THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: December 8, 2006 12:00 PM Friday;
Millie meeting at Kaiser to evaluate IBC treatment strategy.
2...Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
3...Complex Patient History Knowledge Management Dilemma Issues Grow 36
4...Vitals Show Stable Medical Condition
5...CA 15-3 Cancer Marker 67 Erratic Changes Since 060928
6...CA 15-3 67 Cancer Marker Falls Significantly Rises Significantly
7...Digestion Problems Increasing Relatively Infrequent Mild
8...Esophagitis Not Compared in Current PET Test with Prior Report
9...Cellulitis Complications Lymphedema Relapsed Reaction to Cat Bite
10...Left Axillary No Evidence Lymphadenopathy Cellulitis Treatment Ends
11...Post Operation Localized Edema Left Axillary Swelling Reduced
12...Right Axillary Possible Involvement Red Rash Spreads Right Breast
13...Right Breast Red Rash Spreads Possible Involvement Right Axillary
14...Red Rash Right Breast Spreads Possible Involvement Right Axillary
15...Left Supraclavicular Examination PET Test Report Finding SUV 4.5
16...Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
17...Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
18...Pockets of Resistance to Treatment of IBC Red Rash Left Breast
19...IBC Red Rash Left Breast Extends Slightly onto the Right Breast
20...Examination Left Breast IBC Inflammation Spreads to Right Breast
21...Measurable Disease IBC Inflammation Spreading to Right Brease
22...Diflucan Fluconazole 200 MG Diagnose Possible New Ring Rash
23...Ring Rash Diagnosed By Treatment with Diflucan Antibiotic
24...Research Diflucan Treat Fungal Infections...
........US National Library of Medicine
........National Institutes of Health
25...Side Effects Compound Symptoms of Pulmonary Embolism Esophagitis....
26...Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
27...Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
28...Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
29...Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
30...Slow Response to Treatment Mastectomy Removed Blood Vessels
31...Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
32...Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
33...Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
34...Biopsy to Determine Biology of IBC and Guide Choice of Treatment
35...Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
36...PET CT Image Testing Distant Metastasis Risks Secondary Cancer
37...IBC Test Distant Metastasis Discouraged Avoid Risk Secondary Cancer
38...Radiation Image Tests PET CT Limit to Reduce Risk Secondary Cancer
39...Risk Secondary Cancer Exposure Radiation Image Testing CT PET Scan
40...Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
41...Exercise Vigor Strength Engagement Ease Distress Living with Cancer
42...Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
43...Strategy Treatment Options Scenarios Planning Treatment Navelbine
44...Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
45...Tumor Board Review on Changing Treatment Expansion of Disease
46...Navelbine Single Agent Combine Taxotere Capecitabine Conflict 2nd Opinions
47...Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
48...Treatment Switch from Taxotere and Capecitabine (Xeloda) to Navelbine
49...Navelbine Planning New Treatment Begin Consideration UCSF Drug Trial
50...Taxotere and Capecitabine (Xeloda) 7th-Cycle Treatment Continue
51...Navelbine Protocol Pharmacology Submitted for Review
52...Drug Trials Kaiser Research UCSF and Other Proposals
53...Case Study Chemotherapy Drug Trials Promoted Rarely Yield Results
54...Drug Trials UCSF 2 Proposals Kaiser Review Pending Needs Support
55...UCSF 2 Drug Trial Proposals Kaiser Needs Support to Complete Review
56...Chemotherapy Holiday Treatments Deferred 4 Weeks Holiday Season
57...Schedule Treatment Start Navelbine 4 Weeks Chemotherapy Holiday
58...Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
59...Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
60...Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
61...Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
62...Cor Pulmonale Heart Disorder Enlarged Right Ventricle
63...Heart Examination Not Ordered Investigate Enlarged Right Ventricle
64...Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
65...Medical Chart Computer Record Lock Down Prevents Correction Feedback
66...Work Plan Received Communications Doctor/Patient Partnership
67...Communications Doctor Submits Work Plan Doctor/Patient Partnership
68...Doctor/Patient Partnership Communications Doctor Submits Work Plan
Click here to comment!
1...The doctor has not had time to comment on Millie's letter submitted
2...The doctor did not remember conflict in the UCSF recommendations for
Meeting Doctor Examination 8th Review Prepare Changing Protocols aft
1903 - ..
1904 - Summary/Objective
190501 - Follow up ref SDS H4 0000. ref SDS G8 0000.
190503 - Work plan strategy change chemotherapy to Navelbine, ref SDS 0 RW5I,
190504 - to replace Taxotere and capecitabine. ref SDS 0 PF3O Treatments will
190505 - be paused giving Millie a short chemotherapy "holiday" for a few weeks
190506 - during the Christmas season. ref SDS 0 N96O Pharmacology indicates
190507 - side effects of Navelbine align with symptoms of pulmonary embolism.
190508 - ref SDS 0 CX9M PET/CT test was ordered today for a new baseline to
190509 - evaluate change in treatment. ref SDS 0 EY5O Possible dramatic change
190510 - in patient profile confirmed today, with red rash spreading from left
190511 - breast across the sternum and slightly onto the right breast.
190512 - ref SDS 0 025H Examination shows fine red lines from the rash in the
190513 - left breast region to the new rash on the right breast, similar to
190514 - lines previously observed between the left breast region and the left
190515 - shoulder diagnosed with Cellulitis. ref SDS 0 WZ4I Rash on the right
190516 - breast might therefore be Cellulitis rather than cancer (IBC). Biopsy
190517 - was again not ordered for diagnosis. ref SDS 0 WZ5J The doctor
190518 - noticed a circular or "ring" appearance combining the left and now
190519 - right side of the rash. ref SDS 0 WZ3N Treatment for 10 days was
190520 - prescribed to diagnose the ring-like character of the rash, similar to
190521 - patient history on the left breast. ref SDS 0 KW45 If IBC disease has
190522 - advanced, this may present measurable disease that meets UCSF
190523 - requirements for Millie to participate in drug trials for cancer.
190524 - Kaiser has not submitted results on searching for drug trials. The
190525 - doctor advised today that the Protocol nurse cannot find anything to
190526 - help Millie. The doctor requested a letter from the patient to
190527 - identify drug trials proposed by UCSF. ref SDS 0 WI3J This past week,
190528 - relapse of Cellulitis indicates complications of lymphedema continue,
190529 - possibly due to a cat bite some weeks earlier. ref SDS 0 ME8O
190530 - Treatment with antibiotics reduced inflammation; swelling from
190531 - lymphedema continues above normal. ref SDS 0 CO7O Comment in the
190532 - Medical Chart associating metastatic cancer with lung and lymph nodes
190533 - requires clarification from Kaiser. ref SDS 0 G25K PET test can
190534 - perform comparisons to assess esophagitis. ref SDS 0 JP6K Pulmonary
190535 - embolism symptoms continue under treatment. ref SDS 0 CV5L PET and CT
190536 - test may be able to complete analysis of prior comparisons on
190537 - seriousness of this problem, ref SDS 0 Q93H, including Cor Pulmonale
190538 - that presents a heart disorder from enlarged right ventricle. The
190539 - doctor feels referral to a heart specialist to assess this matter is
190540 - not needed. ref SDS 0 J14I Errors compounding in the Medical Chart,
190541 - ref SDS 0 FE4I, because Kaiser computer "lock down" technology
190542 - prevents correcting mistakes with feedback loops. ref SDS 0 N54K
190544 - [On 070201 Millie begins treatment with cetuximab clincial
190545 - study drug trial at UCSF. ref SDS J1 0001
190547 - ..
190548 - [On 070301 IBC disease spreads significantly begin
190549 - consideration to change treatments. ref SDS J3 4140
190551 - ..
190552 - [On 070329 patient responds to treatment dramatic decline CA
190553 - 15-3 cancer marker, IBC rash subsides. ref SDS J4 LB5L
190559 - ..
1908 - Progress
190901 - Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
190903 - Follow up ref SDS H4 SM6M, ref SDS G8 SM6M.
190905 - This is the 8th review meeting for the 7th chemotherapy cycle since
190906 - starting treatment on 060711, ref SDS C4 SM6M, for the 3rd relapse of
190907 - IBC, ref SDS C4 8Y8I, and 15th total cycle with Taxotere and
190908 - capecitabine. This meeting considers changing treatment protocols.
190909 - The doctor had a hectic schedule today, and so the meeting scheduled
190910 - to start at 1200 actually started at 1226.
190912 - ..
190913 - Millie submitted a letter this morning, ref DIT 1 0001, with an agenda
190914 - for the meeting today...
190916 - 1. CA 15-3 erratic, cat bite effect??............. ref SDS 0 GJ5M
190917 - 2. Lymphedema/Cellulitis controlled............... ref SDS 0 MW8J
190918 - 3. Breast exam IBC biopsy measurable disease...... ref SDS 0 025H
190919 - 4. IBC spread right breast or cellulitis.......... ref SDS 0 AX6G
190920 - 5. PET schedule ck esophagitis PE r ventricle?.... ref SDS 0 EY5O
190921 - 6. Treatment plan change Gemzar Taxotere.......... ref SDS 0 K36G
190922 - 7. Drug trials UCSF proposals??................... ref SDS 0 WI3J
190923 - 8. Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
190924 - 9. Symptoms cough clearing throat fatigue......... ref SDS 0 CV5L
190925 - 10. Cor Pulmonale enlarged r ventricle heart doctor ref SDS 0 VJ4J
190926 - 11. Esophagitis, heart burn PET test check......... ref SDS 0 JP6K
190927 - 12. Eyes tearing................................... ref SDS 0 OH6I
190929 - ..
190930 - The doctor's hectic schedule did not have enough time to enter the
190931 - agenda into the Medical Chart, ref SDS 0 684G, as was done the past
190932 - few months, reported on 061110. ref SDS G8 K84N Discussions were
190933 - guided by the list in Millie's letter.
190935 - [On 070105 doctor resumes practice transferring agenda
190936 - into Kaiser's electronic Medical Chart and using the list
190937 - to guide discussions for productive communications.
190938 - ref SDS I5 K84N
190940 - ..
190941 - Scheduled next meeting in 4 weeks on 070105 1040, to schedule starting
190942 - new treatments. ref SDS 0 N96O
Complex Patient History 36 Issues Overwhelms Span of Attention Drive
210401 - ..
210402 - Complex Patient History Knowledge Management Dilemma Issues Grow 36
210404 - Follow up ref SDS H4 LU3J, ref SDS G8 LU3J.
210406 - Sampling of issues patient history diagnosis and treatment...
210408 - 1. CA 15-3 monitors advance of cancer response to treatment
210409 - 2. Lymphedema complicated by mastectomy surgery
210410 - 3. Broken finger from minor fall complicates lymphedema
210411 - 4. Esophagitis reflux digestion issues
210412 - 5. Immune system chemotherapy increases risk of infection
210413 - 6. Chemotherapy increase risk of infection
210414 - 7. Cat bites increase risk of infection complicates lymphedema
210415 - 8. Pneumonia chemotherapy increases risk of infection
210416 - 9. Metastatic cancer increases risk pulmonary embolism
210417 - 10. Lymphadenopathy left axilla local regional metastasis
210418 - 11. Lymphadenopathy right axilla distant metastasis
210419 - 12. Lymphadenopathy left supraclavicular diagnose metastatic cancer
210420 - 13. Breast cancer secondary IBC 3rd relapse left breast
210421 - 14. Cancer mutates slow response chemotherapy treatment
210422 - 15. Mastectomy surgery impact on treatment IBC relapse
210423 - 16. Blood vessels removed mastectomy slow chemotherapy treatments
210424 - 17. Treatment options, strategy, planning, schedule
210425 - 18. Drug trials increase declining pool chemotherapy agents
210426 - 19. UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
210427 - 20. Pulmonary embolism blood clots in lungs
210428 - 21. INR weekly adjustments Coumadin treatment blood clots
210429 - 22. Enlarged right ventricle heart problem core pulmonale
210430 - 23. Dizziness symptom enlarged right ventricle cor pulmonale
210431 - 24. Fatigue shortness breath side effect chemotherapy loss fitness
210432 - 25. Fatigue shortness breath symptom pulmonary embolism
210433 - 26. Shortness breath fatigue dizzy symptoms pulmonary embolism
210434 - 27. Coagulapathy hypercoagulable state work up genetic risks
210435 - 28. Testing resolution of errors (see Benz 2nd opinion 060821)
210436 - 29. Testing distant metastatic disease
210437 - 30. Testing pulmonary emoblism and heart disease
210438 - 31. Communication hectic schedule not enough time to manage details
210439 - 32. Emotional stress and well being
210440 - 33. Cellulitis inflammation temperature 102.6 on chemotherapy
210441 - 34. Urinary tract bladder infection
210443 - ..
