THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: January 30, 2007 01:00 PM Tuesday;
Millie meeting at UCSF prepare for new treatment IBC on 070201.
2...Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
3...Complex Patient History Knowledge Management Dilemma Issues Grow 36
4...Vitals Show Stable Medical Condition
5...Collaboration Primary Care at Kaiser with UCSF Standard of Care
6...CA 15-3 Cancer Marker 68 Erratic Changes Since 060928
7...CA 15-3 74 Cancer Marker Rises Significantly Aligns IBC Rash Increase
8...Blood Tests Ready for Treatment Tomorrow
9...Digestion Problems Increasing Relatively Infrequent Mild
10...Esophagitis Not Compared in Current PET Test with Prior Report
11...Cellulitis Complications Lymphedema Subsiding No Examination
12...Left Axillary No Evidence Lymphadenopathy Cellulitis Treatment Ends
13...Post Operation Localized Edema Left Axillary Swelling Reduced
14...Lymphedema Cellulitis Case Study on Possible Causation Factors
15...Right Axillary Possible Involvement Red Rash Spreads Right Breast
16...Right Breast Red Rash Spreads Possible Involvement Right Axillary
17...Red Rash Right Breast Spreads Possible Involvement Right Axillary
18...Left Supraclavicular Examination PET Test Report Finding SUV 4.5
19...Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
20...Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
21...Erratic Rash IBC Aligns Erratic CA 15-3 Results Case Study
22...Case Study Erratic Changes IBC Rash Aligns Changes CA 15-3
23...IBC Red Rash Left Breast Expands Toward Stomach Wraps Toward Back
24...Examination Left Breast IBC Inflammation Expanding Stomach Back
25...Stomach Back IBC Rash Spreading
26...IBC Progression Spreads Stomach and Back
27...Progression IBC Disease Spreads Stomach and Back
28...Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
29...Local IBC Infection No Record Distant Metastasis Improves Chances
30...Prognosis Favorable No Lymphadenopathy 2006 No Distant Metastasis 5 Years
31...Measurable Disease IBC Spreads from Left to Right Breast
32...Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
33...Measurable Disease IBC Observed with Tape Measure Photograph Pictures
34...CA 15-3 Diagnostic Measurable Disease IBC Not Meaured by Image Testing
35...Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
36...Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
37...Pockets of Resistance to Treatment of IBC Red Rash Left Breast
38...Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
39...Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
40...Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
41...Clinical Study Benefits from Biopsy of IBC Targeted Tissue
42...Biopsy Determine Biology of IBC and Guide Choice of Treatment
43...Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
44...CT Test Baseline Clinical Trial PE Expedite Collaborate with Kaiser
45...Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
46...Exercise Vigor Strength Engagement Ease Distress Living with Cancer
47...Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
48...Patient History Presented for Profile Work Up Planning and Strategy
49...Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
50...Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
51...Referral Authorization Resolution
52...Examination Initial Patient Work Up Starting Cetuximab Treatments
53...Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
54...Treatment 1st Cycle Cetuximab Carboplatin 070201 8th Cycle 3rd Relapse
55...8th Cycle Treatment 3rd Relapse 1st Cycle Cetuximab Carboplatin
56...Drug Trial Clinical Study Protocol Side Effects Randomized Cetuximab
57...Cetuximab Carboplatin Randomize Patient Can Still Get Carboplatin
58...Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
59...Strategy Other Treatments After Cetuximab Carboplatin Clinical Study
60...Other Treatments after Cetuximab Carboplatin Clinical Study
61...Treatments Millie Qualifies for Other UCSF Clinical Trial Studies
62...UCSF Other Treatments Clinical Study Drug Trials May Help Millie
63...Progression of disease monitored by examination and testing...
64...Schedule Treatment Start Cetuximab Carboplatin 070201
65...Cetuximab UCSF Clinical Study Treatment Begins 070201
66...UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
67...Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
68...Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
69...Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
70...Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
71...Cor Pulmonale Heart Disorder Enlarged Right Ventricle
72...Heart Examination Not Ordered Investigate Enlarged Right Ventricle
73...Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
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1...Lung cancer seems like a matter that could effect clinical study
2...Jackie commented on difficulty preparing for the meeting today from
3...the doctor seemed to suggest today examination by a cardiologist and
Meeting Doctor Examination 10th Review Prepare Changing Protocols af
1203 - ..
