THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: January 5, 2007 10:40 AM Friday;
Millie meeting at Kaiser to change and schedule IBC treatment.
2...Agenda Develop Work Plan Stage IV Breast Cancer 14 Mos after Mastectomy
3...Complex Patient History Knowledge Management Dilemma Issues Grow 36
4...Vitals Show Stable Medical Condition
5...CA 15-3 Cancer Marker 74 Increase Aligns Rise IBC Rash
6...CA 15-3 74 Cancer Marker Rises Significantly Aligns IBC Rash Increase
7...Digestion Problems Increasing Relatively Infrequent Mild
8...Esophagitis Not Compared in Current PET Test with Prior Report
9...Cellulitis Complications Lymphedema Recovering Improved
10...Left Axillary No Evidence Lymphadenopathy Lymphedema Improving
11...Post Operation Localized Edema Left Axillary No Evidence Lymphadenopathy
12...Lymphadenopathy Left Axillary No Evidence Lymphedema Improving Cellulitus Recovered
13...Right Axillary No Evidence Cancer Red Rash Spreads Right Breast
14...Right Breast Red Rash Spreads No Evidence Disease Right Axillary
15...Red Rash Right Breast Spreads No Evidence Cancer Right Axillary
16...Left Supraclavicular Examination PET Test Report Finding SUV 4.5
17...Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
18...Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
19...Pockets of Resistance to Treatment of IBC Red Rash Left Breast
20...IBC Red Rash Left Breast Extends Slightly onto the Right Breast
21...Examination Left Breast IBC Inflammation Spreads to Right Breast
22...Measurable Disease IBC Inflammation Spreading to Right Breast
23...Diflucan Fluconazole 200 MG Prescription Not Effective Treatment Ends
24...Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
25...Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
26...Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
27...Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
28...Slow Response to Treatment Mastectomy Removed Blood Vessels
29...Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
30...Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
31...Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
32...Biopsy to Determine Biology of IBC and Guide Choice of Treatment
33...Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
34...PET/CT Test 061227 No Evidence Distant Metastatis
35...Distant Metastatis No Evidence PET/CT Test 061227
36...NED PET/CT Test 061227 Shows No Evidence Distant Metastasis
37...Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
38...Exercise Vigor Strength Engagement Ease Distress Living with Cancer
39...Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
40...Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
41...Work Up Patient History Kaiser Summary Avoids Treatment Strategy Options
42...Tumor Board Review on Changing Treatment Expansion of Disease
43...Navelbine Treatment Deferred Pending Results Clinical Study Cetuximab
44...Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
45...Treatment Complete 7th Cycle Taxotere and Capecitabine (Xeloda)
46...7th Cycle Taxotere and Capecitabine (Xeloda) Treatment Concludes
47...Taxotere and Capecitabine (Xeloda) 7th-Cycle Treatment Concludes
48...Cetuximab Clinical Study Drug Trial Start Treatment at UCSF Pending
49...Cetuximab Carboplatin UCSF Clinical Study Expedite Treatment
50...UCSF Clinical Studies Kaiser Authorizes Referral Schedule Treatment
51...Drug Trials Kaiser Authorizes Referral to UCSF Expedite Treatment Schedule
52...Expedite Treatment UCSF Cetuximab Carboplatin Clinical Study Drug Trial
53...Schedule Treatment Pending Start Clinical Study Cetuximab at UCSF
54...Chemotherapy Holiday Treatment Delayed Pending Start Drug Trial at UCSF
55...Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
56...Lung Damage Permanent Cannot Resume Exercise to Build Immune System
57...Pulmonary Emboli PET/CT Test Failed Perform Doctor's Order Comparison
58...Immune System Cancer Recovery Exercise Prevented Permanent Lung Damage
59...Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
60...Cor Pulmonale Heart Disorder Enlarged Right Ventricle
61...Heart Examination Not Ordered Investigate Enlarged Right Ventricle
62...Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
63...Crisis Management Defers Investigation Until Time Runs Out for Analysis
64...Context Management Complements Chronology and Connection Working Intelligently
65...Information Management Prevents Understanding Chronology Context Connections
66...Proactive Management Chronology Context Connections Prevents Constant Crises
67...Work Plan Received Communications Doctor/Patient Partnership
68...Communications Doctor Submits Work Plan Doctor/Patient Partnership
69...Doctor/Patient Partnership Communications Doctor Submits Work Plan
Click here to comment!
Meeting Doctor Examination 8th Review Prepare Changing Protocols aft
2003 - ..
2004 - Summary/Objective
200501 - Follow up ref SDS H4 0000. ref SDS H1 0000.
200503 - The doctor performed due diligence on UCSF proposals to treat Millie
200504 - in a clinical study with a new drug for breast cancer. ref SDS 0 P256
200505 - Kaiser therefore delayed starting treatment today with Navelbine to
200506 - replace Taxotere and capecitabine, which have become ineffective, so
200507 - that Millie qualifies for the clinical study. ref SDS 0 Y45G Kaiser
200508 - and UCSF have agreed on arrangements for referral authorization and
200509 - payment of costs for Millie's treatment at UCSF. ref SDS 0 PK68 The
200510 - doctor advised that referral to UCSF is the best course for treating
200511 - Millie's IBC. Clinical studies expand the list of chemotherapy drugs
200512 - for treating Millie, which is otherwise limited by a complex patient
200513 - profile. ref SDS 0 LU3J Cetuximab and carboplatin in the UCSF drug
200514 - trial are powerful new drugs targeted to breast cancer cells, and so
200515 - do not cause general harm to the entire body and immune system, as do
200516 - conventional chemotherapies available for treating Millie. ref SDS 0
200517 - PK7L Millie asked that UCSF be notified to expedite treatment to
200518 - avoid her cancer from cascading out of control, since her last
200519 - treatment was over a month ago, and examination and diagnostics today
200520 - show that IBC has been rising on her chest. ref SDS 0 Y46N Kaiser has
200521 - not had time to perform trend analysis to determine increased risk
200522 - from pulmonary embolism and heart disorder of enlarged right
200523 - ventricle. ref SDS 0 CV5L The recent PET/CT test failed to perform
200524 - comparisons ordered by the doctor to support diagnosis. ref SDS 0 XX8H
200525 - The doctor advised that Millie may have permanent lung damage, and may
200526 - not be able to recover her former level of fitness. ref SDS 0 MA9K
200527 - The doctor told Millie she can resume exercising in the gym.
200528 - ref SDS 0 G35K Stethoscope examination and Sa02 diagnostic indicates
200529 - favorable cardio-pulmonary function. ref SDS 0 Q35O Millie remains
200530 - concerned about diagnosis of enlarged right ventricle in the CT test
200531 - on 060930, and rising symptoms of fatigue, weakness, shortness of
200532 - breath. She requested CT testing and examination by a heart
200533 - specialist to assess severity of heart disorder before resuming
200534 - vigorous exercise. ref SDS 0 SU4L The doctor explained a practice of
200535 - ignoring irrelevant matters to save time focusing on immediate
200536 - problems, and emphasized the importance of context. ref SDS 0 MA8O
200537 - The doctor indicated that Cor Pulmonale is not an immediate problem
200538 - compared to the current crisis on making referral for treating
200539 - Millie's cancer. ref SDS 0 SG5M
200541 - [On 070329 review at Kaiser cites success of strategy making
200542 - referral for targeted treatment of IBC. ref SDS K0 K36G
200548 - ..
2008 - Progress
200901 - Agenda Develop Work Plan Stage IV Breast Cancer 14 Mos after Mastectomy
200903 - Follow up ref SDS H4 SM6M, ref SDS H1 SM6M.
200905 - This is the 9th review meeting for the 7th chemotherapy cycle since
200906 - starting treatment on 060711, ref SDS C1 SM6M, for the 3rd relapse of
200907 - IBC. ref SDS C1 8Y8I The meeting today plans changing treatment
200908 - protocols from Navelbine to a clinical study drug trial using
200909 - cetuximab and carboplatin. The doctor had a hectic schedule today,
200910 - and so the meeting scheduled to start at 1200 actually started at
200911 - 1226.
200913 - ..
200914 - Millie submitted a letter this morning, ref DIT 1 E06F, with an agenda
200915 - for the meeting today...
200917 - 1. CA 15-3 rising rapidly......................... ref SDS 0 GJ5M
200918 - 2. Lymphedema/Cellulitis controlled............... ref SDS 0 MW8J
200919 - 3. Breast exam IBC spreads measurable disease..... ref SDS 0 025H
200920 - 4. IBC spread right breast or cellulitis.......... ref SDS 0 AX6G
200921 - 5. PET/CT doctor's review......................... ref SDS 0 EY5O
200922 - 6. Treatment plan change Navelbine or Other??..... ref SDS 0 K36G
200923 - 7. Drug trials UCSF schedule meeting Doctor Rugo.. ref SDS 0 P256
200924 - 8. Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
200925 - 9. Symptoms cough clearing throat fatigue......... ref SDS 0 CV5L
200926 - 10. Cor Pulmonale enlarged r ventricle heart doctor ref SDS 0 VJ4J
200927 - 11. Esophagitis, heart burn PET test check......... ref SDS 0 JP6K
200929 - ..
200930 - The doctor's Progress Notes in the Medical Chart list this agenda,
200931 - which the doctor displayed on the computer in the examination room to
200932 - guide discussions, ref SDS 0 684G, as was done on 061020, and 061110,
200933 - ref SDS G5 NO6O, but was missed for the meeting on 061208. ref SDS H4
200934 - K84N
200936 - ..
200937 - Scheduled next meeting in 4 weeks on 070202 1420, to review effect of
200938 - new treatments. ref SDS 0 N96O
200940 - ..
200941 - Millie's daughter, Pam, attended the meeting today, following up
200942 - previous support on 041130. ref SDS 51 SM6M
Complex Patient History 37 Issues Overwhelms Span of Attention Drive
220401 - ..
220402 - Complex Patient History Knowledge Management Dilemma Issues Grow 36
220404 - Follow up ref SDS H4 LU3J, ref SDS H1 LU3J.
220406 - Complexity overwhelms span of attention, cited below, ref SDS 0 EM5N,
220407 - from expanding issues of diagnosis and treatment...