210444 - Added new issues...
210446 - 35. IBC rash spreads to right breast
210447 - 36. Right breast rash may be "ring" infection, not cancer
Vitals Obtain from Infusion Clinic Progress Note Meeting Doctor John
230401 - ..
230402 - Vitals Show Stable Medical Condition
230404 - Follow up ref SDS H4 KB5L, ref SDS G8 KB5L.
230406 - ..
230407 - Bld Prssr Pulse Temp Weight SaO2
230408 - ..
230409 - 061208 1226............ 152 90 76 97.8 147 99%
230410 - 061201 1430............ 123 76 76 97.5
230411 - 061110................. 136 83 73 97.0 150 98%
230412 - 061020 1534............ 140 79 67 99.8 151 97
230413 - 060929 1452............ 141 78 66 98.3
230414 - 060908 1335............ 139 79 73 98.1
230415 - 060814 1610............ 139 80 59 98.2
230416 - * 060808.................
230417 - 060711................. 172 87 54 97.5 147
230418 - 060623................. 141 87 71 98.0 147 99%
230419 - 060428................. 129 73 80 99.4 149 99%
230420 - 060217................. 153 81 61 98.6 150 99%
230422 - ...per the doctor's report in the Medical Chart shown below.
230423 - ref SDS 0 JQ4J
CA 15-3 67 Erratic Changes Aligns with IBC Rash Changes Similar to E
330401 - ..
330402 - CA 15-3 Cancer Marker 67 Erratic Changes Since 060928
330404 - Follow up ref SDS H4 087J, ref SDS G8 087J.
330406 - There were no blood tests during the past week.
330408 - ..
330409 - Test Date Date Received
330410 - 061130......... 67 H............. 061201, ref SDS H4 087J
330411 - 061116......... 66 H............. 061201, ref SDS H4 087J
330412 - 061110......... 56 H............. 061201, ref SDS H4 087J
330413 - 061109......... 61 H............. 061110, ref SDS G8 087J
330414 - 061026......... 57 H............. 061110, ref SDS G8 087J
330415 - 061019......... 56 H............. 061020, ref SDS F7 087J
330416 - 060928......... 51 H............. 060929, ref SDS F0 087J
330417 - 060907......... 68 H............. 060929, ref SDS F0 087J
330418 - 060813......... 73 H............. 060817, ref SDS E5 U24M
330419 - 060809......... 87 H............. 060810, ref SDS E3 2N5J
330420 - 060708......... 71 H............. 060711, ref SDS C4 087J
330421 - 060616......... 63 H............. 060623, ref SDS C2 UQ5Q
330422 - 060522......... 59 H............. 060605, ref SDS B7 UQ5Q
330423 - 060501......... 49 H............. 060522, ref SDS B4 MC4F
330424 - 060421......... 44 H............. 060428, ref SDS A8 087J
330425 - 060330......... 40 H............. 060428, ref SDS A8 087J
330426 - 060303......... 36............... 060428, ref SDS A8 087J
330427 - 060210......... 33............... 060217, ref SDS 98 087J
330428 - 060109......... 34............... 060126, ref SDS 97 KV59
330429 - 051223......... 34............... 060106, ref SDS 96 087J
330430 - 051202......... 28............... 060106, ref SDS 96 087J
330431 - 051116......... 31............... 051121, ref SDS 94 087J
330432 - 051109......... 30............... 051121, ref SDS 94 087J
330433 - 051102......... 34............... 051121, ref SDS 94 087J
330434 - 050909......... 45 H............. 051007, ref SDS 88 087J
330435 - 050826......... 45 H............. 050913, ref SDS 82 087J
330436 - 050819......... 45 H............. 050913, ref SDS 82 087J
330437 - 050812......... 39 .............. 050819, ref SDS 75 3K6L
330438 - 050729......... 45 H............. 050819, ref SDS 75 EA5G
330439 - 050708......... 46 H............. 050729, ref SDS 74 087J
330440 - 050701......... 37 .............. 050729, ref SDS 74 087J
330441 - 050617......... 45 H............. 050729, ref SDS 74 087J
330442 - 050527......... 56 H............. 050610, ref SDS 71 087J
330443 - 050512......... 67 H............. 050520, ref SDS 69 087J
330444 - 050506......... 80 H............. 050520, ref SDS 69 087J
330445 - ..
330446 - 050415.........105 H............. 050422, ref SDS 66 087J
330447 - 050325.........100 H............. 050329, ref SDS 64 087J
330448 - 050318.........101 H............. 050325, ref SDS 63 2N5J
330449 - 050304......... 88 H............. 050311, ref SDS 61 087J
330450 - 050225......... 95 H............. 050308, ref SDS 60 0001
330451 - 050211......... 78 H............. 050214, ref SDS 59 02BB
330452 - 050128......... 67 H............. 050204, ref SDS 57 087J
330453 - 041228......... 56 H............. 041230, ref SDS 56 087J
330454 - 041204......... 43 H............. 041210, ref SDS 54 087J
330455 - 041007......... 39............... 041104, ref SDS 50 087J
330456 - 040923......... 49 H............. 041005, ref SDS 48 087J
330457 - 040908......... 44 H............. 040909, ref SDS 47 087J
330458 - 040825......... 47 H............. 040909, ref SDS 47 087J
330459 - 040811......... 42 H............. 040812, ref SDS 46 087J
330460 - 040728......... 43 H............. 040729, ref SDS 44 2N5J
330461 - 040712......... 47 H............. 040713, ref SDS 43 087J
330462 - 040614......... 55 H............. 040615, ref SDS 42 PX6X
330463 - 040517......... 78 H............. 040601, ref SDS 40 2N5J
330464 - 040311......... 70 H............. 040318, ref SDS 32 SM6M
330465 - 040205......... 60 H............. 040211, ref SDS 29 SM6M
330466 - 031201......... 62 H............. 031205, ref SDS 27 SM6M
330467 - 030912......... 66 H............. 030915, ref SDS 26 SM6M
330468 - 030708......... 68 H............. 030710, ref SDS 25 SM6M
330469 - 030503......... 54 H............. 030508, ref SDS 23 SM6M
330470 - 030403......... 45 H............. 030508, ref SDS 23 SM6M
330471 - 030215......... 46 H............. 030220, ref SDS 22 5E6L
330472 - 030106......... 37 H............. 030109, ref SDS 21 SM6M
330473 - 021202......... 41 H?............ 021204, ref SDS 20 SP5G
330474 - 021111......... 36 H?............ 021113, ref SDS 19 Y65I
330475 - 021023......... 33 H?............ 021023, ref SDS 18 SQ5I
330476 - 020930......... 33 H?..39........ 021002, ref SDS 17 SQ5I
330477 - 020917......... 36 H?............ 020924, ref SDS 16 SQ5I
330478 - 020717......... 59 H?............ 020726, ref SDS 15 YN5K
330479 - 020629......... 75 H ............ 020705, ref SDS 13 UX6I
330480 - 020608........ 67 H ............ 020614, ref SDS 11 0001
330481 - 020603........ 108 H ............ 020607, ref SDS 10 X67F
330482 - 020511........ 117 H ............ 020603, ref SDS 9 PJ4J
330483 - 020419......... 81 H ............ 020430, ref SDS 7 7N5H
330484 - 020321......... 85 H ............ 020405, ref SDS 6 6T8K
330490 - ..
3307 - Analysis
330801 - CA 15-3 67 Cancer Marker Falls Significantly Rises Significantly
330803 - Follow up ref SDS H4 GJ5M, ref SDS G8 GJ5M.
330805 - The doctor received Millie's letter today reporting correlations with
330806 - patterns of erratic CA 15-3 cancer marker tests, cited by the doctor
330807 - last week on 061201, ref SDS H4 GJ5M, and swings in severity of red
330808 - rash on the left chest observed today showing increased severity, per
330809 - report on examination below, ref SDS 0 AX6G, and possibly correlating
330810 - with cat bite infection, ref DIT 1 Q76O, which was submitted earlier
330811 - today citing analysis from the meeting last Friday on 061201.
330812 - ref SDS H4 P66O
330814 - ..
330815 - The doctor did not have time today for commenting on factors affecting
330816 - patient symptoms.
330818 - [On 061214 CA 15-3 results for blood test were not reported with
330819 - INR. ref SDS H7 GV5N
330821 - [On 061218 letter asks doctor for results of CA 15-3 blood test on
330822 - 061214, and follow up test on 061218. ref SDS H8 FO9H
330824 - ..
330825 - [On 061227 CA 15-3 74 significant rise, erratic change reflects
330826 - IBC rash wax and wane; doctor reports probably represents
330827 - progression metastatic disease. ref SDS I0 UF3I
Digestion Problems GERD Worse Doctor Orders PET Scan Test for Cancer
370401 - ..
370402 - Digestion Problems Increasing Relatively Infrequent Mild
370403 - Esophagitis Not Compared in Current PET Test with Prior Report
370405 - Follow up ref SDS H4 JP6K, ref SDS G8 JP6K.
370407 - Background is reported in the meeting on 061201. ref SDS H4 JP6K
370409 - ..
370410 - The doctor added a request for the analyst to compare the PET scan
370411 - test ordered today, per below, ref SDS 0 EY5O, with prior PET and CT
370412 - tests to clarify diagnosis and lead to a treatment plan for
370413 - esophagitis or other malady that may be causing increased digestion
370414 - problems. This implements planning on 061201. ref SDS H4 5X40
370416 - ..
370417 - The doctor's progress report in the medical chart reflects these
370418 - understandings, noting GERD worse. ref SDS 0 1248
Left Axillary Lymphadenopathy Patient No Complaint of Swelling Disco
540401 - ..
540402 - Cellulitis Complications Lymphedema Relapsed Reaction to Cat Bite
540403 - Left Axillary No Evidence Lymphadenopathy Cellulitis Treatment Ends
540404 - Post Operation Localized Edema Left Axillary Swelling Reduced
540406 - Follow up ref SDS H4 MW8J, ref SDS G8 MW8J.
540408 - ..
540409 - Patient history of left axillary lymphadenopathy and lymphedema is
540410 - reported on 060106. ref SDS 96 S164
540412 - ..
540413 - There was no examination today for cancer in left axilla. The patient
540414 - again made no complaint of lumps or discomfort from swelling under the
540415 - left arm.
540417 - ..
540418 - Background on lymphedema and complications of Cellulitis is reported
540419 - in the record for the meeting last week on 061201. ref SDS H4 5Y5F
540421 - ..
540422 - Subsequently, on 061203 patient relapsed again with Cellulitis in the
540423 - left arm, which could be delayed reaction to a cat bite some weeks
540424 - ago, ref SDS H5 MF9H, also discussed below considering expanding rash
540425 - from the left to the right breast, and erratic CA 15-3 cancer marker
540426 - diagnostics. ref SDS 0 PG4I
540428 - ..
540429 - Observation on 061203 found fine red lines from the rash on the left
540430 - chest running to the left shoulder where Cellulitis envelops the
540431 - entire left arm. ref SDS H5 RS6O
540433 - ..
540434 - Millie submitted, ref DIP 8 0001, notifying Kaiser on 061203 of
540435 - recurrence, and requesting renewal of the prescription for treating
540436 - Cellulitis. ref SDS H5 C866 The next day on 061204 Millie reported in
540437 - a follow up letter ref DIP 9 0001, that symptoms of Cellulitis had
540438 - begun to subside without treatment. ref SDS H6 V45L
540440 - ..
540441 - Later, on 061204, the doctor renewed the prescription for antibiotics
540442 - to treat Cellulitis. ref SDS H6 ZS5N,
540444 - ..
540445 - Treatment for Cellulitis was resumed on 061204.
540447 - [...below examination of right breast may have correlations
540448 - with Cellulitis in left arm emanating from rash on left breast
540449 - region. ref SDS 0 WZ4I
540451 - ..