1204 - Summary/Objective
120501 - Follow up ref SDS B0 0000. ref SDS A3 0000.
120503 - Excellent launch meeting for Millie's new medical team at UCSF aiding
120504 - primary care support at Kaiser. Treatment was advanced today, rather
120505 - than further delayed, a welcome relief. ref SDS 0 SM6M The doctor
120506 - made a thorough examination, which showed IBC disease seems less
120507 - intense than occurs with some patients, and in relation to recent
120508 - patient history, however, the rash is now advancing beyond prior left
120509 - breast region. ref SDS 0 M68J Millie was relieved and heartened that
120510 - treatment with the clincial study trial drugs has a good chance of
120511 - being effective. ref SDS 0 M645 UCSF is coordinating with Kaiser to
120512 - advance CT testing so that Millie can get treatment on Thursday under
120513 - Doctor Rugo's supervision. ref SDS 0 EY5O This test helps solve the
120514 - problem to distinguish side effects of cetuximab treatment, which
120515 - makes people weak and tired, from symptoms of pulmonary embolism by
120516 - evaluating whether PE findings on 060930 have improved, worsened or
120517 - stabilized. ref SDS 0 915J
120519 - [On 070130 the doctor submitted report to Kaiser on consultation
120520 - today. ref SDS C6 795I
120522 - ..
120523 - [On 070131 Millie submitted the record to UCSF for review and
120524 - comment. ref SDS C7 FT7G
120526 - ..
120527 - [On 070201 Jackie and Brigid received Millie's letter today, and
120528 - seemed to indicate the record of the meeting today on 070130 is
120529 - thorough and accurate, ref SDS C9 407N; feel there is not enough
120530 - time for the doctor to provide feedback verifying accuracy of
120531 - understandings on case management. ref SDS C9 NW9M
120533 - ..
120534 - [On 070204 UCSF notified no initial side effects of treatment,
120535 - and energy has increased; planning for CT test to evaluate
120536 - pulmonary embolism. ref SDS D1 JJ7O
120541 - ..
1208 - Progress
120901 - Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
120903 - Follow up ref SDS B0 SM6M, ref SDS A3 SM6M.
120905 - The meeting today was scheduled by a call from Jackie this morning,
120906 - who coordinated to advance the work, originally scheduled for Friday.
120907 - ref SDS C4 DH9N
120909 - ..
120910 - Millie asked about payments for seeing the doctor today?
120912 - ..
120913 - The attendent checked Millie's file and said that since she is on a
120914 - clinical trial Millie is not charged for office visits because this is
120915 - paid as part of the cost of the clinical trial.
120917 - [On 070906 Millie's letter to UCSF reports not having been
120918 - notified about coinsurance charges. ref SDS F3 KC8S
120920 - ..
120921 - Doctor Rugo will meet with Millie for examination to approve starting
120922 - a new cycle of treatment every 4 weeks, following the practice at
120923 - Kaiser. In addition, Millie will meet wtih Brigid and Jackie to
120924 - monitor progress prior to the 3rd weekly treatment in each cycle.
120926 - ..
120927 - This is the 10th review meeting for the 8th chemotherapy cycle since
120928 - starting treatment on 060711, ref SDS 76 SM6M, for the 3rd relapse of
120929 - IBC. ref SDS 76 8Y8I This is the first meeting with Doctor Rugo to
120930 - start a new treatment on a clinical study drug trial for cetuximab and
120931 - carboplatin.
120933 - ..
120934 - Since this is the first meeting, an agenda was not submitted to UCSF.
120936 - ..
120937 - The agenda for the meeting at Kaiser on 070105 provides a structure
120938 - for organizing results of the meeting.
120940 - 1. Breast exam IBC spreading...................... ref SDS 0 AX6G
120941 - 2. Measurable disease pictures tape measure....... ref SDS 0 M652
120942 - 3. PET/CT Jackie coordinating schedule............ ref SDS 0 EY5O
120943 - 4. Patient work up develop strategy............... ref SDS 0 K36G
120944 - 5. Treatment plan weekly clinical trial........... ref SDS 0 PF3O
120945 - 6. Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
120947 - ..
