CONTACTS 

SUBJECTS
Meeting Doctor Examination 8th Review Prepare Changing Protocols aft

1903 -
1903 -    ..
1904 - Summary/Objective
1905 -
190501 - Follow up ref SDS H4 0000. ref SDS G8 0000.
190502 -
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
190543 -
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
190554 -
190555 -
190556 -
190557 -
190559 -  ..
1906 -
1907 -
1908 - Progress
1909 -
190901 - Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
190902 -
190903 - Follow up ref SDS H4 SM6M, ref SDS G8 SM6M.
190904 -
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...
190915 -
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.
190934 -
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
190943 -
190944 -
190945 -
190946 -
1910 -

SUBJECTS
Complex Patient History 36 Issues Overwhelms Span of Attention Drive

2103 -
210401 -  ..
210402 - Complex Patient History Knowledge Management Dilemma Issues Grow 36
210403 -
210404 - Follow up ref SDS H4 LU3J, ref SDS G8 LU3J.
210405 -
210406 - Sampling of issues patient history diagnosis and treatment...
210407 -
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...
210445 -
210446 -   35.  IBC rash spreads to right breast
210447 -   36.  Right breast rash may be "ring" infection, not cancer
210448 -
210449 -
210450 -
210451 -
210452 -
2105 -

SUBJECTS
Vitals Obtain from Infusion Clinic Progress Note Meeting Doctor John

2303 -
230401 -  ..
230402 - Vitals Show Stable Medical Condition
230403 -
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%
230421 -
230422 - ...per the doctor's report in the Medical Chart shown below.
230423 - ref SDS 0 JQ4J
230424 -
230425 -
230426 -
230427 -
2305 -

SUBJECTS
CA 15-3 67 Erratic Changes Aligns with IBC Rash Changes Similar to E

3303 -
330401 -  ..
330402 - CA 15-3 Cancer Marker 67 Erratic Changes Since 060928
330403 -
330404 - Follow up ref SDS H4 087J, ref SDS G8 087J.
330405 -
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
330485 -
330486 -
330487 -
330488 -
330490 -  ..
3305 -
3306 -
3307 - Analysis
3308 -
330801 - CA 15-3 67 Cancer Marker Falls Significantly Rises Significantly
330802 -
330803 - Follow up ref SDS H4 GJ5M, ref SDS G8 GJ5M.
330804 -
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.
330817 -
330818 -     [On 061214 CA 15-3 results for blood test were not reported with
330819 -     INR. ref SDS H7 GV5N
330820 -
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
330828 -
330829 -
330830 -
330831 -
330832 -
330833 -
330834 -
3309 -

SUBJECTS
Digestion Problems GERD Worse Doctor Orders PET Scan Test for Cancer

3703 -
370401 -  ..
370402 - Digestion Problems Increasing Relatively Infrequent Mild
370403 - Esophagitis Not Compared in Current PET Test with Prior Report
370404 -
370405 - Follow up ref SDS H4 JP6K, ref SDS G8 JP6K.
370406 -
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
370419 -
370420 -
370421 -
370422 -
3705 -

SUBJECTS
Left Axillary Lymphadenopathy Patient No Complaint of Swelling Disco

5403 -
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
540405 -
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.
540446 -
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
540457 -
540458 -        [...below, today the doctor Progress Notes in the Medical
540459 -        Chart describe lymphedema "improving." ref SDS 0 J59N
540460 -
540461 -
540462 -
540463 -
540464 -
5405 -

SUBJECTS
Right Axillary Lymphadenopathy Patient No Complaint Swelling Discom   4

6003 -
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
600405 -
600406 - Follow up ref SDS H4 3D6K, ref SDS G8 3D6K.
600407 -
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
600431 -
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...
600445 -
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
600457 -
600458 -
600459 -
600460 -
600461 -
600462 -
600463 -
6005 -

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

6803 -
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
680405 -
680406 - Follow up ref SDS H4 8R6M, ref SDS G8 8R6M.
680407 -
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
680418 -
680419 -
680420 -
680421 -
680422 -
6805 -

SUBJECTS
Examination IBC Red Rash Left Breast Spreads to Right Breast Might b

8303 -
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
830406 -
830407 - Follow up ref SDS H4 025H, ref SDS G8 025H.
830408 -
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.
830433 -
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.
830445 -
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
830457 -
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
830474 -
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...
830488 -
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
830521 -
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...
830532 -
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
830540 -
830541 -
830542 -
830543 -
830544 -
830545 -
8306 -