540452 - Today, there was no examination of the left arm. The patient reported
540453 - Cellulitis has responded well to treatment again. Inflammation in the
540454 - left arm seems nearly fully subsided. Lymphedema swelling in the left
540455 - arm remains significantly above prior norms, as described previously
540456 - on 061201. ref SDS H4 656L
540458 - [...below, today the doctor Progress Notes in the Medical
540459 - Chart describe lymphedema "improving." ref SDS 0 J59N
Right Axillary Lymphadenopathy Patient No Complaint Swelling Discom 4
600401 - ..
600402 - Right Axillary Possible Involvement Red Rash Spreads Right Breast
600403 - Right Breast Red Rash Spreads Possible Involvement Right Axillary
600404 - Red Rash Right Breast Spreads Possible Involvement Right Axillary
600406 - Follow up ref SDS H4 3D6K, ref SDS G8 3D6K.
600408 - Background on patient history of testing for lymphadenopathy in the
600409 - right axilla is reported in the record on 060929. ref SDS F0 3D6K
600411 - ..
600412 - On 061204 patient notifies Kaiser that inflammation has spread from
600413 - the left chest area infected with IBC across the sternum and slightly
600414 - onto the right breast. ref SDS H6 AE5I The letter on 061024 describes
600415 - possible complications of Cellulitis from cat bite some weeks ago, as
600416 - further described below. ref SDS 0 PG4I
600418 - ..
600419 - Patient has a long medical history of cancer associated with IBC rash
600420 - on the left breast and lymphadenopathy symptoms in the left axillary,
600421 - see case study on 040517. ref SDS 39 OW3I
600423 - ..
600424 - Examination today shows spread of IBC rash from the left breast region
600425 - to the right breast, which could signal symptoms of swelled lymph
600426 - nodes in the right axillary. The most recent CT test on 060930 showed
600427 - no findings of lymphadenopathy in the right axilla, reviewed on
600428 - 061012. ref SDS F4 2967 Prior PET scan tests on 060120, and later on
600429 - 060414 seemed to show rising lymph nodes in the right axillary,
600430 - reported on 060428. ref SDS A7 OX68
600432 - [On 070105 Kaiser Medical Chart describes IBC rash spreading
600433 - from the left to the right breast. ref SDS I5 4U5K
600435 - ..
600436 - There was no examination today for cancer in the right axilla. The
600437 - patient made no complaint of lumps or discomfort from swelling under
600438 - the right arm. This work aligns with CT test on 060930 that found no
600439 - evidence of disease in the right axillary, reported on 061020.
600440 - ref SDS F7 8T4S
600442 - ..
600443 - The doctor's "Impression" section for Progress Notes in the Medical
600444 - Chart says in part...
600446 - Metastatic breast cancer (IBC)lung and lymph node; chest wall
600447 - recurrence. ref SDS 0 1248
600449 - ..
600450 - The reference to "lymph node" is unclear. (see examination below for
600451 - review of associating cancer with "lung." ref SDS 0 G25K)
600453 - ..
600454 - The doctor examined the red rash on the right breast. Initial
600455 - impression is possible infection treatable with antibiotics, explained
600456 - below. ref SDS 0 KW45
Left Supraclavicular Neck CT Test Contrast Study on 060505 Finds No
680401 - ..
680402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
680403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
680404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
680406 - Follow up ref SDS H4 8R6M, ref SDS G8 8R6M.
680408 - Background of image testing, and consideration for radiation treatment
680409 - of left supraclavicular is reported on 060623. ref SDS C2 8R6M
680411 - ..
680412 - Like the left and right axillary locations, there was no examination
680413 - today for cancer in left supraclavicular region. The patient made no
680414 - complaint of lumps or discomfort from swelling in this area. This
680415 - work aligns with CT test on 060930 that found no evidence of disease
680416 - in the left supraclavicular location, reported on 061020. ref SDS F7
680417 - LP5G
Examination IBC Red Rash Left Breast Spreads to Right Breast Might b
830401 - ..
830402 - Pockets of Resistance to Treatment of IBC Red Rash Left Breast
830403 - IBC Red Rash Left Breast Extends Slightly onto the Right Breast
830404 - Examination Left Breast IBC Inflammation Spreads to Right Breast
830405 - Measurable Disease IBC Inflammation Spreading to Right Brease
830407 - Follow up ref SDS H4 025H, ref SDS G8 025H.
830409 - Background on prior relapse examinations is listed on 060711.
830410 - ref SDS C4 8Y7O
830412 - ..
830413 - On 061204 Millie submitted a letter, ref DIP 9 I93X, notifying the
830414 - doctor that IBC may have spread from the left chest area to the right
830415 - breast, ref SDS H6 I93X Millie's follow up letter to Kaiser later in
830416 - the day on 061204 reported remarkable improvement in the red rash on
830417 - the left breast and some lessening of the rash on the right breast.
830418 - ref SDS H6 2P8U
830420 - ..
830421 - The doctor examined Millie's left and right breast today. IBC rash
830422 - shows no evident improvement toward recovery, and seems to be
830423 - worsening again with pockets of resistance to treatment, as reported
830424 - in the examination a week ago on 061201. ref SDS H4 RU6J Slow
830425 - response to treatment due to loss of blood vessels removed by
830426 - mastectomy surgery last year on 051021 is discussed below. ref SDS 0
830427 - EH3F
830429 - ..
830430 - Observation today again shows a prominent red rash extending from the
830431 - original rash on the left chest across the sternum and slightly onto
830432 - the right breast.
830434 - [On 091112 0930 IBC has now spread significantly onto
830435 - Millie's right side for the first time in 8 years of
830436 - treatment, and caused by cancer untreated in the breastbone
830437 - for 6 months, due to medical mistakes getting radiation
830438 - treatments at UCSF on referral from Kaiser. ref SDS J7 8G6O
830440 - ..
830441 - The doctor's Progress Notes in the Medical Chart describe "increased
830442 - erythema on lower chest wall," ref SDS 0 ZL5W, unchanged from
830443 - examination on 061201. ref SDS H4 YU4K There is no mention in the
830444 - Medical Chart of the rash spreading to the right breast.
830446 - [On 070130 IBC progression spreads to stomach and wrapping
830447 - toward back, examination at UCSF. ref SDS J0 M68J
830449 - ..
830450 - [On 070222 examination at UCSF indicates rash on upper left arm
830451 - likely expanding IBC. ref SDS J2 B64F
830453 - ..
830454 - Expanding IBC rash onto the right breast presents measurable disease,
830455 - which qualifies Millie for participation in UCSF drug trials, reviewed
830456 - below. ref SDS 0 P256
830458 - [On 061228 Kaiser's report to UCSF presents lesions on left
830459 - chest for measurable disease, but does not cite spread of IBC
830460 - from left to right breast indicating "measurable disease" that
830461 - qualifies Millie for drug trials. ref SDS I1 IQ6J
830463 - ..
830464 - [On 061230 Kaiser's follow up letter responding to questions
830465 - from UCSF on measurable disease does not cite IBC lesions nor
830466 - spread from left to right breast. ref SDS I2 PO3V
830468 - ..
830469 - This record seems to present erratic fluctuations in severity and
830470 - spread of IBC rash, which aligns with erratic CA 15-3 cancer marker
830471 - diagnostics, reported above, ref SDS 0 GJ5M, and patient history,
830472 - first noted by Doctor Benz in UCSF 2nd opinion received on 041117.
830473 - ref SDS 51 OS6W
830475 - [On 061227 report red rash worsens again, after seeming
830476 - improvement the week of 061218. ref SDS I0 ZT8H
830478 - ..
830479 - [On 061227 CA 15-3 74 significant rise, erratic change after
830480 - slight decline, reflects IBC rash wax and wane; doctor reports
830481 - probably represents progression metastatic disease. ref SDS I0
830482 - UF3I
830484 - ..
830485 - Millie's letter submitting the agenda for the meeting today discusses
830486 - erratic changes in the cancer marker and in the severity of the red
830487 - rash on the left, and now the right breast, and says in part...
830489 - It may only be coincidence, but the pattern of erratic CA
830490 - 15-3 levels that you presented during the meeting last week
830491 - on 061201 is very similar to the pattern after I suffered a
830492 - cat bite last year and was hospitalized on 050212. Could
830493 - the recent cat bite on 061114 be a factor in erratic
830494 - diagnostics? ref DIT 1 Q76O
830496 - ..
830497 - Complications from a cat bite on 061114 were cited analyzing erratic
830498 - CA 15-3 cancer marker reviewed by the doctor during the meeting last
830499 - week on 061201, citing a similar pattern of dramatic change in both
830500 - directions following a cat bite on 050212. ref SDS H4 P66O
830502 - ..
830503 - The doctor commented that the red rash on the left chest, and now
830504 - extending slightly onto the right breast presents a "circle" or
830505 - "ring," and so suggests another complication besides IBC and
830506 - Cellulitis, since both are being treated, and this problem seems to
830507 - progress despite such treatments.
830509 - ..
830510 - There was discussion that fine lines observed today linking the rash
830511 - on the left side to the new rash starting on the right breast, are
830512 - similar to lines observed with recent relapse on 061203 of Cellulitis
830513 - in the left arm. ref SDS H5 RS6O Correlation with Cellulitis in the
830514 - left arm is also discussed above. ref SDS 0 ME8O
830516 - ..
830517 - Similar fine lines starting from the red rash on the left chest region
830518 - and extending onto the left shoulder were observed by Doctor Jaine on
830519 - 061027 when Millie was treated in the Emergency Room, and hospitalized
830520 - for Cellulitis in the left arm. ref SDS G0 V79M
830522 - [On 070130 IBC progression spreads to stomach and wrapping
830523 - toward back, examination at UCSF. ref SDS J0 M68J
830525 - ..
830526 - [On 070222 examination at UCSF indicates rash on upper left arm
830527 - likely expanding IBC. ref SDS J2 B64F
830529 - ..
830530 - At this time, Millie presents possible compound involvement on the
830531 - left and right breast regions...
830533 - 1. IBC
830534 - 2. Cellulitis
830535 - 3. Ring infection (circular appearance).... ref SDS 0 WZ3N
830537 - ..
830538 - Biopsy considerations to diagnose problems is discussed below.
830539 - ref SDS 0 KT7J
Diflucan Fluconazole 200 MG Diagnose Possible New Ring Circular Rash
910401 - ..
910402 - Diflucan Fluconazole 200 MG Diagnose Possible New Ring Rash
910403 - Ring Rash Diagnosed By Treatment with Diflucan Antibiotic
910405 - The doctor proposed diagnosing "ring" rash, per above, ref SDS 0 WZ3N,
910406 - and spreading from left to the right breast, ref SDS 0 T99I, by
910407 - prescribing a 10 day treatment, rather than perform a biopsy, as
910408 - discussed further below. ref SDS 0 WZ5J The doctor indicated that if
910409 - the rash is cleared up by the prescription this will establish
910410 - pathology, including that the problem is not IBC on the right breast.
910411 - On 030109 this method was tried to diagnose initial rash on the left
910412 - breast by prescribing treatment for Cellulitis. ref SDS 21 KW5F
910414 - ..
910415 - The doctor's Progress Notes summarize a new prescription...
910417 - 4. Diflucan for rash.......... ref SDS 0 125V
910419 - ..
910420 - There is no description of the actual "rash" being different from IBC
910421 - or Cellulitis.
910423 - ..
910424 - Millie asked about possible conflicts with other medications,
910425 - especially Coumadin (warfarin) for pulmonary embolism, as occurred on
910426 - 061020 when it turned out there was a conflict with capecitabine
910427 - (Xeloda)? ref SDS F7 YQ7L
910429 - ..
910430 - The doctor said Kaiser has a new software program that automatically
910431 - notifies everyone about changes in current medications. There was not
910432 - enough time today for the doctor to explain how the new computer
910433 - system corrects previous failed notice by computer, as described on
910434 - 061026. ref SDS F8 TZ4I The doctor's medical chart for Millie does
910435 - not list the new prescription. ref SDS 0 SE86
910437 - [On 061214 treatment mistake pulmonary embolism warfarin
910438 - (Coumadin) conflicts with prescription for Diflucan; blood test
910439 - INR rises 6.4 danger zone for hemorrhaging; blood clot
910440 - coagulation treatment paused for 3 days; INR update test
910441 - advanced. ref SDS H7 HF4O
910443 - ..
910444 - [On 061218 Millie notifies doctor of INR increased on Diflucan.
910445 - ref SDS H8 5M5Y
910447 - ..