120948 - Scheduled next meeting for either Thursday or Friday when Millie will
120949 - have the first treatment with cetuximab and carboplatin. ref SDS 0
120950 - N96O
120952 - ..
120953 - The doctor was assisted by two aides...
120955 - 1. Jackie, Clinical Research Coordinator, coordinating
120956 - 2. Rosendo So-Rosillo, MD, assisting
Complex Patient History 36 Issues Overwhelms Span of Attention Drive
160401 - ..
160402 - Complex Patient History Knowledge Management Dilemma Issues Grow 36
160404 - Follow up ref SDS B0 LU3J, ref SDS A3 LU3J.
160406 - Sampling of issues patient history diagnosis and treatment...
160408 - 1. CA 15-3 monitors advance of cancer response to treatment
160409 - 2. Lymphedema complicated by mastectomy surgery
160410 - 3. Broken finger from minor fall complicates lymphedema
160411 - 4. Esophagitis reflux digestion issues
160412 - 5. Immune system chemotherapy increases risk of infection
160413 - Chemotherapy increase risk of infection
160414 - 6. Cat bites increase risk of infection complicates lymphedema
160415 - 7. Pneumonia chemotherapy increases risk of infection
160416 - 8. Metastatic cancer increases risk pulmonary embolism
160417 - 9. Lymphadenopathy left axilla local regional metastasis
160418 - 10. Lymphadenopathy right axilla distant metastasis
160419 - 11. Lymphadenopathy left supraclavicular diagnose metastatic cancer
160420 - 12. Breast cancer secondary IBC 3rd relapse left breast
160421 - 13. Cancer mutates slow response chemotherapy treatment
160422 - 14. Mastectomy surgery impact on treatment IBC relapse
160423 - 15. Blood vessels removed mastectomy slow chemotherapy treatments
160424 - 16. Treatment options, strategy, planning, schedule
160425 - 17. Drug trials increase declining pool chemotherapy agents
160426 - 18. UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
160427 - 19. Pulmonary embolism blood clots in lungs
160428 - 20. INR weekly adjustments Coumadin treatment blood clots
160429 - 21. Enlarged right ventricle heart problem core pulmonale
160430 - 22. Dizziness symptom enlarged right ventricle cor pulmonale
160431 - 23. Fatigue shortness breath side effect chemotherapy loss fitness
160432 - 24. Fatigue shortness breath symptom pulmonary embolism
160433 - 25. Shortness breath fatigue dizzy symptoms pulmonary embolism
160434 - 26. Coagulapathy hypercoagulable state work up genetic risks
160435 - 27. Testing resolution of errors (see Benz 2nd opinion 060821)
160436 - 28. Testing distant metastatic disease
160437 - 29. Testing pulmonary emoblism and heart disease
160438 - 30. Communication hectic schedule not enough time to manage details
160439 - 31. Emotional stress and well being
160440 - 32. Cellulitis inflammation temperature 102.6 on chemotherapy
160441 - 33. Urinary tract bladder infection
160442 - 34. IBC rash spreads to right breast
160443 - 35. Right breast rash may be "ring" infection, not cancer
160444 - 36. Lung cancer seems to be diagnosed in the Medical Chart
160445 - 37. IBC rash spreads to stomach and toward back
Vitals Submitted by Doctor UCSF Blood Pressure Pulse High Demonstrat
180401 - ..
180402 - Vitals Show Stable Medical Condition
180404 - Follow up ref SDS B0 KB5L, ref SDS A3 KB5L.
180406 - ..
180407 - Bld Prssr Pulse Temp Weight SaO2
180408 - ..
180409 - * 070130 1300............ 140 83 87 98.???
180410 - * 070105 1040............
180411 - 061208 1226............ 152 90 76 97.8 147 99%
180412 - 061201 1430............ 123 76 76 97.5
180413 - 061110................. 136 83 73 97.0 150 98%
180414 - 061020 1534............ 140 79 67 99.8 151 97
180415 - 060929 1452............ 141 78 66 98.3
180416 - 060908 1335............ 139 79 73 98.1
180417 - 060814 1610............ 139 80 59 98.2
180418 - * 060808.................