220409 - 1. CA 15-3 monitors advance of cancer response to treatment
220410 - 2. Lymphedema complicated by mastectomy surgery
220411 - 3. Broken finger from minor fall complicates lymphedema
220412 - 4. Esophagitis reflux digestion issues
220413 - 5. Immune system chemotherapy increases risk of infection
220414 - 6. Chemotherapy increase risk of infection
220415 - 7. Cat bites increase risk of infection complicates lymphedema
220416 - 8. Pneumonia chemotherapy increases risk of infection
220417 - 9. Metastatic cancer increases risk pulmonary embolism
220418 - 10. Lymphadenopathy left axilla local regional metastasis
220419 - 11. Lymphadenopathy right axilla distant metastasis
220420 - 12. Lymphadenopathy left supraclavicular diagnose metastatic cancer
220421 - 13. Breast cancer secondary IBC 3rd relapse left breast
220422 - 14. Cancer mutates slow response chemotherapy treatment
220423 - 15. Mastectomy surgery impact on treatment IBC relapse
220424 - 16. Blood vessels removed mastectomy slow chemotherapy treatments
220425 - 17. Treatment options, strategy, planning, schedule
220426 - 18. Drug trials increase declining pool chemotherapy agents
220427 - 19. UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
220428 - 20. Pulmonary embolism blood clots in lungs
220429 - 21. INR weekly adjustments Coumadin treatment blood clots
220430 - 22. Enlarged right ventricle heart problem cor pulmonale
220431 - 23. Dizziness symptom enlarged right ventricle cor pulmonale
220432 - 24. Fatigue shortness breath side effect chemotherapy loss fitness
220433 - 25. Fatigue shortness breath symptom pulmonary embolism
220434 - 26. Shortness breath fatigue dizzy symptoms pulmonary embolism
220435 - 27. Coagulapathy hypercoagulable state work up genetic risks
220436 - 28. Testing resolution of errors (see Benz 2nd opinion 060821)
220437 - 29. Testing distant metastatic disease
220438 - 30. Testing pulmonary embolism and heart disease
220439 - 31. Communication hectic schedule not enough time to manage details
220440 - 32. Emotional stress and well being
220441 - 33. Cellulitis inflammation temperature 102.6 on chemotherapy
220442 - 34. Urinary tract bladder infection
220443 - 35. IBC rash spreads to right breast
220444 - 36. Right breast rash may be "ring" infection, not cancer
220445 - 37. Lung cancer seems to be diagnosed in the Medical Chart
220446 - 38. Kaiser authorize treatment UCSF cetuximab clinical study
Vitals Not Submitted Doctor Progress Note Medical Chart Meeting Doct
240401 - ..
240402 - Vitals Show Stable Medical Condition
240404 - Follow up ref SDS H4 KB5L, ref SDS H1 KB5L.
240406 - ..
240407 - Bld Prssr Pulse Temp Weight SaO2
240408 - ..
240409 - * 070105 1040............
240410 - 061208 1226............ 152 90 76 97.8 147 99%
240411 - 061201 1430............ 123 76 76 97.5
240412 - 061110................. 136 83 73 97.0 150 98%
240413 - 061020 1534............ 140 79 67 99.8 151 97
240414 - 060929 1452............ 141 78 66 98.3
240415 - 060908 1335............ 139 79 73 98.1
240416 - 060814 1610............ 139 80 59 98.2
240417 - * 060808.................
240418 - 060711................. 172 87 54 97.5 147
240419 - 060623................. 141 87 71 98.0 147 99%
240420 - 060428................. 129 73 80 99.4 149 99%
240421 - 060217................. 153 81 61 98.6 150 99%
240423 - ...per the doctor's report in the Medical Chart shown below.
240424 - ref SDS 0 JQ4J
240426 - * For some reason, vitals not submitted.
CA 15-3 74 Rising Cancer Marker Aligns with IBC Rash Spreading Indic
400401 - ..
400402 - CA 15-3 Cancer Marker 74 Increase Aligns Rise IBC Rash
400404 - Follow up ref SDS H4 087J, ref SDS H1 087J.
400406 - Millie had two blood tests during the current period since the last
400407 - meeting with the doctor on 061208, ref SDS H4 087J, and since the last
400408 - report on CA 15-3 during the meeting on 061201. ref SDS H1 087J On
400409 - 061227 the doctor submitted results of tests on 061214, and on 061218.
400410 - ref SDS H8 6P9F
400412 - ..
400413 - Test Date Date Received
400414 - 061218......... 74 H............. 061227, ref SDS H8 6P9F
400415 - 061214......... 63 H............. 061227, ref SDS H8 6P9F
400416 - 061130......... 67 H............. 061201, ref SDS H1 087J
400417 - 061116......... 66 H............. 061201, ref SDS H1 087J
400418 - 061110......... 56 H............. 061201, ref SDS H1 087J
400419 - 061109......... 61 H............. 061110, ref SDS G5 087J
400420 - 061026......... 57 H............. 061110, ref SDS G5 087J
400421 - 061019......... 56 H............. 061020, ref SDS F4 087J
400422 - 060928......... 51 H............. 060929, ref SDS E7 087J
400423 - 060907......... 68 H............. 060929, ref SDS E7 087J
400424 - 060813......... 73 H............. 060817, ref SDS E2 U24M
400425 - 060809......... 87 H............. 060810, ref SDS E0 2N5J
400426 - 060708......... 71 H............. 060711, ref SDS C1 087J
400427 - 060616......... 63 H............. 060623, ref SDS B9 UQ5Q
400428 - 060522......... 59 H............. 060605, ref SDS B4 UQ5Q
400429 - 060501......... 49 H............. 060522, ref SDS B1 MC4F
400430 - 060421......... 44 H............. 060428, ref SDS A4 087J
400431 - 060330......... 40 H............. 060428, ref SDS A4 087J
400432 - 060303......... 36............... 060428, ref SDS A4 087J
400433 - 060210......... 33............... 060217, ref SDS 94 087J
400434 - 060109......... 34............... 060126, ref SDS 93 KV59
400435 - 051223......... 34............... 060106, ref SDS 92 087J
400436 - 051202......... 28............... 060106, ref SDS 92 087J
400437 - 051116......... 31............... 051121, ref SDS 90 087J
400438 - 051109......... 30............... 051121, ref SDS 90 087J
400439 - 051102......... 34............... 051121, ref SDS 90 087J
400440 - 050909......... 45 H............. 051007, ref SDS 84 087J
400441 - 050826......... 45 H............. 050913, ref SDS 78 087J
400442 - 050819......... 45 H............. 050913, ref SDS 78 087J
400443 - 050812......... 39 .............. 050819, ref SDS 71 3K6L
400444 - 050729......... 45 H............. 050819, ref SDS 71 EA5G
400445 - 050708......... 46 H............. 050729, ref SDS 70 087J
400446 - 050701......... 37 .............. 050729, ref SDS 70 087J
400447 - 050617......... 45 H............. 050729, ref SDS 70 087J
400448 - 050527......... 56 H............. 050610, ref SDS 67 087J
400449 - 050512......... 67 H............. 050520, ref SDS 65 087J
400450 - 050506......... 80 H............. 050520, ref SDS 65 087J
400451 - ..
400452 - 050415.........105 H............. 050422, ref SDS 62 087J
400453 - 050325.........100 H............. 050329, ref SDS 60 087J
400454 - 050318.........101 H............. 050325, ref SDS 59 2N5J
400455 - 050304......... 88 H............. 050311, ref SDS 57 087J
400456 - 050225......... 95 H............. 050308, ref SDS 56 0001
400457 - 050211......... 78 H............. 050214, ref SDS 55 02BB
400458 - 050128......... 67 H............. 050204, ref SDS 53 087J
400459 - 041228......... 56 H............. 041230, ref SDS 52 087J
400460 - 041204......... 43 H............. 041210, ref SDS 51 087J
400461 - 041007......... 39............... 041104, ref SDS 47 087J
400462 - 040923......... 49 H............. 041005, ref SDS 45 087J
400463 - 040908......... 44 H............. 040909, ref SDS 44 087J
400464 - 040825......... 47 H............. 040909, ref SDS 44 087J
400465 - 040811......... 42 H............. 040812, ref SDS 43 087J
400466 - 040728......... 43 H............. 040729, ref SDS 41 2N5J
400467 - 040712......... 47 H............. 040713, ref SDS 40 087J
400468 - 040614......... 55 H............. 040615, ref SDS 39 PX6X
400469 - 040517......... 78 H............. 040601, ref SDS 37 2N5J
400470 - 040311......... 70 H............. 040318, ref SDS 29 SM6M
400471 - 040205......... 60 H............. 040211, ref SDS 27 SM6M
400472 - 031201......... 62 H............. 031205, ref SDS 26 SM6M
400473 - 030912......... 66 H............. 030915, ref SDS 25 SM6M
400474 - 030708......... 68 H............. 030710, ref SDS 24 SM6M
400475 - 030503......... 54 H............. 030508, ref SDS 22 SM6M
400476 - 030403......... 45 H............. 030508, ref SDS 22 SM6M
400477 - 030215......... 46 H............. 030220, ref SDS 21 5E6L
400478 - 030106......... 37 H............. 030109, ref SDS 20 SM6M
400479 - 021202......... 41 H?............ 021204, ref SDS 19 SP5G
400480 - 021111......... 36 H?............ 021113, ref SDS 18 Y65I
400481 - 021023......... 33 H?............ 021023, ref SDS 17 SQ5I
400482 - 020930......... 33 H?..39........ 021002, ref SDS 16 SQ5I
400483 - 020917......... 36 H?............ 020924, ref SDS 15 SQ5I
400484 - 020717......... 59 H?............ 020726, ref SDS 14 YN5K
400485 - 020629......... 75 H ............ 020705, ref SDS 12 UX6I
400486 - 020608........ 67 H ............ 020614, ref SDS 10 0001
400487 - 020603........ 108 H ............ 020607, ref SDS 9 X67F
400488 - 020511........ 117 H ............ 020603, ref SDS 8 PJ4J
400489 - 020419......... 81 H ............ 020430, ref SDS 6 7N5H
400490 - 020321......... 85 H ............ 020405, ref SDS 5 6T8K
400496 - ..
4007 - Analysis
400801 - CA 15-3 74 Cancer Marker Rises Significantly Aligns IBC Rash Increase
400803 - Follow up ref SDS H4 GJ5M, ref SDS H1 GJ5M.