910448 - [On 061218 Doctor advises Millie to stop taking Diflucan.
910449 - ref SDS H8 NT6J
910451 - ..
910452 - The name on the prescription bottle received from the pharmacy
910453 - says...
910456 - Fluconazole 200 MB tablets
910457 - For: Diflucan
Diflucan Fluconazole Research Antibiotic Treat Fungal Infections Lef
980401 - ..
980402 - Research Diflucan Treat Fungal Infections...
980405 - After the meeting, research found...
980407 - Medline Plus
980408 - US National Library of Medicine
980409 - National Institutes of Health
980411 - http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a690002.html
980413 - ..
980414 - Fluconazole is used to treat fungal infections, including
980415 - yeast infections of the vagina, mouth, throat, esophagus (tube
980416 - leading from the mouth to the stomach), abdomen (area between
980417 - the chest and waist), lungs, blood, and other organs.
980418 - Fluconazole is also used to treat meningitis (infection of the
980419 - membranes covering the brain and spine ) caused by fungus.
980420 - Fluconazole is also used to prevent yeast infections in
980421 - patients who are likely to become infected because they are
980422 - being treated with chemotherapy or radiation therapy before a
980423 - bone marrow transplant (replacement of unhealthy spongy tissue
980424 - inside the bones with healthy tissue). Fluconazole is in a
980425 - class of antifungals called triazoles. It works by slowing the
980426 - growth of fungi that cause infection.
980428 - ..
980429 - Fluconazole is also sometimes used to treat serious fungal
980430 - infections that begin in the lungs and can spread through the
980431 - body and fungal infections of the eye, prostate (a male
980432 - reproductive organ), skin and nails. Fluconazole is also
980433 - sometimes used to prevent fungal infections in people who are
980434 - likely to become infected because they have human
980435 - immunodeficiency virus (HIV) or cancer or have had a
980436 - transplant operation (surgery to remove an organ and replace
980437 - it with a donor or artificial organ). Talk to your doctor
980438 - about the possible risks of using this drug for your
980439 - condition.
Diflucan Fluconazole Side Effects Compound Symptoms of Pulmonary Emb
A40401 - ..
A40402 - Side Effects Compound Symptoms of Pulmonary Embolism Esophagitis....
A40404 - Medline article lists side effects for Diflucan...
A40406 - Fatigue, lack of energy, extreme tiredness
A40407 - Difficulty breathing or swallowing
A40408 - Dizziness
A40409 - Seizures
A40410 - Heartburn
A40411 - Upset stomach
A40412 - Stomach pain, including in the upper right part of stomach
A40413 - Loss of appetite
A40414 - Cannot taste food
A40415 - Unusual brusing or bleeding
A40416 - Rash hives itching
A40417 - Swelling of face, throat, tongue, lips, hands, feet, legs
A40418 - Dierrhea, dark urine, pale stool
A40420 - ..
A40421 - If you experience a serious side effect, you or your doctor may
A40422 - send a report to the Food and Drug Administration's (FDA)
A40423 - MedWatch Adverse Event Reporting program online at
A40425 - http://www.fda.gov/MedWatch/report.htm
A40427 - ...or by phone 800 332 1088.
A40429 - ..
A40430 - These side effects are similar to the list for Navelbine reviewed in
A40431 - the record below. ref SDS 0 CX9M
A40433 - ..
A40434 - Compound side effects create "wicket problems" diagnosing medical
A40435 - problems, reported on 060722. ref SDS D0 346F
Lung Cancer Metastatic Disease Lymph Nodes Doctor's Progress Notes M
AJ0401 - ..
AJ0402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
AJ0403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
AJ0405 - The doctor's Progress Notes in the Medical Chart further show under
AJ0406 - Impressions...
AJ0408 - Metastatic breast cancer (IBC)lung and lymph node; chest wall
AJ0409 - recurrence, ref SDS 0 1248
AJ0411 - ..
AJ0412 - There was nothing discussed during the meeting today, nor at any time
AJ0413 - in patient history associating metastatic disease with "lung," as
AJ0414 - represented in the Medical Chart received after the meeting today.
AJ0415 - Similarly, nothing has been presented in examinations nor in extensive
AJ0416 - testing during this year that associates cancer with lymph nodes,
AJ0417 - sometimes summarized as "lymphadenopathy." The patient has complained
AJ0418 - of continuing fatigue, and shortness of breath, and this has been
AJ0419 - associated with pulmonary embolism, per below, and more recently with
AJ0420 - anemia that can occur from continuing chemotherapy.
AJ0422 - ..
AJ0423 - If the doctor has an "impression" of lung cancer, this would be a
AJ0424 - dramatic change in patient history, and should be supported with
AJ0425 - citations to evidence and analysis.
AJ0427 - [On 070112 Millie's letter asks the doctor to explain support
AJ0428 - for notation of lung in Medical Chart. ref SDS I7 NM6G
AJ0430 - ..
AJ0431 - [On 070117 primary care physician cited several CT tests past
AJ0432 - few years report small pulmonary nodules involving the right
AJ0433 - lung, which are smaller than 5 mm, and so do not appear in PET
AJ0434 - scan tests. ref SDS I9 TS8G Case study on patient history
AJ0435 - confirms that CT tests beginning in 2002 report nodules in the
AJ0436 - lungs; none are identified as cancer, and none show growth
AJ0437 - common to cancer. ref SDS I9 4Q46
AJ0439 - ..
AJ0440 - [On 070329 CT test on 070326 shows no evidence lung cancer.
AJ0441 - ref SDS J4 123I
AJ0443 - ..
AJ0444 - This may have occurred from distraction that commingled other events,
AJ0445 - creating confusion and mistakes that make communication the biggest
AJ0446 - risk in enterprise, see POIMS. ref OF 9 IE6L Case study on 040416
AJ0447 - illustrates communication drifts off course, ref SDS 35 GN7J, that
AJ0448 - drives the high cost of medical mistakes, reported on 990912.
AJ0449 - ref SDS 4 0001
Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
AN0401 - ..
AN0402 - Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
AN0404 - Follow up ref SDS H4 OH6I.
AN0406 - Millie has not yet had a chance to schedule a meeting with the Eye
AN0407 - doctor to evaluate tearing eyes, discussed during the meeting last
AN0408 - week on 061201. ref SDS H4 OH6I
AN0410 - ..
AN0411 - Since this is the last week of current chemotherapy therapy regimen,
AN0412 - the patient could defer setting a meeting to see if the problem is
AN0413 - cleared by switching to a different chemotherapy treatment.
AN0415 - ..
AN0416 - After the meeting today, Millie contacted Kaiser and schedule a
AN0417 - meeting with the eye clinic for 061222.
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea
AT0401 - ..
AT0402 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
AT0403 - Slow Response to Treatment Mastectomy Removed Blood Vessels
AT0404 - Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
AT0405 - Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
AT0407 - Follow up ref SDS H4 EH3F, ref SDS G8 EH3F.
AT0409 - Background on slow response to treatment and impending progression of
AT0410 - disease due to mastectomy surgery on 051021 was reviewed in the record
AT0411 - for the meeting on 061020, ref SDS F7 EH3F, and again on 061110.
AT0412 - ref SDS G8 EH3F
AT0414 - ..
AT0415 - The doctor has not had time to comment on Millie's letter submitted
AT0416 - 061027 asking about expectations for recovery from IBC due to pockets
AT0417 - of resistance to systemic chemotherapy treatments from mastectomy
AT0418 - surgery on 051021 that removed blood vessels, which prevents
AT0419 - delivering treatment, and cited on 061011. ref SDS G8 H53F
Biopsy Right Breast Rash Spreads from Left Breast Evaluate IBC Simil
B60401 - ..
B60402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
B60403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
B60404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
B60406 - Follow up ref SDS H4 KT7J, ref SDS G8 KT7J.
B60408 - Can a biopsy contribute to patient work up for developing a strategy
B60409 - and treatment plan, discussed on 060711, ref SDS C4 K36G, and more
B60410 - recently on 061020? ref SDS F7 KH6H Further review on 061110 presents
B60411 - objectives and rationale based on evidence of cancer mutating for
B60412 - biopsy of IBC red rash o left breast. ref SDS G8 448F
B60414 - ..
B60415 - There was discussion of taking a biopsy to evaluate the rash spreading
B60416 - from the left to slightly on the right breast, as observed in the
B60417 - examination today, per above, ref SDS 0 AX6G, based on patient history
B60418 - discovering IBC with a biopsy on 040419. ref SDS 36 789F
B60420 - ..
B60421 - The doctor feels a biopsy on the right breast is unnecessary overkill,
B60422 - and indicated the condition can be tested by prescribing antibiotic
B60423 - treatment, per above, ref SDS 0 KW45, and if the problem responds,
B60424 - this will indicate diagnosis of the new problem. This method was
B60425 - unsuccessful for 18 months to diagnose a similar rash on the left
B60426 - breast, shown in the case study in the record on 040517. ref SDS 39
B60427 - S66O
B60429 - ..
B60430 - A few weeks earlier, on 040504, the doctor discussed advantages of
B60431 - biopsy for diagnosis in the case of a rash on the breast, and
B60432 - explained weaknesses and risks using treatment methods for diagnostics
B60433 - that avoid biopsy, ref SDS 38 WI8F, as tried again today, per above.
B60434 - ref SDS 0 KW45
B60436 - ..
B60437 - Case study on 040416 illustrates high cost of medical mistakes,
B60438 - ref SDS 35 GN7J, reported on 990912. ref SDS 4 0001
PET/CT Scan Test Order 061227 Baseline New Treatment Navelbine Analy
BH0401 - ..
BH0402 - PET CT Image Testing Distant Metastasis Risks Secondary Cancer
BH0403 - IBC Test Distant Metastasis Discouraged Avoid Risk Secondary Cancer
BH0404 - Radiation Image Tests PET CT Limit to Reduce Risk Secondary Cancer
BH0405 - Risk Secondary Cancer Exposure Radiation Image Testing CT PET Scan
BH0407 - Follow up ref SDS H4 EY5O, ref SDS G8 EY5O.
BH0409 - During the meeting today, the doctor ordered a PET scan test to
BH0410 - evaluate cancer, and set a baseline for changing treatment protocols,
BH0411 - per change in strategy today, shown below. ref SDS 0 RW5I This
BH0412 - implements planning last week on 061201. ref SDS H4 EY5O
BH0414 - ..
BH0415 - Pulmonary embolism - this test can resolve issues pending from
BH0416 - previous tests cited on 061110 to compare findings of pulmonary
BH0417 - embolism in tests on 041103 and on 060930, including severity of
BH0418 - enlarged right ventricle, ref SDS G8 EY5O, discussed further below.
BH0419 - ref SDS 0 VJ4J
BH0421 - [On 070102 received report for CT test performed on 061227; for
BH0422 - some reason Kaiser failed to compare with CT test on 060930
BH0423 - that diagnosed pulmonary embolism, and enlarged right
BH0424 - ventricle. ref SDS I4 AK9H
BH0426 - ..
BH0427 - The doctor noted again that a special form of CT test is the best
BH0428 - method for evaluating pulmonary embolism, confirming understandings
BH0429 - from the meeting on 061020. ref SDS F7 S56G None-the-less, the PET
BH0430 - scan test analyst should compare and contrast findings to shed as much
BH0431 - light as possible on this issue, discussed further below. ref SDS 0
BH0432 - CV5L
BH0434 - ..
BH0435 - A few days later, Jessica in Nuclear Medicine, where PET scan tests
BH0436 - are performed, called Millie and advised that Kaiser will use a
BH0437 - combined CT and PET scan technology for this next test. Millie had
BH0438 - this combined test previously on 051005, reported on 051007.
BH0439 - ref SDS 88 QRTQ
BH0441 - ..
BH0442 - Jessica scheduled the test for 061227 1530.
BH0444 - ..
BH0445 - This may solve the problem to correct past mistakes failing to compare
BH0446 - severity of pulmonary embolism findings, including enlarged right
BH0447 - ventricle. The doctor reported on 061020 that the CT test for
BH0448 - pulmonary embolism is more rigorous than normally used to diagnose
BH0449 - cancer. ref SDS F7 S56G
BH0451 - ..
BH0452 - Esophagitis - the doctor further ordered the PET scan test analysis to
BH0453 - correlate with the PET test on 060120, and the CT test on 060505 which
BH0454 - both seemed to make findings that relate to esophagitis, per
BH0455 - discussion above. ref SDS 0 JP6K
BH0457 - ..