180419 - 060711................. 172 87 54 97.5 147
180420 - 060623................. 141 87 71 98.0 147 99%
180421 - 060428................. 129 73 80 99.4 149 99%
180422 - 060217................. 153 81 61 98.6 150 99%
180424 - * For some reason, vitals not submitted.
180426 - ..
180427 - High blood pressure reflects pressure on patient about effectivenss of
180428 - new treatment and arrangements between UCSF and Kaiser for timely
180429 - care, discussed below. ref SDS 0 Y642
Coordination Plan Kaiser UCSF Collaboration Clinical Study Drug Tria
370401 - ..
370402 - Collaboration Primary Care at Kaiser with UCSF Standard of Care
370404 - Kaiser referral to UCSF for clinical study of drug trial treatment
370405 - with cetuximab for IBC creates divided responsibilities that increase
370406 - complexity of communications within a compound matrix management
370407 - model.
370409 - ..
370410 - Coordination will be required to avoid "wicked problems" by providing
370411 - timely and comprehensive continuity of patient history for medical
370412 - tests, e.g., blood, CT, PET imaging. Similarly, matrix management at
370413 - UCSF and Kaiser must distinguish side effects caused by chemotherapy
370414 - treatment for IBC, from symptoms that diagnose pulmonary embolism and
370415 - enlarged right ventricle, which present similarly, but significantly
370416 - increased risk, reported in research on 060722. ref SDS 78 346F UCSF
370417 - and Kaiser coordination must further distinguish symptoms of IBC now
370418 - being treated at UCSF from symptoms of lymphedema and complications of
370419 - Cellulitis being treated at Kaiser.
370421 - ..
370422 - Doctor Rugo related experience working with Kaiser shows everyone
370423 - benefits from taking time in the beginning, as done in this case, to
370424 - coordinate resolution of authorization and payment issues before
370425 - starting work in the clinical trial, reported on 070119. ref SDS B7
370426 - YF8U She feels that resolution reported on 070126, ref SDS C2 F175,
370427 - will avoid the patient being presented with a big bill down the road
370428 - that gets everyone upset.
370430 - [On 070202 Millie examined by primary care physician at Kaiser
370431 - performing oversight of work at UCSF, ref SDS D0 0001
370433 - ..
370434 - [On 070222 Jackie discussed having a meeting to develop a referral
370435 - coordination plan, ref SDS D8 VK5N, to resolve issues with Kaiser
370436 - on Millie's treatment in the clinical trial. ref SDS D8 KL5G
370438 - ..
370439 - [On 070830 Millie gets "big bill" of over $10K claimed by UCSF
370440 - because Kaiser and UCSF failed to complete coordination for
370441 - referral. ref SDS F1 W05N
370443 - ..
370444 - [On 070904 Millie requests assistance from the doctor to resolve
370445 - evident error resulting in Millie getting a "big bill."
370446 - ref SDS F2 6Q8W
370448 - ..
370449 - [On 070925 Kaiser primary care physician assigns staff to solve
370450 - problems caused by failing to develop referral coordination plan
370451 - for Millie's treatment at UCSF. ref SDS F4 G54J
370453 - ..
370454 - [On 071018 Doctor Rugo advised she gathered from communication
370455 - with Kaiser after 070119 that Millie was "cut loose" from Kaiser
370456 - failing to perform duties of insurance carrier to manage the work
370457 - by UCSF. ref SDS F5 PY5F
370459 - ..
370460 - Asked about meeting to develop a referral work plan care, rather than
370461 - leave coordination between Kaiser and UCSF to ad hoc calls, email, and
370462 - adjustments that caused delays with referral authorization this past
370463 - month, reported in another record today. ref SDS C5 RM4G
370465 - ..
370466 - The medical team indicated UCSF typically does not issue referral
370467 - coordination plans. Kaiser and UCSF have experienced professionals
370468 - using well established procedures from past and ongoing referrals for
370469 - other patients. With so many medical issues to address, ref SDS 0
370470 - LU3J, coordination with Kaiser seems resolved.