400805 - On 061227 the doctor reported CA 15-3 74 significant rise from 67 to
400806 - 74. ref SDS H8 EE5T Rising cancer marker aligns with IBC rash
400807 - spreading to the right breast, and increased severity reported, also,
400808 - on 061227. ref SDS H8 DY9T Examination today shows IBC rash continues
400809 - spreading to the right breast. the doctor reported this probably
400810 - represents progression of metastatic disease, ref SDS 0 025H, which
400811 - requires changing treatments. The doctor noted that rising CA 15-3 is
400812 - a common diagnostic for measurable disease to evaluate clinical study
400813 - drug trials.
400815 - ..
400816 - [On 070110 CA 15-3 56 dropped significantly, indicating
400817 - possible delayed reaction to treatment. ref SDS I5 087J
400819 - ..
400820 - [On 070123 CA 15-3 68 rises significantly, indicating rising
400821 - IBC from progression of disease. ref SDS J2 GK5B
400823 - ..
400824 - [On 070123 CA 15-3 rise indicating progression of metastatic
400825 - cancer requires Kaiser authorization for treatment at UCSF to
400826 - avoid IBC cascading out of control. ref SDS J2 SX5W
Digestion Problems GERD PET Scan Test on 061227 Failed Perform Analy
440401 - ..
440402 - Digestion Problems Increasing Relatively Infrequent Mild
440403 - Esophagitis Not Compared in Current PET Test with Prior Report
440405 - Follow up ref SDS H4 JP6K, ref SDS H1 JP6K.
440407 - Background is reported in the meeting on 061201. ref SDS H1 JP6K
440409 - ..
440410 - During the meeting at Kaiser on 061208, the doctor added a request to
440411 - compare the PET scan test ordered at that time, ref SDS H4 EY5O, and
440412 - later performed on 061227, with prior PET and CT tests to clarify
440413 - diagnosis for planning treatment of esophagitis or other malady that
440414 - may be causing increased digestion problems. Requesting comparison
440415 - for trend analysis of esophagitis implemented planning on 061201,
440416 - ref SDS H1 5X40, and aligned with the doctor's progress report in the
440417 - medical chart on 061208 noting GERD worse. ref SDS H4 1248
440419 - ..
440420 - Review on 070102 of PET scan test on 061227 shows the doctor's order
440421 - to compare with prior findings of esophagitis in the PET scan test on
440422 - 060106, and with the CT test on 060505, was not performed. ref SDS I2
440423 - AK9H
440425 - ..
440426 - There was no discussion of this issue today.
440428 - ..
440429 - The doctor's medical chart for today does not mention GERD.
440430 - ref SDS 0 1248, which is described as "worse," in prior reports,
440431 - raising a question on the basis of no review. ref SDS H4 1248
Left Axillary Lymphadenopathy Patient No Complaint Swelling Discomfo
570401 - ..
570402 - Cellulitis Complications Lymphedema Recovering Improved
570403 - Left Axillary No Evidence Lymphadenopathy Lymphedema Improving
570404 - Post Operation Localized Edema Left Axillary No Evidence Lymphadenopathy
570405 - Lymphadenopathy Left Axillary No Evidence Lymphedema Improving Cellulitus Recovered
570407 - Follow up ref SDS H4 MW8J, ref SDS H1 MW8J.
570409 - ..
570410 - Patient history of left axillary lymphadenopathy and lymphedema is
570411 - reported on 060106. ref SDS 92 S164
570413 - ..
570414 - There was no examination today for cancer in left axilla. The patient
570415 - again made no complaint of lumps or discomfort from swelling under the
570416 - left arm.
570418 - ..
570419 - Background on lymphedema and complications of Cellulitis when Millie
570420 - was hospitalized on 061027 is reported in the record for the meeting
570421 - on 061201. ref SDS H1 5Y5F Cellulitis relapsed on 061203, ref SDS H2
570422 - MF9H, and on 061204, the doctor renewed the prescription for
570423 - antibiotics to treat Cellulitis. ref SDS H3 ZS5N On 061208 patient
570424 - reported Cellulitis subsided and lymphedema seems controlled, though
570425 - swelling in the left arm remains significantly above prior norms,
570426 - ref SDS H4 CO7O, and citing examination on 061201. ref SDS H1 656L
570428 - ..
570429 - Today, cellulitis appears controlled; no evident inflammation.
570430 - Swelling of left arm from lymphedema remains significant, and
570431 - continues to prevent routine exercise for fitness.
570433 - ..
570434 - Below elbow measures 11.5" slightly increased from a month ago, shown
570435 - in case study on 060509. ref SDS A9 HO7F
570437 - ..
570438 - Doctor Progress Notes in the Medical Chart for 061208 describe
570439 - lymphedema "improving." ref SDS H4 J59N Similar description is
570440 - reported in the Medical Chart for today, per below. ref SDS 0 1248
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom
640401 - ..
640402 - Right Axillary No Evidence Cancer Red Rash Spreads Right Breast
640403 - Right Breast Red Rash Spreads No Evidence Disease Right Axillary
640404 - Red Rash Right Breast Spreads No Evidence Cancer Right Axillary
640406 - Follow up ref SDS H4 3D6K, ref SDS H1 3D6K.
640408 - Background on patient history of testing for lymphadenopathy in the
640409 - right axilla is reported in the record on 060929. ref SDS E7 3D6K
640411 - ..
640412 - On 061204 patient notified Kaiser that inflammation spread from the
640413 - left chest area infected with IBC across the sternum and slightly onto
640414 - the right breast. ref SDS H3 AE5I This was observed by the doctor
640415 - during examination on 061208. ref SDS H4 LG9I
640417 - ..
640418 - Examination today yielded the following report in the Medical
640419 - Chart...
640421 - Chest wall: increased erythema on lower left chest wall and
640422 - now extending to the right breast. ref SDS 0 ZL5W
640424 - ..
640425 - The doctor determined from examination today that lack of improvement
640426 - from treatment with Diflucan prescribed on 061208, ref SDS H4 KW45,
640427 - and discussed below, ref SDS 0 KW45, rules out diagnosis of infection
640428 - treatable with antibiotics, and indicates more strongly progression of
640429 - IBC disease.
640431 - ..
640432 - There was no examination today for cancer in the right axilla. The
640433 - patient made no complaint of lumps or discomfort from swelling under
640434 - the right arm. This work aligns with CT test on 061227. Review of
640435 - test results on 070102 show no findings of disease in the right
640436 - axillary. ref SDS I2 9X4S
640438 - ..
640439 - Efforts today are now focused on starting treatment for IBC on
640440 - clinical study with cetuximab that targets breast cancer, sponsored by
640441 - UCSF. ref SDS 0 PK7L
Left Supraclavicular Neck CT Test Contrast Study on 060505 Finds No
720401 - ..
720402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
720403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
720404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
720406 - Follow up ref SDS H4 8R6M, ref SDS H1 8R6M.
720408 - Background of image testing, and consideration for radiation treatment
720409 - of left supraclavicular is reported on 060623. ref SDS B9 8R6M
720411 - ..
720412 - Like the left and right axillary locations, there was no examination
720413 - today for cancer in left supraclavicular region. The patient made no
720414 - complaint of lumps or discomfort from swelling in this area. This
720415 - work aligns with CT test on 060930 that found no evidence of disease
720416 - in the left supraclavicular location, reported on 061020. ref SDS F4
720417 - LP5G
Examination IBC Red Rash Left Breast Spreads to Right Breast Aligns
780401 - ..
780402 - Pockets of Resistance to Treatment of IBC Red Rash Left Breast
780403 - IBC Red Rash Left Breast Extends Slightly onto the Right Breast
780404 - Examination Left Breast IBC Inflammation Spreads to Right Breast
780405 - Measurable Disease IBC Inflammation Spreading to Right Breast
780407 - Follow up ref SDS H4 025H, ref SDS H1 025H.
780409 - Background on prior relapse examinations is listed on 060711.
780410 - ref SDS C1 8Y7O
780412 - ..
780413 - On 061204 Millie submitted a letter, ref DIP 1 I93X, notifying the
780414 - doctor that IBC spread from the left chest area to the right breast.
780415 - ref SDS H3 I93X This was observed by the doctor during examination
780416 - on 061208. ref SDS H4 RU6J
780418 - ..
780419 - On 061227 red rash on the left chest area worsens again, after seeming
780420 - improvement the week of 061218. ref SDS H8 ZT8H On 061227 CA 15-3 74
780421 - significant rise, erratic change after slight decline, reflects IBC
780422 - rash wax and wane, cited by Doctor Benz in a 2nd opinion received on
780423 - 041117. ref SDS 48 OS6W The primary care physician advised on 061227
780424 - that volatile changes in IBC rash probably represents progression of
780425 - metastatic disease. ref SDS H8 6P9F
780427 - ..
780428 - The doctor's examination today shows no improvement; IBC rash seems to
780429 - be worsening with pockets of resistance to treatment, as reported in
780430 - the examination on 061208. ref SDS H4 RU6J Worsening IBC spreading
780431 - from left to right breast, also, noted above, ref SDS 0 T99I, aligns
780432 - with rising CA 15-3 cancer marker, shown above. ref SDS 0 GJ5M Slow
780433 - response to treatment due to loss of blood vessels removed by
780434 - mastectomy surgery last year on 051021 was reviewed in the record for
780435 - the meeting on 061208. ref SDS H4 EH3F
780437 - ..
780438 - The doctor's Progress Notes in the Medical Chart today describe "Chest
780439 - wall: increased erythema on lower left chest wall and now extending to
780440 - the right breast," ref SDS 0 ZL5W, which is a significant change from
780441 - examination on 061201, and corrects the Medical Chart report on
780442 - 061208. ref SDS H4 ZL5W
780444 - [...below, doctor defers treatment today with Navelbine in order
780445 - to qualify Millie for more effective treatment on clinical study
780446 - sponsored by UCSF. ref SDS 0 PF3O
780448 - ..
780449 - [...below, discuss notifying UCSF to expedite start of treatment
780450 - on clinical study. ref SDS 0 Y46N
780452 - ..
780453 - [On 070130 IBC progression spreads to stomach and wrapping toward
780454 - back, examination at UCSF. ref SDS J4 M68J
780456 - ..
780457 - [On 070202 doctor's examination at Kaiser, and progress notes
780458 - report cancer spreading toward the stomach, and around toward the
780459 - back. ref SDS J6 368I
780461 - ..