BH0458 - Right breast IBC - as with prior image tests, the analyst should look
BH0459 - for thickened skin to assess prospect of IBC, reported for the first
BH0460 - time today, per above. ref SDS 0 025H Background on CT tests
BH0461 - reporting thickened skin, but not diagnosing IBC is listed in the
BH0462 - record on 060711. ref SDS C4 YU6M
Emotional Trauma Increases 2 New Issues Rash Spread Right Breast Dia
BM0401 - ..
BM0402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
BM0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
BM0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
BM0406 - Follow up ref SDS H4 Y642, ref SDS G8 Y642.
BM0408 - The proposal today changing treatment from every 3 weeks, with a week
BM0409 - off, to treatment once a week with Navelbine creates trauma from
BM0410 - emotional stress worrying about constant debilitation and anemia that
BM0411 - prevents living routine daily life, including continuing work. The
BM0412 - prospect of increase recovery from cancer now seems less achievable.
BM0414 - ..
BM0415 - There is some emotional relief in trying another treatment method,
BM0416 - here considering Navelbine. ref SDS 0 RW5I
BM0418 - ..
BM0419 - The explanation that weekly treatments are less potent to reduce
BM0420 - debilitating side effects, also, seems somewhat reassuring.
BM0421 - Uncertainty increases emotional stress presented previously on 061110,
BM0422 - ref SDS G8 Y642, and citing the list of issues on 061020 that increase
BM0423 - stress and trauma, ref SDS F7 R24G, and reflects complex patient
BM0424 - history, also listed on 061020. ref SDS F7 PB3H
BM0426 - ..
BM0427 - Spread of rash from left to the right breast is a dramatic change in
BM0428 - patient profile, especially if it is IBC. ref SDS 0 025H Creates
BM0429 - mixed emotions from expanding disease, that may however meet
BM0430 - requirements for measurable disease to qualify patient for drug
BM0431 - trials that expand range of chemotherapy drugs to discover effective
BM0432 - treatment, per discussion below. ref SDS 0 P27L
BM0434 - ..
BM0435 - Failure to perform biopsy to diagnose the new rash on the right
BM0436 - breast, per above, ref SDS 0 WZ5J, avoids trauma of prolonged recovery
BM0437 - from biopsy wound on the left breast which took 18 months to cure,
BM0438 - reported on 050727. ref SDS 73 906K Proposal to diagnose new rash by
BM0439 - prescribing treatment with antibiotics, also, per above, ref SDS 0
BM0440 - KW45, increases trauma from prior similar effort that failed and
BM0441 - prevented timely treatment of IBC for 18 months on the left breast,
BM0442 - illustrated by the record on 040318. ref SDS 32 IM6J
BM0444 - ..
BM0445 - Error in medical chart describing metastatic disease in connection
BM0446 - with lungs and lymph nodes, per above, ref SDS 0 G25K, creates stress
BM0447 - about quality of medical practice. If the report is correct and not
BM0448 - disclosed to the patient except by sending a copy of the medical chart
BM0449 - this is even more traumatic on failure to disclose, and on learning of
BM0450 - dramatic worsening in medical condition.
Strategy Treatment Plan IBC 3rd Relapse Scope Tumor Board Review UCS
BX0401 - ..
BX0402 - Strategy Treatment Options Scenarios Planning Treatment Navelbine
BX0403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
BX0404 - Tumor Board Review on Changing Treatment Expansion of Disease
BX0406 - Follow up ref SDS H4 K36G, ref SDS G8 K36G.
BX0408 - Background on requirements and challenge performing requirements for
BX0409 - planning and proactive management in time for action to be effective
BX0410 - is reported on 060825. ref SDS E7 K36G
BX0412 - ..
BX0413 - Millie is now on the 7th chemotherapy cycle since starting treatment
BX0414 - on 060711, ref SDS C4 SM6M, for the 3rd relapse of IBC. ref SDS C4
BX0415 - 8Y8I She had 8 cycles of this protocol in 2005, ending on 050916,
BX0416 - ref SDS 83 407N, making a total of 15 cycles with Taxotere and
BX0417 - capecitabine. She had a total of 6 cycles of Taxotere in 2002 by
BX0418 - itself, ending on 021204. ref SDS 20 F5Z5 Four (4) cycles were given
BX0419 - in Phase 2 adjuvant treatment, and 2 cycles were given previously in
BX0420 - Phase 1 treatment, when the doctor switched from Adriamycn Cytoxin
BX0421 - (AC) to Taxotere on 020610, as reported on 021204. ref SDS 20 MO7O
BX0423 - ..
BX0424 - This makes a total of...
BX0426 - 1. 21 treatments with Taxotere since 2002.
BX0427 - 2. 15 treatments with capecitabine since 2005
BX0429 - ..
BX0430 - Millie was further treated with Taxol as part of the drug trial for
BX0431 - bevacizumab (Avastin). She had a total of 7 cycles until treatment
BX0432 - was stopped on 041104 due to diagnosis of pulmonary embolism.
BX0433 - ref SDS 50 RZ4I
BX0435 - ..
BX0436 - This makes a total of 28 treatments with taxanes.
BX0438 - ..
BX0439 - Millie's letter to Kaiser, ref DIP 5 ZL6L, on 061027 asks for review
BX0440 - of treatment strategy to address slow response to treatment.
BX0441 - ref SDS F9 KJ7K
BX0443 - ..
BX0444 - This might be a good time for Tumor Board review, perhaps Kaiser can
BX0445 - assemble a team of experts treating IBC. Tumor Board was previously
BX0446 - considered in Millie's letter to Kaiser on 060720. ref SDS C6 5S8F At
BX0447 - that time, on 060721 the primary care physician responded saying in
BX0448 - part "Tumor Board could offer no more." ref SDS C8 IP9L
BX0450 - ..
BX0451 - Follow up review with Doctor Benz was proposed by the primary care
BX0452 - physician on considering UCSF drug trials, per below. ref SDS 0 D58F
BX0454 - [On 061218 letter to Kaiser confirms request for Tumor Board with
BX0455 - panel that has experience treating secondary IBC relapse, post
BX0456 - mastectomy surgery. ref SDS H8 OT5I
BX0458 - ..
BX0459 - [On 061228 doctor submits summary of patient history
BX0460 - submitted to UCSF for participation in clincial drug trial
BX0461 - as providing "5 year review" of complex patient history in
BX0462 - place of Tumor Board support for analysis of diagnosis and
BX0463 - treatment planning. ref SDS I1 NP8G
BX0465 - ..
BX0466 - Last week on 061201 the doctor cited erratic CA 15-3 cancer marker
BX0467 - test results. ref SDS H4 GJ5M Examination showed stable to worse red
BX0468 - rash on the left chest. ref SDS H4 RU7M Today, the doctor found rash
BX0469 - has spread to the right breast, confirming Millie's letter on 061204,
BX0470 - as reported above ref SDS 0 025H
BX0472 - ..
BX0473 - This may reflect lower effectiveness of taxanes due to cancer
BX0474 - mutation.
BX0476 - ..
BX0477 - Other factors in patient history causing slow response to treatment
BX0478 - were reviewed on 060922, ref SDS E8 GA8H, citing scenario #2 reported
BX0479 - on 060808. ref SDS E0 HT5K For example, loss of blood vessels removed
BX0480 - during mastectomy surgery may prevent delivery of systemic treatment
BX0481 - to infected tissue, creating "pockets of resistance," reviewed on
BX0482 - 061201. ref SDS H4 P66G A recent factor could be a cat bite causing
BX0483 - erratic CA 15-3 test results, along with rising rash on the left
BX0484 - chest, with slight rash now on the right breast, noted on 061201,
BX0485 - ref SDS H4 P66O, and discussed again today.
BX0487 - ..
BX0488 - Last week on 061201 the doctor proposed changing from Taxotere and
BX0489 - capecitabine (Xeloda), to treatment with Navelbine or Gemzar
BX0490 - chemotherapy drug agents in hopes of improving recovery from cancer.
BX0491 - ref SDS H4 ZZ9N
BX0493 - ..
BX0494 - Today, the doctor decided to start treatments on 070105 with
BX0495 - Navelbine, per below. ref SDS 0 PF3O
BX0497 - ..
BX0498 - The doctor seemed to say there is no specific rationale or criteria
BX0499 - for trying Navelbine first, reviewed on 060711, ref SDS C4 S07M, and
BX0500 - later switching to Gemzar, also, reviewed on 060711, ref SDS C4 576N,
BX0501 - when Navelbine declines and disease progresses, as Doctor Benz
BX0502 - discussed in a 2nd opinion on 060821, reviewed on 060929. ref SDS F1
BX0503 - WR3Y The expression was used that choosing between Gemzar and
BX0504 - Navelbine is merely a "flip of the coin."
BX0506 - [On 061230 letter from the doctor proposes deferring treatment
BX0507 - with Gemzar so that Millie has a better chance of qualifying for
BX0508 - clincial drug trials. ref SDS I2 TR9H
BX0510 - ..
BX0511 - [On 070105 the doctor clarified the letter today was a mistake; he
BX0512 - intended to say that treatment with both Navelbine and Gemzar
BX0513 - should be deferred so that Millie has a better chance of
BX0514 - qualifying for treatment in clinical studies of new, more
BX0515 - effective chemotherapy agents. ref SDS I5 PF3O
BX0517 - ..
BX0518 - [On 070510 woman on clinical study treatment with cetuximab and
BX0519 - carboplatin for 10 months was switched to Gemzar when disease
BX0520 - progressed. ref SDS J5 5P88
BX0522 - ..
BX0523 - Tolerance of side effects is an important criteria, especially if
BX0524 - treatments are given weekly, as discussed by the doctor today for
BX0525 - Navelbine. On 060711, the primary care physician seemed to indicate
BX0526 - that most patients tolerate Gemzar better than Navelbine. ref SDS C4
BX0527 - 576N
BX0529 - ..
BX0530 - Another issue is prognosis for treatment with Navelbine. Research on
BX0531 - 060711 yielded a case of a woman with IBC who was treated with
BX0532 - Navelbine and died quickly in about 3 months. In that case, CA 15-3
BX0533 - increased above 300. ref SDS C4 9U3L
BX0535 - ..
BX0536 - This record supports investigating other treatment options with drug
BX0537 - trials presented in a 2nd opinion prepared by Doctor Benz, and
BX0538 - received from UCSF on 060929, reviewed below with the doctor.
BX0539 - ref SDS 0 P256
BX0541 - [On 070201 Millie begins treatment with cetuximab clincial
BX0542 - study drug trial at UCSF. ref SDS J1 0001
BX0544 - ..
BX0545 - [On 070301 IBC disease spreads significantly begin
BX0546 - consideration to change treatments. ref SDS J3 4140
BX0548 - ..
BX0549 - [On 070329 patient responds to treatment dramatic decline CA
BX0550 - 15-3 cancer marker, IBC rash subsides. ref SDS J4 LB5L
BX0552 - ..
BX0553 - The doctor ordered a PET scan test today for a new baseline to assess
BX0554 - the change in strategy to switch treatment protocols, per above.
BX0555 - ref SDS 0 EY5O
Navelbine Vinorelbine Tartrate Protocol Single Agent Combine Taxoter
C30401 - ..
C30402 - Navelbine Single Agent Combine Taxotere Capecitabine Conflict 2nd Opinions
C30404 - Follow up ref SDS F1 WR3Y.
C30406 - On 060929 Doctor Benz again recommended Navelbine and Gemzar single
C30407 - agents, or in combination with capecitabine, ref SDS F1 WR3Y, rather
C30408 - than with Taxotere, originally proposed by Doctor Benz in an opinion
C30409 - on 041018, reviewed on 041117, and again on 060711. ref SDS F1 LT30
C30411 - ..
C30412 - The primary care physician today recommended treatment with single
C30413 - agents, rather than couplets, which aligns with earlier comments on
C30414 - 041130. ref SDS 52 5X4J On 050329 the doctor prescribed multi-agent
C30415 - treatment with Taxotere and capecitabine recommended by Doctor Benz.
C30416 - ref SDS 64 T58M
C30418 - [On 061218 doctor repeats generalization about using single
C30419 - agent treatments to avoid exhausing drugs to treat Millie,
C30420 - without listing available drugs for IBC, and conflicting with
C30421 - patient history prescribing double-agent treatments.