SUBJECTS
Diflucan Fluconazole 200 MG Diagnose Possible New Ring Circular Rash

9103 -
910401 -  ..
910402 - Diflucan Fluconazole 200 MG Diagnose Possible New Ring Rash
910403 - Ring Rash Diagnosed By Treatment with Diflucan Antibiotic
910404 -
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...
910416 -
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
910436 -
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...
910454 -
910456 -            Fluconazole 200 MB tablets
910457 -            For:  Diflucan
910458 -
910459 -
910460 -
9105 -

SUBJECTS
Diflucan Fluconazole Research Antibiotic Treat Fungal Infections Lef

9803 -
980401 -  ..
980402 - Research Diflucan Treat Fungal Infections...
980403 -
980404 -
980405 - After the meeting, research found...
980406 -
980407 -        Medline Plus
980408 -        US National Library of Medicine
980409 -        National Institutes of Health
980410 -
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.
980440 -
980441 -
980442 -
9805 -

SUBJECTS
Diflucan Fluconazole Side Effects Compound Symptoms of Pulmonary Emb

A403 -
A40401 -  ..
A40402 - Side Effects Compound Symptoms of Pulmonary Embolism Esophagitis....
A40403 -
A40404 - Medline article lists side effects for Diflucan...
A40405 -
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
A40424 -
A40425 -            http://www.fda.gov/MedWatch/report.htm
A40426 -
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
A40436 -
A40437 -
A40438 -
A40439 -
A405 -

SUBJECTS
Lung Cancer Metastatic Disease Lymph Nodes Doctor's Progress Notes M

AJ03 -
AJ0401 -  ..
AJ0402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
AJ0403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
AJ0404 -
AJ0405 - The doctor's Progress Notes in the Medical Chart further show under
AJ0406 - Impressions...
AJ0407 -
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.
AJ0426 -
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
AJ0450 -
AJ0451 -
AJ0452 -
AJ0453 -
AJ0454 -
AJ0455 -
AJ05 -

SUBJECTS
Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy

AN03 -
AN0401 -  ..
AN0402 - Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
AN0403 -
AN0404 - Follow up ref SDS H4 OH6I.
AN0405 -
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.
AN0418 -
AN0419 -
AN0420 -
AN0421 -
AN0422 -
AN0423 -
AN05 -

SUBJECTS
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea

AT03 -
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
AT0406 -
AT0407 - Follow up ref SDS H4 EH3F, ref SDS G8 EH3F.
AT0408 -
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
AT0420 -
AT0421 -
AT0422 -
AT0423 -
AT0424 -
AT05 -

SUBJECTS
Biopsy Right Breast Rash Spreads from Left Breast Evaluate IBC Simil

B603 -
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
B60405 -
B60406 - Follow up ref SDS H4 KT7J, ref SDS G8 KT7J.
B60407 -
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
B60439 -
B60440 -
B60441 -
B60442 -
B605 -

SUBJECTS
PET/CT Scan Test Order 061227 Baseline New Treatment Navelbine Analy

BH03 -
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
BH0406 -
BH0407 - Follow up ref SDS H4 EY5O, ref SDS G8 EY5O.
BH0408 -
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
BH0420 -
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
BH0463 -
BH0464 -
BH0465 -
BH0466 -
BH0467 -
BH0468 -
BH05 -

SUBJECTS
Emotional Trauma Increases 2 New Issues Rash Spread Right Breast Dia

BM03 -
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
BM0405 -
BM0406 - Follow up ref SDS H4 Y642, ref SDS G8 Y642.
BM0407 -
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.
BM0451 -
BM0452 -
BM0453 -
BM0454 -
BM0455 -
BM0456 -
BM05 -

SUBJECTS
Strategy Treatment Plan IBC 3rd Relapse Scope Tumor Board Review UCS

BX03 -
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
BX0405 -
BX0406 - Follow up ref SDS H4 K36G, ref SDS G8 K36G.
BX0407 -
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...
BX0425 -
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
BX0453 -
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."
BX0505 -
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
BX0540 -
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
BX0556 -
BX0557 -
BX0558 -
BX06 -

SUBJECTS
Navelbine Vinorelbine Tartrate Protocol Single Agent Combine Taxoter

C303 -
C30401 -  ..
C30402 - Navelbine Single Agent Combine Taxotere Capecitabine Conflict 2nd Opinions
C30403 -
C30404 - Follow up ref SDS F1 WR3Y.
C30405 -
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
C30417 -
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
C30437 -
C30438 -
C30439 -
C30440 -
C305 -

SUBJECTS
Strategy Treatment Plan Surgery Remove Pockets of Resistance to Chem

C903 -
C90401 -  ..
C90402 - Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
C90403 -
C90404 - Follow up ref SDS E7 WE8K, ref SDS C4 X54L.
C90405 -
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
C90423 -
C90424 -
C90425 -
C90426 -
C905 -