370472 - [On 070215 example Kaiser refers diagnosis and treatment of new
370473 - rash to UCSF for evaluation of side effects of cetuximab treatment
370474 - for IBC, expanding IBC, or Cellulitis. ref SDS D4 HK5O
370476 - ..
370477 - [On 070330 example symptoms of Cellulitis difficult to distinguish
370478 - from side effects of cetuximab, and/or symptoms of worsening IBC.
370479 - ref SDS E6 T87G
370481 - ..
370482 - [On 070330 example doctor diagnosis Cellulitis and prescribes
370483 - treatment rather than defer to UCSF for coordinated analysis, as
370484 - occurred previously. ref SDS E6 F46F
370486 - ..
370487 - [On 070610 primary care physician advises channels of
370488 - communication now established with UCSF for referral case
370489 - management. ref SDS F0 GV9G
370491 - ..
370492 - Case studies on Millie's treatment the past 6 years at Kaiser, show
370493 - excellent opportunities to support medical practice, reported 061018.
370494 - ref SDS 93 0001 Case study on Kaiser referral to UCSF illustrates
370495 - patient care can be strengthened through comprehensive coordination
370496 - performing divided responsibilities. ref SDS C5 RM4G In some respects
370497 - this is a project management problem solved with proactive
370498 - coordination planning.
370500 - [On 070201 Jackie provides telephone number for patient to call
370501 - for emergencies, and questions on the clinical study; case study
370502 - on collaboration between Kaiser and UCSF indicates need for
370503 - coordination plan. ref SDS C9 ST3G
370505 - ..
370506 - [On 070202 meeting at Kaiser with primary care physician cites
370507 - requirement for written coordination plan between Kaiser and UCSF
370508 - with respect to mediciation prescriptions and emergencies.
370509 - ref SDS D0 2O5H
370511 - ..
370512 - [On 070215 letter to Kaiser illustrates confusion about handling
370513 - coordination between Kaiser and UCSF with respect to mediciation
370514 - prescriptions and emergencies. ref SDS D4 VW6U
370516 - ..
370517 - [On 070216 Jackie notifies Millie to call UCSF if fever and
370518 - rash increase. ref SDS D5 AM4N
370520 - ..
370521 - [On 070217 Millie requests clarification of coordination
370522 - planning on emergency treatment; notes that patient history
370523 - shows treatment at Kaiser Emergency does not require
370524 - calling a number, just show up; notes that driving to San
370525 - Francisco for emergency treatment at UCSF might enocunter
370526 - fatal traffic delays. ref SDS D6 4Q8O
370528 - ..
370529 - [On 070222 Jackie proposed UCSF and Kaiser develop coordination
370530 - plan to facilitate collaboration on care for Millie's complex
370531 - patient history. ref SDS D8 VK5N
370533 - ..
370534 - [On 070222 scope coordination planning developed. ref SDS D8 KL5G
370536 - ..
370537 - [On 070228 letter to UCSF requests draft of coordination
370538 - plan for review during meeting on 070301. ref SDS D9 LQ6R
370540 - ..
370541 - [On 070301 there wasn't enough time to review draft coordination
370542 - plan. ref SDS E0 HH7H
370544 - ..
370545 - [On 070301 UCSF asks patient to coordinate communications with
370546 - Kaiser on integrated care and divided responsibilities.
370547 - ref SDS E0 O67N
370549 - ..
370550 - [On 070330 example blood test problem failure maintain continuity
370551 - of comprehensive data from UCSF transmitted to Kaiser, but not
370552 - entered in Kaiser's Medical Chart records. ref SDS E6 128S
370554 - ..
370555 - UCSF arranged to facilitate weekly treatments with reduced cost of
370556 - parking.
370558 - [On 070130 Millie asked about procedures for completing this
370559 - task. ref SDS C7 FT6Q
370561 - [On 070201 Millie received signed form from Jackie.
370562 - ref SDS C9 YY3F
CA 15-3 68 Rising After Falling to 56 from 74 Erratic Changes Cancer
480401 - ..
480402 - CA 15-3 Cancer Marker 68 Erratic Changes Since 060928
480404 - Follow up ref SDS B0 087J, ref SDS A3 087J.