780462 - [On 070222 examination at UCSF indicates rash on upper left arm
780463 - likely expanding IBC. ref SDS J9 B64F
Diflucan Fluconazole Terminated Treatment Not Effective Red Rash Lef
850401 - ..
850402 - Diflucan Fluconazole 200 MG Prescription Not Effective Treatment Ends
850404 - Follow up ref SDS H4 KW45.
850406 - During the meeting on 061208, Diflucan was prescribed as a trial
850407 - treatment to diagnose "ring" rash ref SDS H4 WZ3N, spreading from
850408 - left to the right breast. ref SDS H4 KW45
850410 - ..
850411 - On 061214 treatment for pulmonary embolism warfarin (Coumadin)
850412 - conflicted with prescription for Diflucan; blood test INR increased to
850413 - 6.4, which is a danger zone for hemorrhaging; blood clot coagulation
850414 - treatment was paused for 3 days, and the INR update blood test was
850415 - advanced. ref SDS H5 HF4O On 061218 Millie notified the doctor that
850416 - INR increased on Diflucan. ref SDS H6 5M5Y The doctor advised Millie
850417 - to stop taking Diflucan. ref SDS H6 NT6J
Lung Cancer Metastatic Disease Lymph Nodes Doctor's Progress Notes M
920401 - ..
920402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
920403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
920405 - Follow up ref SDS H4 G25K.
920407 - The doctor's Progress Notes in the Medical Chart for 061208 shows
920408 - under Impressions...
920410 - Metastatic breast cancer (IBC)lung and lymph node; chest wall
920411 - recurrence, ref SDS H4 1248
920413 - ..
920414 - The same construction is shown again in the medical chart for today.
920415 - ref SDS 0 1248
920417 - ..
920418 - Millie's letter to Kaiser on 061227 cited the doctor's note on lung
920419 - cancer to illustrate requirements for accuracy in medical practice.
920420 - ref SDS H8 Z89Y
920422 - [On 070112 Millie's letter asks the doctor to explain support
920423 - for notation of lung cancer in Medical Chart. ref SDS I6 NM6G
920425 - ..
920426 - [On 070117 primary care physician cited several CT tests over
920427 - the past few years report small pulmonary nodules involving the
920428 - right lung, which are smaller than 5 mm, and so do not appear
920429 - in PET scan tests. ref SDS I9 TS8G Case study on patient
920430 - history confirms that CT tests beginning in 2002 report nodules
920431 - in the lungs; none are identified as cancer, and none show
920432 - growth common to cancer. ref SDS I9 4Q46
920434 - ..
920435 - There was no discussion of this issue, as reported previously on
920436 - 061208. ref SDS H4 G25K
920438 - ..
920439 - The doctor advised today that Millie may have suffered permanent lung
920440 - damage from pulmonary embolism, reported below. ref SDS 0 MA9K This
920441 - seems like a different issue from lung cancer.
Eyes Tearing Subsides Side Effect Taxotere Capecitabine (Xeloda) Che
960401 - ..
960402 - Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
960404 - Follow up ref SDS H4 OH6I, ref SDS H1 OH6I.
960406 - Millie met with the optometrist at Kaiser on 06122 for an eye
960407 - examination for prescription glasses.
960409 - ..
960410 - Tearing eyes problem has largely ended since ending treatment with
960411 - Taxotere and capecitabine (Xeloda) on 061201.
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea
A20401 - ..
A20402 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
A20403 - Slow Response to Treatment Mastectomy Removed Blood Vessels
A20404 - Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
A20405 - Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
A20407 - Follow up ref SDS H4 EH3F, ref SDS H1 EH3F.
A20409 - Background on slow response to treatment and impending progression of
A20410 - disease due to mastectomy surgery on 051021 was reviewed in the record
A20411 - for the meeting on 061020, ref SDS F4 EH3F, and again on 061110.
A20412 - ref SDS G5 EH3F
A20414 - ..
A20415 - There was no discussion today on Millie's letter submitted 061027
A20416 - asking about expectations for recovery from IBC due to pockets of
A20417 - resistance to systemic chemotherapy treatments from mastectomy surgery
A20418 - on 051021 that removed blood vessels, which prevents delivering
A20419 - treatment, and cited on 061011. ref SDS G5 H53F
Biopsy Right Breast Rash Spreads from Left Breast Evaluate IBC Simil
AF0401 - ..
AF0402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
AF0403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
AF0404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
AF0406 - Follow up ref SDS H4 KT7J, ref SDS H1 KT7J.
AF0408 - Biopsy was not discussed today for patient work up to develop strategy
AF0409 - and treatment plan, discussed on 060711, ref SDS C1 K36G, and more
AF0410 - recently on 061020? ref SDS F4 KH6H Further review on 061110 presents
AF0411 - objectives and rationale based on evidence of cancer mutating for
AF0412 - biopsy of IBC red rash on the left breast. ref SDS G5 448F
AF0414 - ..
AF0415 - There was no discussion today of taking a biopsy to evaluate rash
AF0416 - spreading from the left to the right breast, as observed on 061208,
AF0417 - ref SDS H4 AX6G, and reported in the doctor's progress notes for
AF0418 - examination today, per above, ref SDS 0 YU4K Patient history shows
AF0419 - IBC was originally diagnosed with a biopsy on 040419. ref SDS 33 789F
AF0420 - On 060821 Doctor Benz discussed during a 2nd opinion consultation
AF0421 - doing a biopsy to verify diagnosis of IBC recurrence on the left
AF0422 - breast. ref SDS E3 6Q6O This was confirmed in the doctor's written
AF0423 - opinion letter received from Kaiser on 060929. ref SDS E8 WY79
AF0425 - [On 070116 consent documents for cetuximab carboplatin clinical
AF0426 - study drug trial call for biopsy of cancer tumor. ref SDS I7
AF0427 - 5U7S Additional tumor biopsies are also part of the, drug
AF0428 - trial, but are optional based on patient history. ref SDS I7
AF0429 - 0348
PET/CT Scan Test 061227 Baseline New Treatment Clinical Study Not Ev
AN0401 - ..
AN0402 - PET/CT Test 061227 No Evidence Distant Metastatis
AN0403 - Distant Metastatis No Evidence PET/CT Test 061227
AN0404 - NED PET/CT Test 061227 Shows No Evidence Distant Metastasis
AN0406 - Follow up ref SDS H4 EY5O, ref SDS H1 EY5O.
AN0408 - PET/CT test on 061227 received on 070102. ref SDS I2 9X6O
AN0410 - ..
AN0411 - The doctor seemed to indicate that the PET/CT test shows no evidence
AN0412 - of distant metastasis, as shown by review on 070102, ref SDS I2 RG4J,
AN0413 - continuing patient history having never been diagnosed with distant
AN0414 - metastasis. ref SDS I2 1Y8G
AN0416 - ..
AN0417 - Kaiser did not make findings of pulmonary embolism and enlarged right
AN0418 - ventricle, which the doctor ordered on 061208, ref SDS H4 ZY5L,
AN0419 - because CT tests for pulmonary embolism, previously explained by the
AN0420 - doctor on 061020, ref SDS F4 S56G, cannot be accomplished with PET/CT
AN0421 - test equipment and procedures.
AN0423 - ..
AN0424 - There was no discussion of Kaiser failing to make comparisons with
AN0425 - prior tests on 060120, and on 060505, which were ordered by the doctor
AN0426 - on 061208, ref SDS H4 LZ6J, as reported on 070102. ref SDS I2 AK9H
AN0428 - ..
AN0429 - The doctor advised that the CT test on 061227 will support the new
AN0430 - treatment at UCSF, so there will not be a delay waiting to order
AN0431 - another test, per scheduling below. ref SDS 0 NX9N
Emotional Trauma Increases 36 Issues Drive Knowledge Management Dile
B10401 - ..
B10402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
B10403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
B10404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
B10406 - Follow up ref SDS H4 Y642, ref SDS H1 Y642.
B10408 - Medical issues create an emotional roller coaster that increase
B10409 - patient stress and trauma listed in the record on 061020. ref SDS F4
B10410 - Y642
B10412 - ..
B10413 - Current issues that drive and help resolve anxiety....
B10415 - 1. Worry rises from treatment the past 6 months with Taxotere and
B10416 - capecitabine (Xeloda), which was very effective in 2005, and
B10417 - evidently not effective to treat relapse, beginning on 070121,
B10418 - and which recently spread from left to the right breast.
B10419 - ref SDS 0 025H
B10421 - ..
B10422 - 2. Worry subsides with PET/CT test showing no evidence of distant
B10423 - metastasis 5 years after diagnosis of breast cancer.
B10424 - ref SDS 0 EY5O
B10426 - ..
B10427 - 3. Kaiser's progress reported on 061230, ref SDS I0 3X6K, and on
B10428 - 070101 collaborating with UCSF on referral authorization for
B10429 - Millie to get treatment, ref SDS I1 E23W, helps relieve tension
B10430 - and stress about the future, including IBC progressing from
B10431 - left to the right breast. ref SDS 0 AX6G
B10433 - ..
B10434 - 4. Knowledge Management dilemma complexity from 32 medical issues,
B10435 - reported on 061020, ref SDS F4 Z56M, now expands to 36, per
B10436 - above. ref SDS 0 LU3J Expanding complexity overwhelms span of
B10437 - attention, and drives desire to simplify analysis by ignoring
B10438 - issues, creating increased worry, stress, trauma for the
B10439 - patient. ref SDS F4 MO4K
B10441 - ..
B10442 - 5. Worry about what will happen with the new treatment for IBC,
B10443 - and when treatment will start at UCSF in the context of
B10444 - dwindling treatments, and prolonged period since 061201 without
B10445 - treatment. ref SDS 0 PK7L
B10447 - ..
B10448 - 6. Lung cancer reports in the Medical Chart create considerable
B10449 - anxiety in the context of no explanation nor evident support in
B10450 - the record. ref SDS 0 G25K
B10452 - ..
B10453 - 7. Prognosis today that there may be permanent lung damage, before
B10454 - notice in extensive testing for 5 years, and before making
B10455 - efforts to treat the lungs before damage became permenant.
B10456 - ref SDS 0 WR4J,
B10458 - ..
B10459 - 8. Pulmonary embolism recurrence on 061002 slow recovery compared
B10460 - to fast recovery with treatment for original diagnosis on
B10461 - 041104, reported on 041230.