C30422 - ref SDS H8 JU7J
C30424 - ..
C30425 - This further aligns with recent comments by Doctor Benz at UCSF on
C30426 - 060821 indicating that capecitabine (Xeloda) may be sufficient for
C30427 - Millie's treatment without combining Taxotere, ref SDS E6 968J,
C30428 - contrary to the initial recommendation in the UCSF 2nd opinion
C30429 - received on 041117. ref SDS 51 OU6S
C30431 - ..
C30432 - The doctor did not remember conflict in the UCSF recommendations for
C30433 - treatment with Navelbine and Gemzar. The first opinion received on
C30434 - 041117 seemed to recommend combining with Taxotere, like capecitabine,
C30435 - and the more recent opinion received on 060929 recommends combination
C30436 - with capecitabine. ref SDS F1 WR3Y
Strategy Treatment Plan Surgery Remove Pockets of Resistance to Chem
C90401 - ..
C90402 - Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
C90404 - Follow up ref SDS E7 WE8K, ref SDS C4 X54L.
C90406 - Surgery to treat "pockets of resistance" to chemotherapy was discussed
C90407 - only briefly again today. As on 061201, ref SDS H4 ZZ5F, there was
C90408 - not enough time again today to review background in the record on
C90409 - 061110. ref SDS G8 RU81 The doctor seemed to comment today that
C90410 - surgery would be palliative, which aligns with previous comments on
C90411 - 051007 changing strategy for surgery from "local control" to prevent
C90412 - distant metastasis, to "palliation." ref SDS 88 IV4G
C90414 - ..
C90415 - Patient history on considerations for surgery in this case are
C90416 - reported on 040416. ref SDS 54 657F
C90418 - ..
C90419 - Surgery to remove infected tissue and rebuild the breast for better
C90420 - response to chemotherapy in the event of relapse was postponed by the
C90421 - Surgery Department on 051007, and then considered again to treat
C90422 - relapse on 060711. ref SDS C4 X54L
Treatment 7th Cycle Complete Capecitabine (Xeloda) Taxotere IBC 3rd
CE0401 - ..
CE0402 - Treatment Switch from Taxotere and Capecitabine (Xeloda) to Navelbine
CE0403 - Navelbine Planning New Treatment Begin Consideration UCSF Drug Trial
CE0404 - Taxotere and Capecitabine (Xeloda) 7th-Cycle Treatment Continue
CE0406 - Follow up ref SDS H4 PF3O, ref SDS G8 PF3O.
CE0408 - Treatment considerations today primarily focused on switching
CE0409 - chemotherapy from Taxotere and capecitabine (Xeloda) to Navelbine that
CE0410 - may increase effectiveness, per above. ref SDS 0 Q74O
CE0412 - ..
CE0413 - The doctor ordered PET/CT test today that was later scheduled for
CE0414 - 061227, per above, ref SDS 0 EY5O, for setting a new baseline to
CE0415 - evaluate treatment with Navelbine, which is scheduled to start on
CE0416 - 070105, per below. ref SDS 0 N96O
CE0418 - [On 061230 letter from the doctor proposes deferring treatment
CE0419 - with Gemzar so that Millie has a better chance of qualifying for
CE0420 - clincial drug trials. ref SDS I2 TR9H
CE0422 - ..
CE0423 - [On 070105 the doctor clarified the letter today was a mistake; he
CE0424 - intended to say that treatment with both Navelbine and Gemzar
CE0425 - should be deferred so that Millie has a better chance of
CE0426 - qualifying for treatment in clinical studies of new, more
CE0427 - effective chemotherapy agents. ref SDS I5 PF3O
CE0429 - ..
CE0430 - Despite hectic schedule, noted above, ref SDS 0 SM6M, the doctor began
CE0431 - consideration of ideas, research, and strategy to improve Millie's
CE0432 - recovery from IBC on the left and spreading to the right breast by
CE0433 - arranging for treatment on a clinical study drug trial proposed by
CE0434 - UCSF Cancer Center, per below. ref SDS 0 WI3J This implements
CE0435 - strategy reported by the doctor on 041130 to use drug trials for
CE0436 - expanding limited treatments available for Millie's complex patient
CE0437 - profile. ref SDS 56 028N
Navelbine Vinorelbine Tartrate Protocol Pharmacology Review Change C
CK0401 - ..
CK0402 - Navelbine Protocol Pharmacology Submitted for Review
CK0404 - The doctor proposes replacing treatment with Taxotere and
CK0405 - capecitabine, with single agent Navelbine. Using single agent or
CK0406 - combining Navelbine with Taxotere or capecitabine is considered above.
CK0407 - ref SDS 0 Q74O
CK0409 - ..
CK0410 - The doctor indicated Navelbine treatment would be weekly. He said the
CK0411 - dose is reduced to reduce side effects.
CK0413 - ..
CK0414 - The doctor submitted pharmacology on Navelbine for review to prepare
CK0415 - for the next meeting in 4 weeks to decide on this course of treatment.
CK0417 - ..
CK0418 - The print is very small; requires a magnifying glass to read.
CK0420 - ..
CK0421 - The document received today from the doctor during the meeting has a
CK0422 - partial URL address on the Internet. Search did not locate this
CK0423 - particular document, possibly because it is restricted for doctors or
CK0424 - requires a subscription, requires cookies, etc.
CK0426 - ..
CK0427 - The document says in part...
CK0429 - Micromedex Healthcare Series: Drugdex Drug Point Page 1 - 4
CK0431 - Thomson
CK0432 - Micromedex
CK0434 - ..
CK0435 - Vinorelbine Tartrate
CK0437 - ..
CK0438 - Tradename: Navelbine
CK0440 - ..
CK0441 - Adult Dose:
CK0443 - Breast cancer: 30 mg/m(2)/week IV over 6 - 10 min
CK0445 - ..
CK0446 - This seems to align with the doctor's comment that the protocol
CK0447 - requires weekly treatments, per above. ref SDS 0 4X5I
CK0449 - ..
CK0450 - The document received today has a section on adverse effects. The
CK0451 - terminology requires expert consultation.
CK0453 - ..
CK0454 - Research on other Internet locations consistently list side
CK0455 - effects...
CK0457 - 1. Low blood counts - white blood cells (WBC) which increases
CK0458 - the risk of infection; red blood cells, platelets
CK0460 - 2. Fatigue
CK0462 - ..
CK0463 - 3. Shortness of breath
CK0465 - ..
CK0466 - 4. Sore throat, mouth pain
CK0468 - ..
CK0469 - 5. Pulmonary emoblism - seems to be rare
CK0471 - ..
CK0472 - These side effects are not expressly presented in the Micromedex
CK0473 - document on Navelbine received today. They may be implied or
CK0474 - interpreted by experts from technical language in the document.
CK0476 - ..
CK0477 - Millie's patient profile of low tolerance for weekly treatments,
CK0478 - reported on 050520, ref SDS 69 VP3N, consistently low blood counts
CK0479 - with weekly treatments shown in case study on 060810, ref SDS E3 HV45,
CK0480 - which cause increased susceptibility to infection, together with
CK0481 - recurrent pulmonary embolism, may present risks using older
CK0482 - technologies of Navebine and Gemzar that require professional
CK0483 - assessment, based on the list of current medical issues, per above.
CK0484 - ref SDS 0 LU3J
CK0486 - ..
CK0487 - For example, on 040402 the protocol nurse presented side effects of a
CK0488 - drug trial for bevacizumab (Avastin) combined with Taxol. There was
CK0489 - no understanding from the meeting that this regimen presented a
CK0490 - serious risk of pulmonary embolism, nor that it is a major threat to
CK0491 - life. ref SDS 33 V77O After starting on the Avastin trial on 040420,
CK0492 - side effects of fatigue, shortness of breath, chronic cough were
CK0493 - continuously reported to Kaiser beginning on 040517. ref SDS 39 RZ4I
CK0494 - This was diagnosed variously as an allergy, a cold, the flu, loss of
CK0495 - fitness, etc., and treated with cough medicine or ignored. For
CK0496 - example, on 040909 reports of cough, shortness of breath, fatigue
CK0497 - presented a dilemma because CT scan tests showed no evidence of
CK0498 - causation. ref SDS 47 RZ4I More recently, on 061020 there was a
CK0499 - report that CT tests require a different technology for diagnosing
CK0500 - pulmonary embolism that causes symptoms. ref SDS F7 S56G
CK0502 - ..
CK0503 - This patient history suggests caution undergoing treatments with side
CK0504 - effects that compound risks for Millie's patient profile.
Drug Trials Case Study Medical Practice Kaiser Advocate Protocol Nur
CZ0401 - ..
CZ0402 - Drug Trials Kaiser Research UCSF and Other Proposals
CZ0403 - Case Study Chemotherapy Drug Trials Promoted Rarely Yield Results
CZ0405 - Follow up ref SDS E7 WB9K, ref SDS C4 WB9K.
CZ0407 - Kaiser has consistently recommended drug trials as the best course for
CZ0408 - treating Millie....
CZ0410 - ..
CZ0411 - 1. On diagnosis of recurrence, primary
CZ0412 - care physician recommended drug
CZ0413 - trial for bevacizumab (Avastin),
CZ0414 - as best treatment for
CZ0415 - Millie............................. 040309, ref SDS 30 WG7F
CZ0417 - ..
CZ0418 - 2. Diagnosis changed to qualify
CZ0419 - Millie for the
CZ0420 - trial.............................. 040402, ref SDS 34 IM6J
CZ0422 - ..
CZ0423 - 3. Protocol Assistant said everyone in
CZ0424 - Oncology was elated that Millie
CZ0425 - was "randomized" to receive
CZ0426 - bevacizumab (Avastin) treatment
CZ0427 - in the study....................... 040416, ref SDS 35 8R6M
CZ0429 - ..
CZ0430 - 4. Family history of pulmonary emboli
CZ0431 - issues, and patient complaints of
CZ0432 - symptoms ignored to maintain
CZ0433 - participation in drug trial that
CZ0434 - was yielding some good
CZ0435 - results............................ 040812, ref SDS 46 RZ4I
CZ0437 - ..
CZ0438 - 5. When Millie was taken off Avastin
CZ0439 - study due to pulmonary embolism,
CZ0440 - primary care physician advised
CZ0441 - that investing time to find another
CZ0442 - drug trial was better than
CZ0443 - continuing treatment for Millie
CZ0444 - using established chemotherapy
CZ0445 - drugs Taxol, Taxotere, Navelbine,
CZ0446 - capecitabine (Xeloda).............. 041130, ref SDS 52 028N
CZ0448 - ..
CZ0449 - 6. Doctor advised that new drug trial
CZ0450 - combining capecitabine with Novel
CZ0451 - Epothilones BMS-247550, ref SDS 54
CZ0452 - CF9F, was the best treatment plan
CZ0453 - for Millie's condition of
CZ0454 - recurring secondary
CZ0455 - IBC................................ 041210, ref SDS 54 CF7H
CZ0457 - ..
CZ0458 - 7. Doctor disappointed when Millie
CZ0459 - could not participate in the trial,
CZ0460 - ref SDS 56 028N, and prescribed
CZ0461 - interim treatment with chemotherapy
CZ0462 - agent which had previously failed
CZ0463 - to improve Millie's condition, but
CZ0464 - would qualify Millie for the drug
CZ0465 - trial.............................. 041230, ref SDS 56 YR8F
CZ0467 - ..
CZ0468 - 8. Doctor Benz cancer researcher reported
CZ0469 - that UCSF has several clinical trials
CZ0470 - that might benefit
CZ0471 - Millie............................. 060929, ref SDS F1 UI9K
CZ0473 - ..
CZ0474 - 9. Case study expanded on clinical
CZ0475 - trial practices and Millie's
CZ0476 - patient history in connection
CZ0477 - with Kaiser's self-referral
CZ0478 - theory to avoid paying for
CZ0479 - standard of care................... 070830, ref SDS J6 SE4H
CZ0481 - ..
CZ0482 - Kaiser's support for drug trials was manifest on 060711, when the
CZ0483 - primary care physician asked the protocol nurse to find another
CZ0484 - chemotherapy study to treat Millie for recurrence of IBC. ref SDS C4
CZ0485 - WB9K
CZ0487 - ..