480406 - On 070110, Millie received results for the blood test on 070104, which
480407 - shows CA 15-3 dropped to 56. ref SDS B1 087J Millie had a blood test
480408 - 2 weeks later on 070118, and received the report on 070123 showing CA
480409 - 15-3 increased to 68. ref SDS B9 GK5B
480411 - ..
480412 - Test Date Date Received
480413 - 070118......... 68 H............. 070123, ref SDS B9 GK5B
480414 - 070104......... 56 H............. 070110, ref SDS B1 087J
480415 - 061218......... 74 H............. 061227, ref SDS A5 6P9F
480416 - 061214......... 63 H............. 061227, ref SDS A5 6P9F
480417 - 061130......... 67 H............. 061201, ref SDS A0 087J
480418 - 061116......... 66 H............. 061201, ref SDS A0 087J
480419 - 061110......... 56 H............. 061201, ref SDS A0 087J
480420 - 061109......... 61 H............. 061110, ref SDS 97 087J
480421 - 061026......... 57 H............. 061110, ref SDS 97 087J
480422 - 061019......... 56 H............. 061020, ref SDS 94 087J
480423 - 060928......... 51 H............. 060929, ref SDS 89 087J
480424 - 060907......... 68 H............. 060929, ref SDS 89 087J
480425 - 060813......... 73 H............. 060817, ref SDS 84 U24M
480426 - 060809......... 87 H............. 060810, ref SDS 83 2N5J
480427 - 060708......... 71 H............. 060711, ref SDS 76 087J
480428 - 060616......... 63 H............. 060623, ref SDS 75 UQ5Q
480429 - 060522......... 59 H............. 060605, ref SDS 74 UQ5Q
480430 - 060501......... 49 H............. 060522, ref SDS 73 MC4F
480431 - 060421......... 44 H............. 060428, ref SDS 70 087J
480432 - 060330......... 40 H............. 060428, ref SDS 70 087J
480433 - 060303......... 36............... 060428, ref SDS 70 087J
480434 - 060210......... 33............... 060217, ref SDS 66 087J
480435 - 060109......... 34............... 060126, ref SDS 65 KV59
480436 - 051223......... 34............... 060106, ref SDS 64 087J
480437 - 051202......... 28............... 060106, ref SDS 64 087J
480438 - 051116......... 31............... 051121, ref SDS 63 087J
480439 - 051109......... 30............... 051121, ref SDS 63 087J
480440 - 051102......... 34............... 051121, ref SDS 63 087J
480441 - 050909......... 45 H............. 051007, ref SDS 60 087J
480442 - 050826......... 45 H............. 050913, ref SDS 56 087J
480443 - 050819......... 45 H............. 050913, ref SDS 56 087J
480444 - 050812......... 39 .............. 050819, ref SDS 54 3K6L
480445 - 050729......... 45 H............. 050819, ref SDS 54 EA5G
480446 - 050708......... 46 H............. 050729, ref SDS 53 087J
480447 - 050701......... 37 .............. 050729, ref SDS 53 087J
480448 - 050617......... 45 H............. 050729, ref SDS 53 087J
480449 - 050527......... 56 H............. 050610, ref SDS 51 087J
480450 - 050512......... 67 H............. 050520, ref SDS 50 087J
480451 - 050506......... 80 H............. 050520, ref SDS 50 087J
480452 - ..