B10463 - ..
B10464 - 9. Kaiser's failure to perform doctor's orders for diagnostic
B10465 - testing to evalute progression of pulmonary embolism disease,
B10466 - ref SDS 0 CV5L
B10468 - ..
B10469 - 10. Research on 060722 indicates 45% of patients die who suffer
B10470 - recurrence of pulmonary embolism. ref SDS C7 BI5J
B10472 - ..
B10473 - 11. Symptoms are documented in the Medical Chart, but ignored
B10474 - because other factors that cause the same symptoms present a
B10475 - "wicked problem" of diagnosis that is not resolved until
B10476 - autoposy after death discovers pulmonary embolism. ref SDS C7
B10477 - 7P9F
B10479 - ..
B10480 - 12. Cor Pulmonale from enlarged right ventricle compounds pulmonary
B10481 - embolism increases emotional stress in the context of failure
B10482 - to perform CT test to assess severity, and assurances from
B10483 - clinical examination that starting exercise in the gym to
B10484 - increase fitness, strengthen the immune system to fight cancer,
B10485 - and help relieve emotional stress will be safe. ref SDS 0 MA9K
B10487 - ..
B10488 - 13. Context critical decision factor allocating time for referral
B10489 - to get cancer treatment, makes spending time seem clinically
B10490 - irrelevant making referral to a heart specialist to assess a
B10491 - heart disorder that may take years, days, weeks or months to
B10492 - become life threatening. ref SDS 0 MA8O
Strategy Treatment Plan IBC 3rd Relapse Referral UCSF Clinical Study
B90401 - ..
B90402 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
B90403 - Work Up Patient History Kaiser Summary Avoids Treatment Strategy Options
B90404 - Tumor Board Review on Changing Treatment Expansion of Disease
B90406 - Follow up ref SDS H4 K36G, ref SDS H1 K36G.
B90408 - Background on requirements and challenge performing requirements for
B90409 - planning and proactive management in time for action to be effective
B90410 - is reported on 060825. ref SDS E4 K36G
B90412 - ..
B90413 - Discussion today of using "context" to avoid "irrelevant" issues
B90414 - illustrates crisis management that resists proactive medical
B90415 - management. ref SDS 0 MA8O
B90417 - ..
B90418 - Review of strategy issues was reported on 061208, ref SDS H4 5Q5I,
B90419 - including consideration of Tumor Board support to address slow
B90420 - response to treatment, ref SDS H4 P69G, and erratic changes in CA 15-3
B90421 - cancer marker and severity of IBC rash. ref SDS H4 ZZ9H
B90423 - ..
B90424 - On 061218 Millie's letter to Kaiser confirmed request for Tumor Board
B90425 - with panel that has experience treating secondary IBC relapse, post
B90426 - mastectomy surgery. ref SDS H6 OT5I On 061228 doctor submitted a copy
B90427 - of a summary of patient history submitted to UCSF for participation in
B90428 - clinical drug trial. The doctor indicated this summary provided a "5
B90429 - year review" of complex patient history in place of Tumor Board
B90430 - support for analysis of diagnosis and treatment planning. ref SDS H9
B90431 - 086H
B90433 - ..
B90434 - There was no discussion today of Tumor Board review to develop opinion
B90435 - on strategy that leverages expertise with diversity of experience to
B90436 - complement analysis by primary care physician, considered on 061228.
B90437 - ref SDS H9 NP8G
B90439 - ..
B90440 - The doctor commented that his research on the clinical study at UCSF
B90441 - for cetuximab and carboplatin offers a better solution for Millie,
B90442 - because these drugs are targeted to her patient profile, having triple
B90443 - negative breast cancer, rather than general chemotherapy that attacks
B90444 - all body cells while attempting to also attack cancer cells, discussed
B90445 - further below. ref SDS 0 PK7L
B90447 - [On 070329 review at Kaiser cites success of strategy making
B90448 - referral for targeted treatment of IBC. ref SDS K0 K36G
B90450 - ..
B90451 - [On 070921 doctor advises that cetuximab is a very expensive
B90452 - drug so referral to UCSF where the drug company pays the cost
B90453 - of treatment was good financial strategy to save Kaiser money.
B90454 - ref SDS K4 QY58
Navelbine Treatment Deferred Pending Results Clinical Study Cetuxima
BE0401 - ..
BE0402 - Navelbine Treatment Deferred Pending Results Clinical Study Cetuximab
BE0404 - Follow up ref SDS H4 Q74O, ref SDS E8 WR3Y.
BE0406 - On 061218 doctor reviewed plans to use use single agent treatments to
BE0407 - avoid exhausting drugs to treat Millie, without listing available drugs
BE0408 - for IBC, and conflicting with patient history prescribing double-agent
BE0409 - treatments. ref SDS H6 JU7J
BE0411 - ..
BE0412 - Navelbine pharmacology was reviewed on 061208. ref SDS H4 3B4N
BE0414 - ..
BE0415 - At this time consideration of Navelbine has been deferred pending
BE0416 - results of treatment at UCSF on clinical study, per below. ref SDS 0
BE0417 - PK68
Strategy Treatment Plan Surgery Remove Pockets of Resistance to Chem
BK0401 - ..
BK0402 - Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
BK0404 - Follow up ref SDS H4 ZZ5F, ref SDS E4 WE8K.
BK0406 - Surgery to treat "pockets of resistance" to chemotherapy was discussed
BK0407 - only briefly on 061208. ref SDS H4 ZZ5F
BK0409 - ..
BK0410 - Patient history on considerations for surgery in this case are
BK0411 - reported on 040416. ref SDS 51 657F
BK0413 - ..
BK0414 - There was no discussion of surgery today, pending results of treatment
BK0415 - on the cetuximab and carboplatin clinical study drug trial, which has
BK0416 - not yet been scheduled by UCSF.
Treatment 8th Cycle IBC 3rd Relapse 1st Cycle 1st Treatment Cetuxima
BR0401 - ..
BR0402 - Treatment Complete 7th Cycle Taxotere and Capecitabine (Xeloda)
BR0403 - 7th Cycle Taxotere and Capecitabine (Xeloda) Treatment Concludes
BR0404 - Taxotere and Capecitabine (Xeloda) 7th-Cycle Treatment Concludes
BR0405 - Cetuximab Clinical Study Drug Trial Start Treatment at UCSF Pending
BR0407 - Follow up ref SDS H4 PF3O, ref SDS H1 PF3O.
BR0409 - Treatment with Navelbine planned on 061208, ref SDS H4 PF3O, has been
BR0410 - deferred by the doctor's letter on 061230. ref SDS I0 OU5K The doctor
BR0411 - clarified his letter explaining that he intended to say defer
BR0412 - treatment with both Navelbine and Gemzar.
BR0414 - ..
BR0415 - No treatment is scheduled at this time, pending implementation of
BR0416 - considerations on 061208 of switching Millie from Taxotere and
BR0417 - capecitabine, to treatment with cetuximab and carboplatin on clinical
BR0418 - study, ref SDS H4 P27L, and as discussed further below. ref SDS 0 P256
BR0420 - ..
BR0421 - Primary consideration is to expedite starting treatment on the
BR0422 - clinical trial to prevent cancer from cascading beyond control,
BR0423 - discussed below on drug trials. ref SDS 0 PK7L
Drug Trials Kaiser Due Diligence UCSF Proposal Clinical Study Advise
C70401 - ..
C70402 - Cetuximab Carboplatin UCSF Clinical Study Expedite Treatment
C70403 - UCSF Clinical Studies Kaiser Authorizes Referral Schedule Treatment
C70404 - Drug Trials Kaiser Authorizes Referral to UCSF Expedite Treatment Schedule
C70405 - Expedite Treatment UCSF Cetuximab Carboplatin Clinical Study Drug Trial
C70407 - Follow up ref SDS H4 P256.
C70409 - On 061201 the doctor discussed plans to change Millie's chemotherapy
C70410 - treatments for IBC because Taxotere and capecitabine (Xeloda) have
C70411 - become increasingly less effective, shown by progression of Millie's
C70412 - cancer. ref SDS H1 GJ5M, The following week on 061208 the doctor
C70413 - proposed switching to older technology, because Millie's complex
C70414 - medical profile limits drugs available for treating her cancer.
C70415 - ref SDS H4 P24L At that time, on 061208 Millie asked about Kaiser's
C70416 - progress finding drug trials to expand treatment options, as the
C70417 - doctor presented on 040318, ref SDS 29 DG4J, and again on on 041130?
C70418 - ref SDS 49 028N
C70420 - ..
C70421 - The doctor reported today that Kaiser cannot find drug trials to treat
C70422 - Millie at Kaiser, because her complex patient history prevents
C70423 - qualifying for clinical study protocols. ref SDS H4 VT7F
C70425 - ..
C70426 - We reviewed the record showing Millie asked Kaiser to perform due
C70427 - diligence on treatment proposals in a 2nd opinion prepared by Doctor
C70428 - Benz at UCSF, and submitted to Kaiser, reported on 060929. ref SDS E8
C70429 - 6L9O The UCSF 2nd opinion states that Millie qualifies for two (2)
C70430 - drug trials sponsored by UCSF. ref SDS E8 UI9K At that time, on
C70431 - 061208, the primary care physician requested help finding the UCSF 2nd
C70432 - opinion proposals submitted to Kaiser. ref SDS H4 P27L
C70434 - ..
C70435 - On 061218 Millie submitted a letter to Kaiser with a link to the
C70436 - record on 060929 reviewing the UCSF proposal on treating Millie with
C70437 - drug trials. ref SDS H6 YV38 On 061226 Kaiser reported performing due
C70438 - diligence collaborating with Doctor Rugo at UCSF to consider drug
C70439 - trial protocols for Millie's patient profile. ref SDS H7 086H
C70441 - ..
C70442 - On 061230 the primary care physician wrote to Millie proposing that
C70443 - Kaiser delay starting treatment with Gemzar or Navelbine chemotherapy
C70444 - drugs so that Millie can qualify for clinical studies. ref SDS I0 OU5K
C70446 - ..
