymphatic system during mastectomy
B80496 -            surgery; patient treated numerous
B80497 -            times in Emergency Room
B80498 -            Department....................... 061027, ref SDS F6 714I
B80500 -             ..
B80501 -        9.  Examinations Kaiser policy to verify
B80502 -            patient ready for treatment relaxed to
B80503 -            benefit patient with timely change in
B80504 -            prescription for progression of cancer;
B80505 -            and required to correct scheduling
B80506 -            mistake and computer system
B80507 -            problems......................... 061201, ref SDS 0 KD44
B80509 -             ..
B80510 -       10.  Neupogen medical necessity accuracy
B80511 -            stage IV cancer patient 5th relapse
B80512 -            deference doctor's discretion correct
B80513 -            mistake prescribe treatment Chemotherapy
B80514 -            Infusion Clinic rather than Kaiser
B80515 -            policy for self-injection
B80516 -            home care........................ 080609, ref SDS H8 IL6I
B80518 -             ..
B80519 -       11.  Stitches removed in Orthopedic Department
B80520 -            which were made in the Emergency Department
B80521 -            to suture wound over Millie's right eye
B80522 -            from fall on 090122; because following
B80523 -            Kaiser policy for patient to return to
B80524 -            ER for removal of stitches was prevented
B80525 -            by ER mistake scheduling the work in the
B80526 -            Orthopedic Department because Millie
B80527 -            needed to go to Orthopedics for follow
B80528 -            up on dislocated shoulder, and the ER
B80529 -            team assumed could take 2 minutes
B80530 -            to remove the stitches rather than
B80531 -            increase time, costs, and stress
B80532 -            with another visit to
B80533 -            the ER........................... 090129, ref SDS H9 01FH
B80535 -             ..
B80536 -       12.  Right arm recovering from dislocated
B80537 -            shoulder was moved at UCSF against Kaiser
B80538 -            policy in Orthopedic Department for 24-7
B80539 -            immobilization under deference to doctor
B80540 -            discretion for medical necessity taking
B80541 -            xrays to layout radiation fields
B80542 -            required for bigger problem providing
B80543 -            treatment in time to be effective
B80544 -            recovering from Millie's
B80545 -            6th relapse of
B80546 -            IBC.............................. 090209, ref SDS I1 MN4L
B80548 -             ..
B80549 -       13.  UCSF took xrays and CT scans to prepare
B80550 -            layout for radiation and hyperthermia
B80551 -            treatment, which conflicted with Kaiser
B80552 -            policy for radiology and lab work for
B80553 -            referral treatment to be performed
B80554 -            at Kaiser; this was required by medical
B80555 -            necessity to treat Millie's 6th
B80556 -            relapse of cancer in time to
B80557 -            be effective, and so applied
B80558 -            deferrence to doctor
B80559 -            discretion...................... 090209, ref SDS I1 MN4L
B80560 -
B80561 -
B80563 -  ..
B80564 - Mistakes Random Computer Problems Entropy Disorder Case Management
B80565 -
B80566 - In this case, a few weeks ago, Kaiser called and said the doctor
B80567 - wanted to change the time for the meeting today from 1140 to 1000.
B80568 - Millie's letter to Kaiser on 061116 confirms these understandings.
B80569 - ref SDS G8 2Q7K  Then about 2 days ago, Kaiser called again, and said
B80570 - the doctor wanted to change the meeting from today to a week later on
B80571 - 061208 1200.  Kaiser indicated that the doctor had a sudden schedule
B80572 - conflict with a seminar, or other off-site Kaiser activity, possibly
B80573 - management meetings, that would take several days, and so he could not
B80574 - meet with Millie today.
B80576 -  ..
B80577 - Delaying Millie's care a week conflicts with the doctor's plan during
B80578 - the previous meeting on 061110, to meet with Millie today, a week
B80579 - early, in order to expedite starting a new treatment for Millie to
B80580 - recover from the 4th relapse of IBC. ref SDS G4 N96O
B80582 -  ..
B80583 - Today, when Abigail admitted Millie into the Chemotherapy Infusion
B80584 - Clinic, the doctor was observed across the adjacent hallway assisting
B80585 - a patient in the Medical Assistant's (MA) Control Center for the
B80586 - Oncology Clinic.  This was entirely fortuitous serendipity, becasue
B80587 - Millie had been told 2 days ago that Doctor Johnson would be off-stie
B80588 - today, and so her meeting today was canceled.
B80590 -  ..
B80591 - While Millie went ahead into the Clinic to start treatment with the
B80592 - currently prescribed regimen, there was discussion with the doctor in
B80593 - the Oncology Department.
B80595 -  ..
B80596 - The doctor advised that changing the date for meeting with Millie was
B80597 - a mistake, because he must see Millie today in order to arrange for
B80598 - starting a new treatment due to progression of cancer.  Someone
B80599 - scheduled the doctor to attend a Kaiser event without telling him, and
B80600 - getting approval.  The doctor advised that Kaiser is using a new