CZ0488 - Millie's letter on 061204 asks about Kaiser's progress reviewing drug
CZ0489 - trials? ref SDS H6 I944 Another letter later in the day asked about
CZ0490 - this again? ref SDS H6 2P9T The doctor responded to the 2nd letter
CZ0491 - saying "no problem," indicating Kaiser has research for review on
CZ0492 - finding drug trials to support Millie's treatment.
CZ0494 - ..
CZ0495 - Today, the doctor related recent conversation with Rosalie, Kaiser's
CZ0496 - Clinical Trial protocol nurse in the Oncology Department. Rosalie
CZ0497 - reported that Kaiser cannot find a drug trial for Millie. That is why
CZ0498 - the doctor proposes switching to Navelbine, discussed above.
CZ0499 - ref SDS 0 3B4N Navelbine was considered on 060711 to treat Millie,
CZ0500 - described as 10-year old technology, and one of only a few remaining
CZ0501 - treatments that fit Millie's complex patient profile. ref SDS C4 PF4M,
CZ0502 - initially reviewed on 060428. ref SDS A8 JF8L Previously, Rosalie
CZ0503 - mentioned on 050204 that Millie's status as stage IV IBC relapse, with
CZ0504 - mastectomy surgery limits ability to qualify for drug trial protocols.
CZ0505 - ref SDS 57 028N
CZ0507 - ..
CZ0508 - There is no record of this communication nor the issue of drug trial
CZ0509 - research in Progress Notes for the Medical Chart, per below.
CZ0510 - ref SDS 0 J59N Failure to produce a written record of research on
CZ0511 - drug trials that can be reviewed for scope and guide additional
CZ0512 - efforts seems conflicting with Kaiser's commitment to drug trials as
CZ0513 - the best course of treatment, per above. ref SDS 0 WI3J
CZ0515 - ..
CZ0516 - For example, since Kaiser strongly recommended a drug trial on 041230,
CZ0517 - what are the prospects for treatment now that the study has completed,
CZ0518 - or otherwise outside of any study? What about other studies for which
CZ0519 - Millie did not qualify? Have any trials over the past 4 years yielded
CZ0520 - treatments that can help Millie outside of studies?
Drug Trials Millie Measurable Disease Spread Left to Right Breast Q C
DA0401 - ..
DA0402 - Drug Trials UCSF 2 Proposals Kaiser Review Pending Needs Support
DA0403 - UCSF 2 Drug Trial Proposals Kaiser Needs Support to Complete Review
DA0405 - There was discussion again today about Kaiser's investigation on
DA0406 - working with UCSF to implement drug trials proposed by Doctor Benz
DA0407 - during consultation at UCSF on 060821. ref SDS E6 W66J UCSF 2nd
DA0408 - opinion received during the meeting at Kaiser on 060929 states that
DA0409 - Millie qualifies for at least 2 clinical drug trials on showing of
DA0410 - measurable disease. ref SDS F1 UI9K During the examination today, the
DA0411 - doctor observed disease has progressed under current chemotherapy
DA0412 - treatment from the left to the right breast, per above. ref SDS 0 ZX4F
DA0413 - Due diligence requires review of UCSF proposals on drug trial
DA0414 - treatments that can arrest advance of disease.
DA0416 - ..
DA0417 - Kaiser's current strategy to begin weekly treatments with Navelbine,
DA0418 - per above, ref SDS 0 3B4N, should be reviewed for additional options
DA0419 - with drug trials to improve poor prognosis under a Navelbine regimen,
DA0420 - also, per above, ref SDS 0 XC8K, and in light of Kaiser's practice to
DA0421 - routinely make referrals for improving patient chances of effective
DA0422 - treatment, reported on 060809. ref SDS E2 NT9X
DA0424 - [On 061228 Kaiser's report to UCSF presents lesions on left
DA0425 - chest; does not cite spread of IBC from left to right breast
DA0426 - indicating "measurable disease" that qualifies Millie for drug
DA0427 - trials. ref SDS I1 IQ6J
DA0429 - ..
DA0430 - [On 061230 Kaiser's follow up letter responding to questions
DA0431 - from UCSF on measurable disease does not cite IBC lesions nor
DA0432 - spread from left to right breast. ref SDS I2 PO3V
DA0434 - ..
DA0435 - [On 070130 Doctor Rugo advised that UCSF has other drug trials
DA0436 - on clinical study which Millie qualifies to treat her IBC, if
DA0437 - disease progresses with cetuximab drug trial. ref SDS J0 TG5G
DA0439 - ..
DA0440 - The primary care physician did not remember that UCSF proposed drug
DA0441 - trials for Millie. The doctor said there are a great many phase I
DA0442 - chemotherapy trials, which Kaiser does not support because they are
DA0443 - too speculative for affirmative treatment, which Millie needs at this
DA0444 - time.
DA0446 - ..
DA0447 - There was discussion that Doctor Benz has a strong reputation in the
DA0448 - oncology field. On 040318 the oncology department at Kaiser
DA0449 - recommended UCSF for 2nd opinion review. ref SDS 32 HC6O The Benz 2nd
DA0450 - opinion received on 041117 supported Kaiser's investigation and timely
DA0451 - treatment of Millie for pulmonary embolism. ref SDS 51 OT5Q Millie's
DA0452 - current treatment with Taxotere and capecitabine was, also,
DA0453 - recommended by Doctor Benz on 041117. ref SDS 51 OU6S This record
DA0454 - indicates UCSF recommendations presented by Doctor Benz to assist
DA0455 - Kaiser in formulating treatment strategy justify review, rather than
DA0456 - dismissal as "too speculative."
DA0458 - ..
DA0459 - The primary care physician concurred that the merits of UCSF's
DA0460 - proposal on treatments for Millie can only be determined by careful
DA0461 - review of evidence on effectiveness, side effects, and costs to
DA0462 - compare trade-offs with other treatments, like Navelbine disucssed
DA0463 - today.
DA0465 - ..
DA0466 - The doctor asked that Millie contact Doctor Benz for clarification of
DA0467 - protocols and requirements on the 2 UCSF drug trials cited in the 2nd
DA0468 - opinion for consultation on 060821, and received at Kaiser on 060929.
DA0469 - ref SDS F1 UI9K
DA0471 - ..
DA0472 - Discussed opportunity for Kaiser to perform due diligence determining
DA0473 - Millie's treatment through direct communication to collaborate with
DA0474 - UCSF, and retain responsibility for case management. Kaiser can
DA0475 - report advance of disease from the left to the right breast, shown by
DA0476 - examination today, per above, ref SDS 0 025H, which meets UCSF
DA0477 - requirements for "measurable disease" listed in the 2nd opinion
DA0478 - received on 060929, ref SDS F1 UI9K, and based on criteria explained
DA0479 - by Doctor Benz during consultation at UCSF on 060821. ref SDS E6 A69N
DA0481 - ..
DA0482 - The doctor advised that searching through 5 years of records in
DA0483 - Millie's medical chart at Kaiser to find the UCSF 2nd opinion prepared
DA0484 - by Doctor Benz will be difficult. He recalled the report was about 5
DA0485 - pages of single spaced narrative with no paragraph breaks, just one
DA0486 - massive stream of text. (actually, the first report prepared by Doctor
DA0487 - Benz on 041018, was the single long paragraph of 5 pages, received
DA0488 - from Kaiser on 041117. ref SDS 51 4P6G) The Benz 2nd opinion for the
DA0489 - consultation on 060821, was correctly formatted, and quite long,
DA0490 - reported on 060929. ref SDS F1 KS8H
DA0492 - ..
DA0493 - The doctor requested a letter from Millie with an electonic link to
DA0494 - the UCSF 2nd opinion at the location where Doctor]Benz discusses 2
DA0495 - drug trials which Millie qualifies for participation upon showing of
DA0496 - measurable disease.
DA0498 - [On 061218 Millie submitted a letter to the primary care
DA0499 - physician, and with a link to the record on 060929 that reviews
DA0500 - the Benz proposal on treating Millie with 2 drug trials.
DA0501 - ref SDS H8 YV38
DA0503 - ..
DA0504 - [On 061226 Kaiser reports performing due diligence collaborating
DA0505 - with Doctor Rugo at UCSF to consider drug trial potocols for
DA0506 - Millie's patient profile. ref SDS H9 086H
DA0508 - ..
DA0509 - [On 061230 Kaiser responding to questions from UCSF on measurable
DA0510 - disease does not cite IBC spreading from left to right breast.
DA0511 - ref SDS I2 3X6I
DA0513 - ..
DA0514 - [On 061230 Kaiser advises Doctor Rugo that Kaiser will pay for any
DA0515 - costs not covered by the trial, including standard of care.
DA0516 - ref SDS I2 3X6K
DA0518 - ..
DA0519 - [On 070102 Doctor Rugo plans to meet with Millie to arrange
DA0520 - treatment for IBC on clinical study. ref SDS I3 YP8O
DA0522 - ..
DA0523 - [On 070105 primary care physician changes prescribed treatment
DA0524 - from Navelbine to cetuximab and carboplatin on clinical study at
DA0525 - UCSF; will monitor progress carrying out responsibility for case
DA0526 - management with examinations every 2 months. ref SDS I5 PK69
DA0528 - ..
DA0529 - [On 070109 Millie requests that Kaiser expedite treatment for
DA0530 - progressing disease. ref SDS I6 WZ4L
DA0532 - ..
DA0533 - [On 070116 Jackie at UCSF called to schedule meeting between
DA0534 - Millie and Doctor Rugo to begin treatment. ref SDS I8 0001
DA0536 - ..
DA0537 - [On 070201 Millie begins treatment with cetuximab clincial
DA0538 - study drug trial at UCSF. ref SDS J1 0001
DA0540 - ..
DA0541 - [On 070301 IBC disease spreads significantly begin
DA0542 - consideration to change treatments. ref SDS J3 4140
DA0544 - ..
DA0545 - [On 070329 patient responds to treatment dramatic decline CA
DA0546 - 15-3 cancer marker, IBC rash subsides. ref SDS J4 LB5L
Schedule Meeting 070105 Review Treatment Navelbine 1st Cycle 16th To
DE0401 - ..
DE0402 - Chemotherapy Holiday Treatments Deferred 4 Weeks Holiday Season
DE0403 - Schedule Treatment Start Navelbine 4 Weeks Chemotherapy Holiday
DE0405 - Follow up ref SDS H4 N96O, ref SDS G8 N96O.
DE0407 - During the meeting today, the doctor scheduled treatment for IBC with
DE0408 - Navelbine to start in 4 weeks on 070105, and will meet with Millie at
DE0409 - that time on 070105 1420, for examination to discuss PET/CT scan test
DE0410 - results for evaluating continuing treatment, as reported above.
DE0411 - ref SDS 0 PF3O
DE0413 - [On 061230 letter from the doctor proposes deferring treatment
DE0414 - with Gemzar so that Millie has a better chance of qualifying for
DE0415 - clincial drug trials. ref SDS I2 TR9H
DE0417 - ..
DE0418 - [On 070105 the doctor clarified the letter today was a mistake; he
DE0419 - intended to say that treatment with both Navelbine and Gemzar
DE0420 - should be deferred so that Millie has a better chance of
DE0421 - qualifying for treatment in clinical studies of new, more
DE0422 - effective chemotherapy agents. ref SDS I5 PF3O
DE0424 - ..
DE0425 - This will give Millie a few weeks break for a "chemotherapy holiday"
DE0426 - until resuming treatment with Navelbine beginning in January 2007, as
DE0427 - currently planned, per above. ref SDS 0 PF3O
Pulmonary Emboli Blood Clots Lungs Symptoms Continue Fatigue Shortne
DL0401 - ..
DL0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
DL0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
DL0404 - Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
DL0406 - Follow up ref SDS H4 CV5L, ref SDS G8 CV5L.
DL0408 - Background on pulmonary embolism recurrence is reported in the record
DL0409 - for the meeting on 061020. ref SDS F7 CV5L The record was updated
DL0410 - last week on 061201 showing symptoms of chronic fatigue, cough,
DL0411 - shortness of breath, clearing of throat continue under a Coumadin
DL0412 - regimen. ref SDS H4 CV5L Treatment with Procrit for anemia was ended
DL0413 - when hemoglobin blood count increased to the normal range. ref SDS H4
DL0414 - 2P9F
DL0416 - ..