C70447 - At that time on 061230, the doctor also submitted correspondence
C70448 - between Kaiser and UCSF on Millie satisfying protocol requirements for
C70449 - the cetuximab and carboplatin clinical study, which is limited to
C70450 - patients who have been previously treated with no more than three (3)
C70451 - drugs. ref SDS I0 PN5X The doctor also reported Millie's treatments
C70452 - for pulmonary embolism, ref SDS I0 PN6R, and her "triple negative"
C70453 - status. ref SDS I0 PO3Q
C70455 - ..
C70456 - [On 070116 consent documentation for cetuximab and carboplatin
C70457 - clinical study shows this drug trial is targeted for "triple
C70458 - negative" patients, which means ER PR HER2 negative.
C70459 - ref SDS I7 0Q7I
C70461 - ..
C70462 - [On 070201 the cetuximab clinical study only counts treatments
C70463 - that were used until ineffective; Avastin was stopped because
C70464 - Millie developed PE, and so was not counted against her
C70465 - qualifying for the study. ref SDS J5 1N6N
C70467 - ..
C70468 - The doctor made arrangements on 061230 with Doctor Rugo authorizing
C70469 - UCSF to treat Millie on referral from Kaiser. ref SDS I0 3X6K Two
C70470 - days later on 070101, Doctor Rugo proposed plans to Kaiser on
C70471 - scheduling a meeting with Millie to start treatment at UCSF.
C70472 - ref SDS I1 086H
C70474 - ..
C70475 - The primary care physician advised today that Navelbine chemotherapy
C70476 - prescribed on 061208 for starting Millie's treatment today,
C70477 - ref SDS H4 P24L, has been changed.
C70479 - ..
C70480 - Doctor Johnson indicated that his research, which was requested in the
C70481 - meeting on 061208, ref SDS H4 P27L, shows treatment at UCSF with
C70482 - cetuximab and carboplatin proposed in the Benz 2nd opinion received
C70483 - from UCSF on 060929, ref SDS E8 UI9K, has a better chance of stopping
C70484 - progression of Millie's cancer than treatment with chemotherapy using
C70485 - Navelbine or Gemzar, per above, ref SDS 0 VQ5K, because Millie's
C70486 - cancer has been medicated repeatedly with chemotherapy, causing her
C70487 - cancer to mutate into cells that now resist chemotherapy, explained
C70488 - previously on 030606. ref SDS 23 N27L However, cetuximab is a newer
C70489 - drug "targeted" to Millie's patient profile of ER, PR, HER2 (triple)
C70490 - negative; and further cetuximab is designed to "target" only cancer.
C70491 - This significantly reduces torturous pain and suffering from killing
C70492 - non-cancerous, healthy cells throughout the body causing people to
C70493 - feel so horrible that death brings welcome relief, as occurs with
C70494 - chemotherapy technology, like AC, Taxotere, Taxol, Navelbine, Gemzar,
C70495 - and capecitabine.
C70497 - ..
C70498 - Doctor Johnson feels that this new class of "targeted" drugs
C70499 - significantly improve chemotherapy giving patients better outcomes for
C70500 - survival and quality of life. This helps solve problems Doctor
C70501 - Johnson presented on 030606, that discourage patients from living
C70502 - while getting chemotherapy. ref SDS 23 ED8H
C70504 - ..
C70505 - The doctor explained that "targeted" drugs do not impair bone marrow
C70506 - producing new blood cells, so blood counts are maintained that in turn
C70507 - maintain patient imunity. Additionally, "targeted" drugs are often
C70508 - more easily tolerated than conventional chemotherapy like
C70509 - capecitabine, Navelbine, Gemzar, and Taxotere. On 050516 the doctor
C70510 - had to reduce the dose of capecitabine to relieve horrible feelings
C70511 - like the "walking dead." ref SDS 64 AQ6G The same problem would occur
C70512 - with Navelbine and Gemzar. Switching to cetuximab "targeted" drug
C70513 - technology enables maintaining a full dose. Maintaining high dose
C70514 - levels with good blood counts creates synergy between steady treatment
C70515 - and high immunity from normal good health to fight cancer, rather than
C70516 - having to pause conventional chemotherapy to allow blood counts to
C70517 - recover for protection against fatal infection.
C70519 - [On 090529 1109 Millie letter to medical team cites Doctor
C70520 - Rugo's opinion that MPA will have less side effects that Millie
C70521 - had from cetuximab; Millie asks if UCSF prescription to treat
C70522 - Millie's 8th relapse of cancer can be expected to have similar
C70523 - sucess that Millie had with cetuximab. ref SDS K9 0N3X
C70525 - ..
C70526 - Additionally, the UCSF study for triple negative patients, like
C70527 - Millie, reported on 020321, ref SDS 4 LA7O, makes her status an
C70528 - advantage that expands treatments (i.e., increases the doctor's "tool
C70529 - kit," explained on 040318, ref SDS 29 DG4J), rather than a negative
C70530 - that limits her options, since most of the newer more powerful cancer
C70531 - drugs are for patients who are ER PR HER2 positive, indicated by
C70532 - Doctor Benz in a 2nd opinion on 041117. ref SDS 48 OU6W
C70534 - ..
C70535 - The doctor will monitor progress of treatment at UCSF with
C70536 - examinations every 2 months, so that Kaiser retains responsibility for
C70537 - case management, per planning on 061208. ref SDS H4 P270
C70539 - ..
C70540 - [On 070830 UCSF and Kaiser working on billing issues for
C70541 - Millie's treatment with clinical trial at UCSF ordered by her
C70542 - doctor at Kaiser. ref SDS K3 T259
C70544 - ..
C70545 - [On 070921 doctor advises that cetuximab is a very expensive
C70546 - drug so referral to UCSF where the drug company pays the cost
C70547 - of treatment for clinical trial was good financial strategy to
C70548 - save Kaiser money. ref SDS K4 QY58
C70550 - ..
C70551 - [On 070925 Kaiser primary care physician assigns staff to
C70552 - solve problems caused by failing to develop referral
C70553 - coordination plan for Millie's treatment at UCSF.
C70554 - ref SDS K5 G54J
C70556 - ..
C70557 - [On 071006 Paula in Kaiser's MCRC unit asks why the doctor
C70558 - prescribed treatment with cetuximab and carboplatin at UCSF.
C70559 - ref SDS K6 Q969
C70561 - ..
C70562 - [On 071128 Kaiser Appeals Committee approved payment for
C70563 - Millie's care on referral to UCSF. ref SDS K7 JZ5R
C70565 - ..
C70566 - [On 071203 Paula advised that Kaiser Appeals Committee ordered
C70567 - examinations every 3 months. ref SDS K8 QF9I
C70569 - ..
C70570 - The doctor said that UCSF has not notified Kaiser when Millie will
C70571 - start treatment. Since Millie's last treatment was 061201, delay
C70572 - risks losing local control of Millie's cancer, which is expanding,
C70573 - shown by examination today, per above. ref SDS 0 555O On 050913 the
C70574 - doctor emphasized the importance of timely treatment for local control
C70575 - of cancer. ref SDS 78 5T4N
C70577 - ..
C70578 - Millie asked the doctor to contact UCSF on expediting referral to
C70579 - start the new treatment, since Millie's last treatment was on 061201,
C70580 - about 6 weeks ago, and to report results of examination today, showing
C70581 - IBC is expanding along with rising cancer marker, per above.
C70582 - ref SDS 0 J44H
C70584 - [On 070202 doctor's examination at Kaiser, and progress notes
C70585 - report cancer spreading toward the stomach, and around toward the
C70586 - back. ref SDS J6 368I
C70588 - ..
C70589 - [On 070329 review at Kaiser cites success of strategy making
C70590 - referral for targeted treatment of IBC. ref SDS K0 K36G
C70592 - ..
C70593 - The doctor feels that sending a letter or calling to expedite the work
C70594 - would be unprofessional and insulting, because UCSF knows Millie has
C70595 - IBC, and, also, knows that IBC is an aggressive metastatic disease
C70596 - that requires urgent care to avoid losing control, cited for example
C70597 - on 060807, ref SDS D5 Q65G, and previous research on 040517.
C70598 - ref SDS 36 TO7L He indicated that, since Doctor Rugo said in a letter
C70599 - on 061231 that arrangements would be made for Millie, ref SDS I1 E23W,
C70600 - Kaiser should not submit a reminder, like telling a cement contractor
C70601 - when to pour the foundation. On 050913 the doctor previously used a
C70602 - construction management analogy to illustrate medical management
C70603 - practices. ref SDS 78 5T4N
C70605 - [...below, the doctor indicated that spending time on referral
C70606 - to UCSF for cancer treatments leaves not enough time for making
C70607 - another referral to a heart specialist to examine heart
C70608 - disorder Cor Pulmonale because symptoms may take years to
C70609 - become life threatening. ref SDS 0 SG5M
C70611 - ..
C70612 - There was discussion that people get busy. There isn't enough time to
C70613 - study at the moment and write up a plan of action for later. Nobody
C70614 - can remember pending action items when time comes for changing course.
C70615 - As a result, everyone needs reminders to follow up in time to be
C70616 - effective.
C70618 - [...below, the doctor indicated there is not enough time for
C70619 - referral to investigate heart disorder because time is focused
C70620 - on referral to UCSF for treating Millie's cancer. ref SDS 0
C70621 - 794K
C70623 - ..
C70624 - [On 070109 Millie asks Kaiser again to request that UCSF
C70625 - schedule Millie for treatment of rising symptoms. ref SDS I4
C70626 - WZ4L
C70628 - ..
C70629 - [On 070110 Kaiser contacted UCSF about Millie starting
C70630 - treatment. ref SDS I5 9R3K
C70632 - ..
C70633 - [On 070116 Millie received consent forms on the Cetuximab
C70634 - and Carboplatin clinical study; UCSF proposes she start
C70635 - treatment on 070124; agreement to this protocol rests on
C70636 - understandings from the meeting at Kaiser on 070105.
C70637 - ref SDS I7 I65I
C70639 - ..
C70640 - [On 070119 UCSF had to delay treatment, because Kaiser delayed
C70641 - referral authorization. ref SDS J1 AS96
C70643 - ..
C70644 - [On 070123 treatment delayed again because referral
C70645 - authorization still delayed. ref SDS J2 0001
C70647 - ..
C70648 - [On 070124 Millie expedites referral authorization. ref SDS J3
C70649 - 0001
C70651 - ..
C70652 - [On 070130 Millie meeting at UCSF with Doctor Rugo to plan
C70653 - starting treatment. ref SDS J4 0001
C70655 - ..