B80601 - computer scheduling system.  When he learned about the mistake a few
B80602 - days ago, the doctor notified the Planning department to maintain his
B80603 - original schedule for today.  By that time the meeting with Millie had
B80604 - already been changed.  When the staff tried to correct the computer,
B80605 - the computer system was down, and experiencing long delays making
B80606 - entries.
B80608 -  ..
B80609 - The doctor explained that, when the computer system came back online,
B80610 - the Planning department had a a backlog of other patients.  Kaiser
B80611 - policy required assigning another patient to the time originally
B80612 - scheduled for meeting with Millie today.  As a result, since the
B80613 - Scheduling software could not find a time slot that correlated with
B80614 - the treatment time, Millie wasn't notified this morning that the
B80615 - doctor intended to meet today, despite being "booked out" for the day,
B80616 - because Millie's rising cancer needs a new treatment starting with
B80617 - examination today, as noted in the section on strategy, above.
B80618 - ref SDS 0 K36G
B80620 -  ..
B80621 - The doctor advised that even though Kaiser's computer software is
B80622 - programmed to implement scheduling policy to allocate the doctor's
B80623 - time for seeing patients, doctors can make accomodations to meet with
B80624 - patients in order to provide needed care.  He explained that doctors
B80625 - give priority to medical necessity over formal policy and procedures.
B80627 -  ..
B80628 - The doctor said today has been very hectic adjusting to the scheduling
B80629 - mistake and computer problems.  He forgot to tell the staff to adjust
B80630 - his schedule, and call Millie to advise that the original schedule
B80631 - would be followed today.  Chance enounter tending to another patient
B80632 - at the precise moment when Millie was admitted in the Infusion Clinic
B80633 - and was walking down the hall and just happened to glance down the
B80634 - adjacent hall to the Medical Assistant's (MA) Control Center enabled a
B80635 - small mistake in scheduling to be corrected in time to be effective
B80636 - preventing a much bigger problem losing control of her cancer.
B80638 -  ..
B80639 - After a few minutes finishing up with the other patient, the doctor
B80640 - walked over to the Chemotherapy Infusion Clinic across the hall from
B80641 - Oncology and visited with Millie's nurse, Abigail.
B80643 -  ..
B80644 - The nurse had finished connecting the infusion IV to Millie's port
B80645 - catheter and started her treatment, reported in another record today
B80646 - on 041201. ref SDS G9 4N5M
B80648 -  ..
B80649 - The doctor asked Abigail to register Millie for a meeting with him
B80650 - today. ref SDS G9 4O9M
B80652 -  ..
B80653 - The nurse said that Kaiser policy requires patients to register at the
B80654 - customer counter outside in the Oncology lobby in order comply with
B80655 - requirements for co-payment.
B80657 -  ..
B80658 - The doctor noted that Millie cannot be in two places at once, and that
B80659 - a Kaiser computer problem prevented the normal registering process.
B80660 - The doctor asked Abigail to help solve this, because Millie needs to
B80661 - care today.
B80663 -  ..
B80664 - Abigail said she will talk with the Charge Nurse to work it out so
B80665 - that Millie is registered to meet the doctor and also to get treatment
B80666 - for cancer currently underway.
B80668 -  ..
B80669 - The doctor left the Chemotherapy Infusion Clinic and walked back to
B80670 - Oncology.  He visited with Jessica in the MA control center.  The
B80671 - doctor asked Jessica to correct the computer problem by changing his
B80672 - schedule to include meeting with Millie today, while she is also
B80673 - getting chemotherapy, even though this conflicts with the policy to
B80674 - perform examinations before treatments in order to verify the patient
B80675 - should continue with the prescribed agent.  A primary concern is to
B80676 - verify blood counts are high enough, and if low, the doctor can make a
B80677 - judgement balancing urgency for the treatment, against risks of
B80678 - infection from weakened immunity with low counts.
B80680 -  ..
B80681 - Jessica checked the computer for the doctor's schedule.  She entered a
B80682 - meeting in the computer for the period of Millie's chemotherapy
B80683 - treatment.  The doctor will let Jennifer know when he finishes with
B80684 - his current patient in about 20 minutes.  Jennifer will walk over to
B80685 - the Chemotherapy Clinic and notify Abigail to assist Millie coming
B80686 - over to the Oncology Department for a meeting with the primary care
B80687 - physician.  Millie will continue getting chemotherapy treatment while
B80688 - walking to the doctor's office in Oncology by using the drip treatment
B80689 - stand and electronic monitor that is on rollers, as was done
B80690 - previously for a meeting on 060929. ref SDS E5 ZG3M
B80692 -  ..
B80693 - Jessica went into the Chemotherapy Clinic to explain the work plan to
B80694 - Abigail.  The charge nurse asked Jessica to take Millie's credit card
B80695 - to the customer counter in the Oncology lobby and make the co-payment
B80696 - transaction for Millie to meet with the doctor.
B80697 -
B80698 -
B80699 -
B80700 -
B808 -