DL0417 - [On 061227 Millie requests examination by a heart specialist to
DL0418 - backup up first impression that her condition of Cor Pulmonale
DL0419 - requires no treatment beyond Coumadin at this time; reports
DL0420 - continuing symptoms chronic fatigue, shortness of breath, and
DL0421 - heavy chest. ref SDS I0 VC4M
DL0423 - ..
DL0424 - The doctor's schedule today did not have enough time again, as on
DL0425 - 061020, ref SDS F7 UQ5M, and during the prior meeting on 061110,
DL0426 - ref SDS G8 HB3K, to review analysis on 061012, and comment on
DL0427 - differences between tests on 041103 that first diagnosed pulmonary
DL0428 - embolism, and the more recent test on 060930 that diagnosed
DL0429 - recurrence, ref SDS F4 7E7G, including a new heart disorder caused by
DL0430 - an enlarged right ventricle, ref SDS F4 IM5J, discussed briefly with
DL0431 - the doctor during the meeting on 061020, ref SDS F7 VJ4J, and again
DL0432 - today, per below. ref SDS 0 VJ4J
DL0434 - [On 061214 treatment mistake pulmonary embolism warfarin
DL0435 - (Coumadin) conflicts with Diflucan; blood test INR rises 6.4
DL0436 - danger zone for hemorrhaging; blood clot coagulation treatment
DL0437 - paused for 3 days; INR update test advanced. ref SDS H7 HF4O
DL0439 - ..
DL0440 - The doctor modified the order for the PET scan test by adding scope
DL0441 - for the analyst to compare prior tests on 041103, and on 060930, with
DL0442 - the new test to assess trends (i.e., worsening, improving, or stable)
DL0443 - in Millie's condition of pulmonary embolism, per above. ref SDS 0 ZY5L
DL0445 - [On 070102 received report for CT test performed on 061227; for
DL0446 - some reason Kaiser failed to compare with CT test on 060930
DL0447 - that diagnosed pulmonary embolism, and enlarged right
DL0448 - ventricle. ref SDS I4 AK9H
Examination Clinical Findings Correlate with Research Stethoscope No
DX0401 - ..
DX0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
DX0404 - Follow up ref SDS H4 Q35O, ref SDS G8 Q35O.
DX0406 - The doctor examined Millie with a stethoscope again today. This
DX0407 - included multiple locations on her her back, and on her chest. He
DX0408 - reported finding no evidence of cardio pulmonary issues from clinical
DX0409 - examination. The doctor's Progress Notes in the Medical Chart report
DX0410 - Lung: Clear to A & P. ref SDS 0 ZL5W
DX0412 - ..
DX0413 - The doctor further noted that SaO2 99% diagnostic today for oxygenated
DX0414 - blood, ref SDS 0 KB5L, indicates Millie is not suffering from loss of
DX0415 - cardio-pulmonary functioning due to pulmonary embolism, including
DX0416 - enlarged left ventricle.
Enlarged Right Ventricle Heart Examination Not Ordered Kaiser Not En
EI0401 - ..
EI0402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
EI0403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
EI0404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
EI0406 - Follow up ref SDS H4 VJ4J, ref SDS G8 VJ4J.
EI0408 - Background is reported in the record for the meeting on 061110,
EI0409 - ref SDS G8 VJ4J Kaiser has not had enough time to determine how
EI0410 - severely the right ventricle is enlarged, as discussed on 061020.
EI0411 - ref SDS F7 VJ4J
EI0413 - ..
EI0414 - Cor Pulmonale was noted by the doctor today, and aligns with enlarged
EI0415 - right ventricle heart disorder reported in findings for the CT scan
EI0416 - test on 060930, and reviewed on 061012. ref SDS F4 L35J The doctor
EI0417 - did not report this finding in Progress Notes for the Medical Chart
EI0418 - per below. ref SDS 0 ZL5W
EI0420 - ..
EI0421 - Millie asked about examination by a heart specialist under Kaiser's
EI0422 - Team Care practice? Continuing fatigue, shortness of breath, and
EI0423 - heavy chest with routine activities has prevented regular exercise in
EI0424 - the gym to restore fitness, strengthen the immune system, and build
EI0425 - emotional stability, noted on 061110, ref SDS G8 GR3J, and citing
EI0426 - Millie's letter on 061027. ref SDS F9 KJ6H
EI0428 - ..
EI0429 - The primary care physician indicted that current diagnostics are not
EI0430 - severe enough yet to require examination by a heart specialist.
EI0432 - [On 061218 Millie requests examination by heart specialist for
EI0433 - clearance to resume exercise in the gym and restore fitness.
EI0434 - ref SDS H8 HX6V
EI0436 - ..
EI0437 - [On 061218 doctor responded that heart disorder enlarged right
EI0438 - ventricle most likely not clinically relevant because symptoms
EI0439 - Cor Pulmonale take years to become life threatening.
EI0440 - ref SDS H8 XQ5H
EI0442 - ..
EI0443 - [On 061227 Millie requests examination by a heart specialist to
EI0444 - backup up first impression that her condition of Cor Pulmonale
EI0445 - requires no treatment beyond Coumadin at this time; reports
EI0446 - continuing symptoms chronic fatigue, shortness of breath, and
EI0447 - heavy chest. ref SDS I0 VC4M
EI0449 - ..
EI0450 - The doctor cited vitals today showing Sa O2 99% test diagnostic.
EI0451 - ref SDS 0 KB5L He feels that examination with a stethoscope, per
EI0452 - above. ref SDS 0 Q35O continues to indicate strong cardio pulmonary
EI0453 - functioning, rather than diminished capacity that would signal
EI0454 - significant impact of enlarged right ventricle.
EI0456 - ..
EI0457 - The doctor feels that current medication treating pulmonary embolism
EI0458 - with Coumadin (warfarin) is sufficient at this time to treat the new
EI0459 - problem of enlarged right ventricle.
EI0461 - ..
EI0462 - The doctor modified the order for the PET scan test specifying that
EI0463 - the analyst compare the prior tests on 041103, and on 060930, with the
EI0464 - new test to report on severity of enlarged right ventricle, e.g., 10%,
EI0465 - 30% 150%, etc. per above. ref SDS 0 ZY5L
EI0467 - [On 070102 received report for CT test performed on 061227; for
EI0468 - some reason Kaiser failed to compare with CT test on 060930
EI0469 - that diagnosed pulmonary embolism, and enlarged right
EI0470 - ventricle. ref SDS I4 AK9H
Work Plan Doctor Submits Doctor/Patient Partnership Communications I
FN0401 - ..
FN0402 - Medical Chart Computer Record Lock Down Prevents Correction Feedback
FN0403 - Work Plan Received Communications Doctor/Patient Partnership
FN0404 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
FN0405 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
FN0407 - Follow up ref SDS H4 FE4I, ref SDS G8 FE4I.
FN0413 - ..
FN0414 - New issues today compound problems in the medical chart from prior
FN0415 - review on 061110. ref SDS G8 EN4K Expanding error in medical records
FN0416 - increases disorder under the locality principle embodied by the 2nd
FN0417 - law of thermodynamics derived from the irreversibility of time,
FN0418 - reviewed on 040312, ref SDS 31 YH4G, and further presented in NWO.
FN0419 - ref OF 17 Q07K Locality is, also, explained in NWO. ref OF 17 I38N
FN0420 - Failure to correct mistakes by adding alignment in the record and
FN0421 - refining accuracy with continual feedback drives management toward
FN0422 - entropy, cited in study by US Air Force Institute of Technology
FN0423 - (USAFIT), reviewed on 970707. ref SDS 2 0108
FN0425 - ..
FN0426 - Example of compoud error affecting patient care occurred on 060821.
FN0427 - Erroneous medical chart saying Millie was being treated for pulmonary
FN0428 - embolism with warfarin (Coumadin) may have led Doctor Benz to ignore
FN0429 - patient's request for 2nd opinion on rising symptoms. ref SDS E6 PM4N
FN0431 - ..
FN0432 - The doctor commented today that Kaiser's electronic Medical Chart
FN0433 - system on the computer, introduced last year on 050520, ref SDS 69
FN0434 - HX6J, does not enable doctors to correct mistakes. Kaiser "locks
FN0435 - down" the record for version control that maintains communication
FN0436 - integrity after the doctor meets with the patient. This makes
FN0437 - feedback from the patient called out by Kaiser's Healthwise Handbook,
FN0438 - reviewed on 990625, ref SDS 3 3960, seem inconvenient and threatening
FN0439 - rather than useful collaboration for reducing medical mistakes through
FN0440 - the doctor patient partnership, called out in Kaiser's requirements
FN0441 - for good care. ref SDS 3 4185 Allowing errors in the medical chart to
FN0442 - stand turns benefits of legible records into "ticking time bombs,"
FN0443 - noted in POIMS. ref OF 10 8844
FN0445 - ..
FN0446 - [On 061218 letter to the doctor asks about using feedback to
FN0447 - correct errors in medical chart, citing understanding that
FN0448 - doctors cannot correct mistakes in the record of patient
FN0449 - history. ref SDS H8 EY7K
FN0451 - ..
FN0452 - Dynamics of health care arising from complexity of human biology
FN0453 - managed through complex organizational culture, commonly called
FN0454 - "bureaucracy," reviewed on 040203, ref SDS 28 E44K and ref SDS 28 E44K
FN0455 - and ref SDS 28 8Y5I, necessarily cause continual mistakes, illustrated
FN0456 - by case study on 040416, ref SDS 35 GN7J, and by review today, shown
FN0457 - below. ref SDS 0 C55J
FN0459 - ..
FN0460 - Errors compounding in the medical chart under Aristotle's rule, cited
FN0461 - in POIMS, ref OF 15 JV3G, conflicts with published requirements for
FN0462 - accurate patient history as the foundation of effective care, also,
FN0463 - reported on 990625. ref SDS 3 GT5O and ref SDS 3 GT62 and ref SDS 3
FN0464 - RK3G This record supports Andy Grove's call for patients to be their
FN0465 - own "project managers" through the doctor patient partnership model
FN0466 - that reduces mistakes by adding time for maintaing alignment, reported
FN0467 - on 041212. ref SDS 55 FQ3G
FN0469 - ..
FN0470 - New issues in the medical chart today include...
FN0472 - 1. Agenda for meeting omitted, but submitted with patient's letter
FN0473 - today. ref SDS 0 4D6J
FN0475 - ..
FN0476 - 2. Narrative omits patient suffered recurrence of pulmonary
FN0477 - embolism, reported on 061002 citing the CT test on 060930.
FN0478 - ref SDS 0 J59N
FN0480 - ..
FN0481 - 3. Right breast rash spreading from left to the right side is a
FN0482 - major new development that should be reported in the narrative,
FN0483 - ref SDS 0 J59N, in the Physical Examination, ref SDS 0 ZL5W,
FN0484 - and in the Impression section. ref SDS 0 1248
FN0486 - ..
FN0487 - 4. Theory spread of rash from left to right breast might not be
FN0488 - IBC. ref SDS 0 ZN4K
FN0490 - ..
FN0491 - 5. Plan section lists "Diflucan for rash" but does not provide
FN0492 - context. "Rash" by itself is vague. ref SDS 0 125V
FN0494 - ..
FN0495 - 6. Name of the rash being treated is not presented. ref SDS 0 125V
FN0497 - ..
FN0498 - 7. Current medications - this might be updated, as recommended
FN0499 - previously, ref SDS 0 SE86, and to include Diflucan prescribed
FN0500 - today, per below. ref SDS 0 125V
FN0502 - ..
FN0503 - 8. Metastatic breast cancer (IBC) lung and lymph node; chest wall
FN0504 - recurrence listed in the Impression section of the Medical
FN0505 - Chart is unclear. What diagnostic associates lung with cancer
FN0506 - in Millie's patient history? ref SDS 0 1248
FN0508 - ..
FN0509 - There wasn't enough time today for the doctor to transfer the agenda
FN0510 - into Kaiser's electronic Medical Chart, per below, ref SDS 0 684G, as
FN0511 - was done the past 2 months, reported on 061110. ref SDS G8 K84N
FN0513 - ..
FN0514 - Progress continues toward good management using the doctor patient
FN0515 - partnership for timely review of patient history, called out in
FN0516 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 3 TD5S, and
FN0517 - reported on 060106. ref SDS 96 FE4I
FN0519 - 1. 12/08/2006 12:26 PM
FN0521 - Wcr-ONnc2 > Main Campus
FN0524 - ..
FN0525 - 2. Your primary care clinician is listed as...