480453 - 050415.........105 H............. 050422, ref SDS 48 087J
480454 - 050325.........100 H............. 050329, ref SDS 46 087J
480455 - 050318.........101 H............. 050325, ref SDS 45 2N5J
480456 - 050304......... 88 H............. 050311, ref SDS 43 087J
480457 - 050225......... 95 H............. 050308, ref SDS 42 0001
480458 - 050211......... 78 H............. 050214, ref SDS 41 02BB
480459 - 050128......... 67 H............. 050204, ref SDS 40 087J
480460 - 041228......... 56 H............. 041230, ref SDS 39 087J
480461 - 041204......... 43 H............. 041210, ref SDS 38 087J
480462 - 041007......... 39............... 041104, ref SDS 36 087J
480463 - 040923......... 49 H............. 041005, ref SDS 33 087J
480464 - 040908......... 44 H............. 040909, ref SDS 32 087J
480465 - 040825......... 47 H............. 040909, ref SDS 32 087J
480466 - 040811......... 42 H............. 040812, ref SDS 31 087J
480467 - 040728......... 43 H............. 040729, ref SDS 30 2N5J
480468 - 040712......... 47 H............. 040713, ref SDS 29 087J
480469 - 040614......... 55 H............. 040615, ref SDS 28 PX6X
480470 - 040517......... 78 H............. 040601, ref SDS 27 2N5J
480471 - 040311......... 70 H............. 040318, ref SDS 24 SM6M
480472 - 040205......... 60 H............. 040211, ref SDS 22 SM6M
480473 - 031201......... 62 H............. 031205, ref SDS 21 SM6M
480474 - 030912......... 66 H............. 030915, ref SDS 20 SM6M
480475 - 030708......... 68 H............. 030710, ref SDS 19 SM6M
480476 - 030503......... 54 H............. 030508, ref SDS 17 SM6M
480477 - 030403......... 45 H............. 030508, ref SDS 17 SM6M
480478 - 030215......... 46 H............. 030220, ref SDS 16 5E6L
480479 - 030106......... 37 H............. 030109, ref SDS 15 SM6M
480480 - 021202......... 41 H?............ 021204, ref SDS 14 SP5G
480481 - 021111......... 36 H?............ 021113, ref SDS 13 Y65I
480482 - 021023......... 33 H?............ 021023, ref SDS 12 SQ5I
480483 - 020930......... 33 H?..39........ 021002, ref SDS 11 SQ5I
480484 - 020917......... 36 H?............ 020924, ref SDS 10 SQ5I
480485 - 020717......... 59 H?............ 020726, ref SDS 9 YN5K
480486 - 020629......... 75 H ............ 020705, ref SDS 8 UX6I
480487 - 020608........ 67 H ............ 020614, ref SDS 7 0001
480488 - 020603........ 108 H ............ 020607, ref SDS 6 X67F
480489 - 020511........ 117 H ............ 020603, ref SDS 5 PJ4J
480490 - 020419......... 81 H ............ 020430, ref SDS 4 7N5H
480491 - 020321......... 85 H ............ 020405, ref SDS 3 6T8K
480497 - ..
4807 - Analysis
480801 - CA 15-3 74 Cancer Marker Rises Significantly Aligns IBC Rash Increase
480803 - Follow up ref SDS B0 GJ5M, ref SDS A3 GJ5M.
480805 - There was no dicsussion of CA 15-3 today. Consideration of measurable
480806 - disease focused on direct measurement with conventional tape measure,
480807 - and using photographic history. ref SDS 0 M652
480809 - ..
480810 - Discussed erratic changes in intensity of IBC rash, ref SDS 0 025H,
480811 - which correlates with recent erratic changes in CA 15-3, per above.
480812 - ref SDS 0 087J
Blood Test 070123 for Clinical Study Cetuximab Carboplatin Drug Tria
570401 - ..
570402 - Blood Tests Ready for Treatment Tomorrow
570404 - Follow up ref SDS B9 AS6M, ref SDS B8 AS6M.
570406 - On 070105, the primary care physician ordered blood work required for
570407 - Millie to get treatment at UCSF on the cetuximab carboplatin clinical
570408 - study. On 070118 Millie went to Kaiser and had blood drawn for the
570409 - test to start treatment scheduled on 070119. ref SDS B6 5S6L
570411 - ..
570412 - UCSF reported on 070119 that Millie's lab work did not meet protocol
570413 - requirements. ref SDS B7 AS6M Jackie coordinated with Arlette to
570414 - schedule Millie for a complete lab. ref SDS B7 Q95H On 070122 the
570415 - primary care physician came into the office from vacation to order
570416 - another lab study for Millie to get treatment at UCSF. ref SDS B8 LX6V
570417 - The next day on 070123 Millie went to Kaiser for another blood test.
570418 - ref SDS B9 AS6M
570420 - ..
570421 - Today, Millie was scheduled for treatment tomorrow based on the blood
570422 - test on 070123 that corrected past problems, and as planned during the
570423 - meeting today. ref SDS 0 LD59
570425 - [On 070131 UCSF requests another blood test before starting
570426 - treatment on 070201. ref SDS C8 NZ4N
570428 - ..