SUBJECTS
Pulmonary Emboli Blood Clots Lungs Symptoms Continue Fatigue Shortne

BG03 -
BG0401 -  ..
BG0402 - Procrit Treatment Anemia Ended Hemoglobin Blood Count Normal
BG0403 - Tired Breathing Difficulty Routine Activity Pulmonary Emboli Symptoms
BG0404 - Coumadin Treatment Pulmonary Embolism Does Not Relieve Symptoms
BG0405 - Pulmonary Embolism Symptoms Continue Fatigue Shortness of Breath
BG0406 -
BG0407 - Follow up ref SDS G4 CV5L, ref SDS F3 CV5L.
BG0408 -
BG0409 - Background on discovering and treating pulmonary embolism recurrence
BG0410 - is reported for the meeting on 061020. ref SDS F3 CV5L  On 061110, the
BG0411 - doctor prescribed Procrit to increase the hemoglobin blood count,
BG0412 - expecting this would relieve symptoms of anemia where Millie has been
BG0413 - tired and continually fatigued. ref SDS G4 OY4H
BG0415 -  ..
BG0416 - Millie's letter to Kaiser on 061113, ref DIP 4 L17H, advised that
BG0417 - symptoms continue of chronic fatigure and shortness of breath due to
BG0418 - pulmonary embolism diagnosed on 061002, ref SDS E8 MI5I, and that she
BG0419 - hoped the prescription for Procrit would relieve overlapping symptoms.
BG0420 - ref SDS G6 2K5P
BG0422 -  ..
BG0423 - The doctor feels that hemoglobin rising to the normal range indicates
BG0424 - that Procrit was effective, as shown in the blood test report received
BG0425 - during treatment today in the Infusion Clinic. ref SDS G9 LA5M
BG0426 - Therefore, the prescription for Procrit was not renewed.
BG0428 -  ..
BG0429 - Due to Scheduling mistakes and computer system problems, per above,
BG0430 - ref SDS 0 KD44, The doctor's schedule today did not have enough time
BG0431 - again, as on 061020, ref SDS F3 UQ5M, and during the prior meeting on
BG0432 - 061110, ref SDS G4 HB3K, to review the patient's preliminary analysis
BG0433 - on 061012, and comment on significance of several differences between
BG0434 - the two tests, ref SDS E9 7E7G, including a new heart disorder caused
BG0435 - by an enlarged right ventricle, ref SDS E9 IM5J, discussed briefly
BG0436 - with the doctor during the meeting on 061020. ref SDS F3 VJ4J
BG0438 -  ..
BG0439 - This can be addressed in the new PET scan test which the doctor plan
BG0440 - to order during the next meeting on 061208, per above. ref SDS 0 EY5O
BG0441 -
BG0442 -
BG0443 -
BG0444 -
BG0445 -
BG05 -