SUBJECTS
Treatment 7th Cycle Complete Capecitabine (Xeloda) Taxotere IBC 3rd

CE03 -
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
CE0405 -
CE0406 - Follow up ref SDS H4 PF3O, ref SDS G8 PF3O.
CE0407 -
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
CE0417 -
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
CE0438 -
CE0439 -
CE0440 -
CE0441 -
CE05 -

SUBJECTS
Navelbine Vinorelbine Tartrate Protocol Pharmacology Review Change C

CK03 -
CK0401 -  ..
CK0402 - Navelbine Protocol Pharmacology Submitted for Review
CK0403 -
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...
CK0428 -
CK0429 -        Micromedex Healthcare Series:  Drugdex Drug Point    Page 1 - 4
CK0430 -
CK0431 -        Thomson
CK0432 -        Micromedex
CK0434 -         ..
CK0435 -        Vinorelbine Tartrate
CK0437 -         ..
CK0438 -        Tradename:  Navelbine
CK0440 -         ..
CK0441 -        Adult Dose:
CK0442 -
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...
CK0456 -
CK0457 -        1.  Low blood counts - white blood cells (WBC) which increases
CK0458 -            the risk of infection; red blood cells, platelets
CK0459 -
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.
CK0505 -
CK0506 -
CK0507 -
CK06 -

SUBJECTS
Drug Trials Case Study Medical Practice Kaiser Advocate Protocol Nur

CZ03 -
CZ0401 -  ..
CZ0402 - Drug Trials Kaiser Research UCSF and Other Proposals
CZ0403 - Case Study Chemotherapy Drug Trials Promoted Rarely Yield Results
CZ0404 -
CZ0405 - Follow up ref SDS E7 WB9K, ref SDS C4 WB9K.
CZ0406 -
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?
CZ0521 -
CZ0522 -
CZ0523 -
CZ0524 -
CZ06 -

SUBJECTS
Drug Trials Millie Measurable Disease Spread Left to Right Breast Q   C

DA03 -
DA0401 -  ..
DA0402 - Drug Trials UCSF 2 Proposals Kaiser Review Pending Needs Support
DA0403 - UCSF 2 Drug Trial Proposals Kaiser Needs Support to Complete Review
DA0404 -
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
DA0423 -
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.
DA0497 -
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
DA0547 -
DA0548 -
DA0549 -
DA0550 -
DA06 -

SUBJECTS
Schedule Meeting 070105 Review Treatment Navelbine 1st Cycle 16th To

DE03 -
DE0401 -  ..
DE0402 - Chemotherapy Holiday Treatments Deferred 4 Weeks Holiday Season
DE0403 - Schedule Treatment Start Navelbine 4 Weeks Chemotherapy Holiday
DE0404 -
DE0405 - Follow up ref SDS H4 N96O, ref SDS G8 N96O.
DE0406 -
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
DE0412 -
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
DE0428 -
DE0429 -
DE0430 -
DE0431 -
DE0432 -
DE0433 -
DE0434 -
DE05 -

SUBJECTS
Pulmonary Emboli Blood Clots Lungs Symptoms Continue Fatigue Shortne

DL03 -
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
DL0405 -
DL0406 - Follow up ref SDS H4 CV5L, ref SDS G8 CV5L.
DL0407 -
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
DL0433 -
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
DL0444 -
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
DL0449 -
DL0450 -
DL0451 -
DL0452 -
DL05 -

SUBJECTS
Examination Clinical Findings Correlate with Research Stethoscope No

DX03 -
DX0401 -  ..
DX0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
DX0403 -
DX0404 - Follow up ref SDS H4 Q35O, ref SDS G8 Q35O.
DX0405 -
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.
DX0417 -
DX0418 -
DX0419 -
DX0420 -
DX0421 -
DX05 -

SUBJECTS
Enlarged Right Ventricle Heart Examination Not Ordered Kaiser Not En

EI03 -
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
EI0405 -
EI0406 - Follow up ref SDS H4 VJ4J, ref SDS G8 VJ4J.
EI0407 -
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.
EI0431 -
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
EI0466 -
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
EI0471 -
EI0472 -
EI0473 -
EI05 -

SUBJECTS
Work Plan Doctor Submits Doctor/Patient Partnership Communications I

FN03 -
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
FN0406 -
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...
FN0471 -
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
FN0518 -
FN0519 -    1.  12/08/2006     12:26 PM
FN0520 -
FN0521 -            Wcr-ONnc2 > Main Campus
FN0524 -         ..
FN0525 -    2.  Your primary care clinician is listed as...
FN0526 -
FN0528 -
FN0858 -
FN0859 -
FN0860 -
FN0861 -
FN0862 -
FN0863 -
FN0864 -
FN09 -