C70656 - [On 070201 Millie was randomized to get only Cetuximab,
C70657 - ref SDS J5 XR3M, and started treatment. ref SDS J5 G68I
Schedule Meeting 070202 Review Effectiveness Side Effects Treatment
C90401 - ..
C90402 - Schedule Treatment Pending Start Clinical Study Cetuximab at UCSF
C90403 - Chemotherapy Holiday Treatment Delayed Pending Start Drug Trial at UCSF
C90405 - Follow up ref SDS H4 N96O, ref SDS H1 N96O.
C90407 - During the meeting today, the doctor scheduled the next meeting in
C90408 - four (4) weeks on 070202 to assess treatment for IBC with a clinical
C90409 - study at UCSF, as reported above. ref SDS 0 PK68
C90411 - ..
C90412 - The doctor will monitor progress with treatment at UCSF with
C90413 - examinations every 60 days.
C90415 - ..
C90416 - Millie will continue without treatment until arrangements are made
C90417 - with UCSF to start treatment with cetuximab and possibly carboplatin,
C90418 - as planned, per above. ref SDS 0 PF3O
C90420 - ..
C90421 - The doctor advised that the CT test on 061227, which was discussed
C90422 - during the meeting today, per above, ref SDS 0 EY5O, will support the
C90423 - new treatment at UCSF, so there will not be a delay scheduling another
C90424 - test.
C90426 - ..
C90427 - The doctor used the computer in the examination room to order a blood
C90428 - test required for Millie to treatment at UCSF with the cetuximab and
C90429 - Carboplatin protocol. This issue is further explained on 060810.
C90430 - ref SDS E0 NH8T Millie can get the test done at any Kaiser facility,
C90431 - when UCSF notifies they have scheduled treatment to start.
C90433 - [On 070116 Jackie advised that the CT test on 061227 will
C90434 - expedite starting treatment before 070124. ref SDS I7 RT7K
C90436 - ..
C90437 - [On 070117 UCSF expedites treatment advances schedule to start
C90438 - on 070119. ref SDS I8 5S85
C90440 - ..
C90441 - [On 070118 UCSF asks Millie to get blood test ordered by
C90442 - primary care physician today, on 070105. ref SDS J0 5S6L
C90444 - ..
C90445 - [On 070119 UCSF requires another lab because the scope of the
C90446 - test at Kaiser on 070118 does not meet requirements for the
C90447 - cetuximab Carboplatin protocol. ref SDS J1 AS6M
Pulmonary Emboli Blood Clots Lungs Symptoms Continue Fatigue Weaknes
CM0401 - ..
CM0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
CM0403 - Lung Damage Permanent Cannot Resume Exercise to Build Immune System
CM0404 - Pulmonary Emboli PET/CT Test Failed Perform Doctor's Order Comparison
CM0405 - Immune System Cancer Recovery Exercise Prevented Permanent Lung Damage
CM0407 - Follow up ref SDS H4 CV5L, ref SDS H1 CV5L.
CM0409 - Background on pulmonary embolism recurrence is reported in the record
CM0410 - for the meeting on 061020. ref SDS F4 CV5L On 061201 symptoms of
CM0411 - chronic fatigue, cough, shortness of breath, clearing of throat
CM0412 - continue under a Coumadin regimen. ref SDS H1 CV5L
CM0414 - ..
CM0415 - Kaiser has not reviewed differences in pulmonary embolism findings for
CM0416 - trend analysis, as reported on 061208. ref SDS H4 HB3K At that time,
CM0417 - the doctor modified the order for the PET/CT scan test by adding scope
CM0418 - for the analyst to compare prior tests on 041103, and on 060930, with
CM0419 - the new test to assess trends (i.e., worsening, improving, or stable)
CM0420 - in Millie's condition of pulmonary embolism, per above. ref SDS H4
CM0421 - ZY5L
CM0423 - ..
CM0424 - On 061227 Millie was concerned the doctor is not aware of how severely
CM0425 - her symptoms of pulmonary embolism were affecting her life.
CM0426 - ref SDS H8 645I She therefore reported in a letter to Kaiser at that
CM0427 - time on 061227 continuing symptoms of chronic fatigue, shortness of
CM0428 - breath, cough, and heavy chest. ref SDS H8 KX6N This complements case
CM0429 - study on pulmonary embolism, listed on 060722, ref SDS C7 6G6O, which
CM0430 - shows patient history of rising symptoms. ref SDS C7 ZV41
CM0432 - ..
CM0433 - The PET/CT was performed on 061227, and the report was received on
CM0434 - 070102, and showed that comparisons ordered by the doctor on 061208
CM0435 - were again not performed. ref SDS I2 AK9H This may reflect Kaiser's
CM0436 - decision to prescribe PET/CT, and this form of test does not support
CM0437 - analysis of pulmonary embolism, as discussed above. ref SDS 0 5D6F As
CM0438 - a result, there is no affirmative evidence in the record that Coumadin
CM0439 - treatments have improved Millie's condition, as occurred after
CM0440 - treatment when Millie was first diagnosed with pulmonary embolism,
CM0441 - reported on 041230. ref SDS 52 RZ4I
CM0443 - ..
CM0444 - Changes in lung scans from original diagnosis of pulmonary embolism on
CM0445 - 041103 and the more recent test on 060930 need professional review for
CM0446 - trend analysis, as shown on 061012. ref SDS F1 7E7G
CM0448 - ..
CM0449 - Millie asked the doctor today about getting professional review of
CM0450 - differences in pulmonary embolism diagnosed on 041103 and on 060930,
CM0451 - in order to make an assessment about when she can resume vigorous work
CM0452 - outs in the gym and hiking to restore physical and emotional fitness,
CM0453 - as previously raised on 061027? ref SDS C7 B28F
CM0455 - ..
CM0456 - Millie commented that she would like a CT test that reports there is
CM0457 - no visualization of pulmonary embolism, like the CT test on 041217,
CM0458 - and reported on 041230, which aligned with relief from symptoms of
CM0459 - fatigue, weakness, shortness of breath, serious cough, associated with
CM0460 - pulmonary embolism. ref SDS 52 PW3K
CM0462 - ..
CM0463 - The doctor advised that Millie has likely, or may likely have,
CM0464 - suffered permanent lung damage, which prevents reaching prior levels
CM0465 - of physical exercise. The doctor seemed emotional saying with
CM0466 - emphasis that he understands Millie's objective to regain health to
CM0467 - work out in the gym. Vigorous exercise to test and increase strength
CM0468 - and endurance helps dissipates emotional stress, discussed above,
CM0469 - ref SDS 0 Y642, and improves Millie's life prospects by strengthening
CM0470 - the immune system, which aids recovery from cancer, including
CM0471 - withstanding debilitating chemotherapy treatments, as previously
CM0472 - discussed on 030606. ref SDS 23 ED8H
CM0474 - ..
CM0475 - The doctor indicated that Millie should go ahead and try working out
CM0476 - in the gym, and start within limits that feel comfortable.
CM0478 - [On 070204 Millie reports exercising in the gym twice on
CM0479 - consecutive days following treatment with cetuximag on clinical
CM0480 - study at UCSF on 070201. ref SDS J7 JJ7O
CM0482 - ..
CM0483 - [On 070218 energy increases, shortness of breath, fatigue,
CM0484 - weakness subside 10 weeks after ending treatment for 3rd relapse
CM0485 - of IBC with Taxotere and cacecitabine; Millie is exercising in the
CM0486 - gym again, playing tennis 2 days her pulse reached 144.
CM0487 - ref SDS J8 N05H
CM0489 - ..
CM0490 - [On 070516 Millie reports to Kaiser training hard in the gym,
CM0491 - feeling well. ref SDS K1 UH4S
CM0493 - ..
CM0494 - [On 070607 Millie suffers recurrence Cellulitis inflammation
CM0495 - envelopes left arm trauma complications lymphedema, high fever
CM0496 - possibly from working out and training too hard in the gym.
CM0497 - ref SDS K2 ZH6I
CM0499 - ..
CM0500 - This seems conflicting with the doctor's report today of permanent
CM0501 - lung damage. There is nothing in the Medical Cart for today that
CM0502 - diagnoses lung damage, and that patient is released for normal,
CM0503 - vigorous exercise in the gym, and cautions to be careful. ref SDS 0
CM0504 - ZL5W
CM0506 - ..
CM0507 - Millie explained that her emotional state, reported above. ref SDS 0
CM0508 - 2T6H, will be calmed after the next CT test for pulmonary embolism and
CM0509 - hopefully reports there is no visualization of former conditions that
CM0510 - diagnosed pulmonary embolism, like the report for the test on 041217,
CM0511 - received from the doctor on 041230. ref SDS 52 PW3K
CM0513 - [...above the doctor does not discuss comment in Medical Chart for
CM0514 - 061208 that seems to report lung cancer. ref SDS 0 M26F
Examination Clinical Findings Correlate with Stethoscope No Findings
CY0401 - ..
CY0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
CY0404 - Follow up ref SDS H4 Q35O, ref SDS H1 Q35O.
CY0406 - The doctor examined Millie with a stethoscope again today. This
CY0407 - included multiple locations on her her back, and on her chest. He
CY0408 - reported finding no evidence of cardio pulmonary issues from clinical
CY0409 - examination. The doctor's Progress Notes in the Medical Chart report
CY0410 - Lung: Clear to A & P. ref SDS 0 ZL5W
CY0412 - ..
CY0413 - For some reason, Kaiser did not report Sa02 diagnostic for oxygenated
CY0414 - blood. The test on 061208 was very good at 99%, ref SDS H4 KB5L,
CY0415 - indicating Millie was not suffering at that time from loss of
CY0416 - cardio-pulmonary functioning due to pulmonary embolism, including
CY0417 - enlarged right ventricle.
Enlarged Right Ventricle Heart Examination Not Ordered Kaiser Not En
DW0401 - ..
DW0402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
DW0403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
DW0404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
DW0406 - Follow up ref SDS H4 VJ4J, ref SDS H1 VJ4J.
DW0408 - The CT scan on 060930 reported findings of enlarged right ventricle.