SUBJECTS
Examination Clinical Findings Correlate with Research Stethoscope No

BS03 -
BS0401 -  ..
BS0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
BS0403 -
BS0404 - Follow up ref SDS G4 Q35O, ref SDS F3 PC6H.
BS0405 -
BS0406 - The doctor examined Millie with a stethoscope again today.  This
BS0407 - included multiple locations on her her back, and on her chest.  He
BS0408 - reported finding no evidence of cardio pulmonary issues from clinical
BS0409 - examination.
BS0410 -
BS0411 -
BS0412 -
BS0413 -
BS05 -

SUBJECTS
Enlarged Right Ventricle Heart Examination Not Ordered Kaiser Not En

CB03 -
CB0401 -  ..
CB0402 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
CB0403 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
CB0404 -
CB0405 - Follow up ref SDS G4 VJ4J, ref SDS F3 VJ4J. ref SDS E9 7E5L.
CB0406 -
CB0407 - Background is reported in the record for the meeting on 061110.
CB0408 - ref SDS G4 VJ4J
CB0410 -  ..
CB0411 - Kaiser has not had enough time to determine how severely the right
CB0412 - ventricle is enlarged, as discussed, also, on 061020. ref SDS F3 VJ4J
CB0414 -  ..
CB0415 - The doctor did not cite vitals that So2 test result shows high oxygen
CB0416 - content, indicating strong cardio pulmonary functioning, rather than
CB0417 - diminished capacity that would signal significant impact of enlarged
CB0418 - right ventricle.
CB0420 -  ..
CB0421 - Maybe the PET scan test planned to be ordered on 061208 will support
CB0422 - a determination on whether to get a review by a heart specialist.
CB0423 -
CB0424 -
CB0425 -
CB0426 -
CB0427 -
CB0428 -
CB05 -

SUBJECTS
Work Plan Doctor Submits Doctor/Patient Partnership Communications I

D203 -
D20401 -  ..
D20402 - Work Plan Received Communications Doctor/Patient Partnership
D20403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
D20404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
D20405 -
D20406 - Follow up ref SDS G4 FE4I, ref SDS F3 FE4I.
D20412 -  ..
D20413 - Issues from Kaiser's Progress Notes continue from prior review on
D20414 - 061110. ref SDS G4 EN4K
D20416 -  ..
D20417 - New issues include...
D20418 -
D20419 -    1.  Narrative omits patient suffered pulmonary embolism recurrence,
D20420 -        and treatment has not corrected symptoms. ref SDS 0 J59N
D20422 -         ..
D20423 -    2.  Cellulitis - patient hospitalized 5 days complications of
D20424 -        lymphedema, not mentioned in the doctor's report for the
D20425 -        Medical Chart.  Neither is there a report of recurrence on
D20426 -        061112. ref SDS 0 IX7K
D20428 -         ..
D20429 -    3.  Current medications - this might be updated, as recommended
D20430 -        previously. ref SDS 0 SE86
D20432 -         ..
D20433 -    4.  Impression section might be updated with respect to status of
D20434 -        Cellulitis continuing, and other issues, including possibility
D20435 -        that cat bite has complicated diagnostics. ref SDS 0 1248
D20437 -  ..
D20438 - Progress continues toward good management using the doctor patient
D20439 - partnership for timely review of patient history, called out in
D20440 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 2 TD5S, and
D20441 - reported on 060106. ref SDS 90 FE4I
D20442 -
D20443 -    1.  11/10/2006     03:40 PM
D20444 -
D20445 -            Wcr-ONnc2 > Main Campus
D20448 -         ..
D20449 -    2.  Your primary care clinician is listed as...
D20450 -
D20452 -
D20781 -
D20782 -
D20783 -
D20784 -
D20785 -
D20786 -
D20787 -
D208 -