DW0409 - This was not reported by Kaiser when pulmonary embolism was disclosed
DW0410 - on 061002, ref SDS F0 MI5I Enlarged right ventricle findings were
DW0411 - noticed during review of test findings after receiving the report from
DW0412 - Kaiser on 061012. ref SDS F1 7E5L Research indicates enlarged right
DW0413 - ventricle is a heart disorder, called Cor Pulmonale, that compounds
DW0414 - pulmonary embolism. ref SDS F1 L35J On 061020 Millie asked the doctor
DW0415 - how much the right ventricle is enlarged? Kaiser has not had time to
DW0416 - make this determination, reported on 061110. ref SDS G5 VJ4J
DW0418 - ..
DW0419 - On 061208 the doctor advised that Kaiser has diagnosed Cor Pulmonale.
DW0420 - ref SDS H4 J14I The doctor did not report findings in Progress Notes
DW0421 - for the Medical Chart on 061208, ref SDS H4 ZL5W, nor again today, per
DW0422 - below, ref SDS 0 ZL5W This seems like an additional medical problem
DW0423 - that prolongs recovery from pulmonary embolism, discussed today, per
DW0424 - above. ref SDS 0 3Q5J
DW0426 - ..
DW0427 - On 061208 Millie requested examination by a heart specialist to assess
DW0428 - rising symptoms of fatigue, weakness, shortness of breath, and heavy
DW0429 - chest with routine activities that prevent regular exercise in the gym
DW0430 - to restore fitness, strengthen the immune system to recover from
DW0431 - cancer, ref SDS H4 HZ39, and build emotional stability. The doctor
DW0432 - deferred referral until symptoms become more severe, ref SDS H4 HZ3O,
DW0433 - and cited favorable Sa02 diagnostics. ref SDS H4 VV4H
DW0435 - ..
DW0436 - The doctor amended the orger for a CT test on 061227 to compare with
DW0437 - the test on 060930 for trend analysis of enlarged right ventricle.
DW0438 - ref SDS H4 Y77J
DW0440 - ..
DW0441 - On 061218 Millie requested examination by heart specialist for
DW0442 - clearance to resume exercise in the gym and restore fitness while
DW0443 - symptoms of fatigue, weakness, cough, shortness of breath increase.
DW0444 - ref SDS H6 HX6V The doctor responded that enlarged right ventricle
DW0445 - most likely not clinically relevant because symptoms Cor Pulmonale
DW0446 - take years to become life threatening. ref SDS H6 XQ5H
DW0448 - ..
DW0449 - On 061227 Millie requested examination by a heart specialist to backup
DW0450 - up the doctor's first impression that Cor Pulmonale is not clinically
DW0451 - relevant; and further reported continuing symptoms of chronic fatigue,
DW0452 - shortness of breath, and heavy chest. ref SDS H8 VC4M The next day,
DW0453 - on 061228 the primary care physician Kaiser advises enlarged right
DW0454 - ventricle heart disorder Cor Pulmonale most likely due to pulmonary
DW0455 - embolism, ref SDS H9 0M6O, after treatment ended a year earlier on
DW0456 - 051007. ref SDS 84 RZ4I
DW0458 - ..
DW0459 - On 070102 review showed that Kaiser failed to make comparison in the
DW0460 - CT test on 061227 ordered by the doctor on 061028 for trend analysis
DW0461 - on the enlarged right ventricle initially reported in the test on
DW0462 - 060930. ref SDS I2 AK9H
DW0464 - ..
DW0465 - With this context, Millie requested examination by a heart specialist
DW0466 - to investigate findings in the CT test on 060930 of enlarged right
DW0467 - ventricle.
Patient History Agenda 2 Referrals Too Many Complexity Overwhelms Me
EK0401 - ..
EK0402 - Crisis Management Defers Investigation Until Time Runs Out for Analysis
EK0403 - Context Management Complements Chronology and Connection Working Intelligently
EK0404 - Information Management Prevents Understanding Chronology Context Connections
EK0405 - Proactive Management Chronology Context Connections Prevents Constant Crises
EK0407 - Follow up ref SDS H8 VC4M.
EK0409 - The doctor drew a diagram on the marking board in the examination room
EK0410 - to illustrate medical practice making complex decisions based on
EK0411 - context. The diagram showed three (3) branchs...
EK0413 - /
EK0414 - /
EK0415 - /-------- Issue 1
EK0416 - /
EK0417 - Issue 2 --------/
EK0418 - /
EK0419 - /
EK0420 - /--------Issue 3
EK0421 - /
EK0422 - /
EK0424 - ..
EK0425 - The doctor explained frustrations making sense of multiple issues,
EK0426 - discussed previously on 061020. ref SDS F4 MO4K Good practice saves
EK0427 - time and money by eliminating irrelevant options to focus on one issue
EK0428 - that seems most urgent based on the context at the time. The doctor
EK0429 - noted that Millie has a complex patient profile, listed above.
EK0430 - ref SDS 0 LU3J In this context, limited time should focus on making
EK0431 - sense of referral to UCSF for Millie to start treatment on a clinical
EK0432 - trial to stop the spread of IBC, discussed above. ref SDS 0 P256
EK0434 - [...above, Millie asks doctor to expedite referral to UCSF.
EK0435 - ref SDS 0 Y46N
EK0437 - ..
EK0438 - [On 070119 treatment at UCSF was delayed because referral
EK0439 - authorization was not performed, following agreement on 061230.
EK0440 - ref SDS J1 AS96
EK0442 - ..
EK0443 - [On 070105 doctor frustrated that multiple issues are hard to
EK0444 - manage; describes focusing on immediate problems rather than
EK0445 - spending time on issues that are irrelevant to the current
EK0446 - context. ref SDS I3 794K
EK0448 - ..
EK0449 - The doctor seemed to indicate today that spending time making referral
EK0450 - for cancer treatment, per above, ref SDS 0 Y47J, leaves no time for,
EK0451 - also, making referral to a heart doctor to investigate heart disorder
EK0452 - diagnosed three (3) months ago on 061012. ref SDS F1 7E5L Kaiser
EK0453 - seems to propose today waiting address findings in the CT test until
EK0454 - symptoms of edemya occur in the lower extremeties, as discussed on
EK0455 - 061208. ref SDS H4 HZ3O, and further notes that Cor Pulmonale make
EK0456 - take years to become life threatening, see above. ref SDS 0 MA49
EK0458 - ..
EK0459 - "Life threatening" disease is a critical "context." Proactive action
EK0460 - may be warranted in the context of Cor Pulmonale identified in CT test
EK0461 - on 060930, reviewed on 061012. ref SDS F1 7E5L Research indicates
EK0462 - this condition compounds pulmonary embolism which is known to cause
EK0463 - sudden death without evidence of clinical symptoms, reported on
EK0464 - 061012. ref SDS F1 IN3H, and citing prior reseach on 060722 presenting
EK0465 - high risk mortality; 45% of patients die who suffer recurrance.
EK0466 - ref SDS C7 BI5J Kaiser diagnosed Millie with recurrance on 061002.
EK0467 - ref SDS F0 MI5I
EK0469 - [On 070202 context missing from CT test on 070131; history cites
EK0470 - breast cancer, does not present pulmonary embolism and enlarged
EK0471 - right ventrical, Cor Pulmonale heart disorder. ref SDS J6 4I3N
EK0473 - ..
EK0474 - Context plays a critical role getting medical advice to resume working
EK0475 - out in the gym that seems relevant to rising symptoms of enlarged
EK0476 - right ventricle, discussed above. ref SDS 0 2T6H
EK0478 - ..
EK0479 - Millie requested timely review of Cor Pulmonale by a heart specialist
EK0480 - to prevent crisis management from discovering problems after prolonged
EK0481 - exposure that complicates recovery, illustrated by case studies on...
EK0483 - IBC.......................... 040517, ref SDS 36 S66O
EK0484 - Pulmonary embolism........... 060722, ref SDS C7 6G6O
EK0485 - Diflucan INR 6.4............. 061217, ref SDS 0 KW45
EK0486 - UCSF drug trials............. 061208, ref SDS H4 P256
EK0487 - UCSF referral authorization.. 061230, ref SDS I0 3X6K
EK0488 - Cor Pulmonale................ 070105, ref SDS 0 2T6H
EK0489 - Lung cancer.................. 070117, ref SDS I9 NM6G
EK0491 - ..
EK0492 - Rather than jumping from one crisis to another, proactive management
EK0493 - enables investigation that increases time for finding solutions that
EK0494 - save lives, time, and money. Background on resistance to planning and
EK0495 - proactive management in time for action to be effective was reviewed
EK0496 - previously on 060825. ref SDS E4 K36G
Work Plan Doctor Submits Doctor/Patient Partnership Communications I
FB0401 - ..
FB0402 - Work Plan Received Communications Doctor/Patient Partnership
FB0403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
FB0404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
FB0406 - Follow up ref SDS H4 FE4I, ref SDS H1 FE4I.
FB0412 - ..
FB0413 - Issues from Kaiser's Progress Notes continue from prior review on
FB0414 - 061110, ref SDS G5 EN4K, and listed again on 061208. ref SDS H4 EN4K
FB0416 - ..
FB0417 - New issues inclued...
FB0419 - 1. Current medications shows Xeloda, which was ended on 061201.
FB0420 - ref SDS 0 SE86
FB0422 - 2. Coumadin treatment are not listed, which began on 061002.
FB0423 - ref SDS 0 SE86, Coumadin is listed in the doctor's "Plan"
FB0424 - section. ref SDS 0 125V
FB0426 - ..
FB0427 - 3. Patient request for examination by heart specialist to evaluate
FB0428 - Cor Pulmonale enlarged right ventricle not reported in the
FB0429 - Medical Chart. ref SDS 0 125V
FB0431 - ..
FB0432 - Progress continues toward good management using the doctor patient
FB0433 - partnership model for timely review of patient history, called out in
FB0434 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 2 TD5S, and
FB0435 - reported on 060106. ref SDS 92 FE4I
FB0437 - ..
FB0438 - Using the patient's agenda transferred into Kaiser's electronic
FB0439 - Medical Chart following procedures set out in the record on 061020,
FB0440 - ref SDS F4 K84N, demonstrates commitment to good management, essential
FB0441 - to sustain transformation. This helps overcome lapses, as occurred
FB0442 - last month on 061208. ref SDS H4 114J
FB0444 - 1. 1/5/2007 11:30 AM
FB0446 - Wcr-ONnc2 > Main Campus
FB0449 - ..
FB0450 - 2. Your primary care clinician is listed as...