570429 - Key consideration will be avoiding trauma from needle penetrations by
570430 - using Millie's port for blood draws to test for ability to withstand
570431 - treatments.
570433 - ..
570434 - Needle penetrations increase risk of bleeding from Coumadin (warfarin)
570435 - treatments for pulmonary embolism, discussed below. ref SDS 0 CV5L
570436 - Port catheter was installed on 040419 because Millie suffered severe
570437 - trauma to her arm from conventional needle applications for blood
570438 - draws and treatment IVs. ref SDS 25 XU5L
570440 - ..
570441 - [On 070131 technician warns about internal bleeding from
570442 - needle penetration for blood draws; need plan to minimize
570443 - using needles, use Millie's port to reduce risk of bleeding
570444 - while on Coumadin (warfarin) for pulmonary embolism.
570445 - ref SDS C8 E87I
570447 - ..
570448 - [On 070201 Millie was randomized to treatment on Cetuximab,
570449 - and without Carboplatin, ref SDS C9 XR3M; Brigid advised
570450 - that the protocol for Cetuximab alone requires only one (1)
570451 - blood draw for each 4 week cycle, rather than weekly.
570452 - ref SDS C9 XR40
Digestion Problems GERD Subside No Examination Nor Consideration PET
610401 - ..
610402 - Digestion Problems Increasing Relatively Infrequent Mild
610403 - Esophagitis Not Compared in Current PET Test with Prior Report
610405 - Follow up ref SDS B0 JP6K, ref SDS A3 JP6K.
610407 - Background is reported in the meeting on 061201. ref SDS A0 JP6K
610408 - During the meeting on 061208, the doctor requested comparison between
610409 - PET scan test scheduled for 061227, and prior PET test on 060120,
610410 - which was reviewed on 060126, ref SDS 65 DH4O, and CT test on 060505,
610411 - reviewed on 060523, ref SDS 73 4O8P, to clarify diagnosis and plan
610412 - treatment of esophagitis or other malady that may be causing increased
610413 - digestion problems. Kaiser's medical chart for the meeting on 061208
610414 - shows GERD worse. ref SDS A3 1248 The medical chart for the meeting
610415 - on 070105 makes no reference to GERD. ref SDS B0 1248
610417 - ..
610418 - There was no discussion of this issue today.
Left Axillary Lymphadenopathy Patient No Complaint of Swelling Disco
750401 - ..
750402 - Cellulitis Complications Lymphedema Subsiding No Examination
750403 - Left Axillary No Evidence Lymphadenopathy Cellulitis Treatment Ends
750404 - Post Operation Localized Edema Left Axillary Swelling Reduced
750406 - Follow up ref SDS B0 MW8J, ref SDS A3 MW8J.
750408 - Patient has a long history of IBC on the left breast and associated
750409 - lymphadenopathy symptoms in the left axillary, see case study on
750410 - 040517. ref SDS 26 OW3I
750412 - ..
750413 - The doctor examined the left axilla. Clinical palpation made no
750414 - findings for lumps or other indications of cancer, swelled lymph nodes
750415 - that might indicate lymphadenopathy. The patient made no complaint of
750416 - lumps or discomfort from swelling under the left arm. These findings
750417 - are consistent with recent image testing listed on 070102. ref SDS A9
750418 - 1Y8G Review of PET/CT test at that time shows no findings of
750419 - lymphadenopathy. ref SDS A9 RG4J
750421 - ..
750422 - There was no examination of the left arm. The patient wore a full arm
750423 - sleeve and hand glove for treating lymphedema. There have been no
750424 - further relapses of Cellulitis, and lymphadema seems improved since
750425 - the last major episode reported on 061204. ref SDS A2 ZS5N
750427 - ..
750428 - Prior to the meeting the left elbow measures 10.75" shown in case
750429 - study on 060509. ref SDS 71 HO7F
750431 - [On 070202 rash observed on upper left arm reported by primary
750432 - care physician during examination at Kaiser, similar to symptoms
750433 - for IBC and/or cellulitus. ref SDS D0 6H6L
750435 - ..
750436 - [On 070214 Millie notifies primary care physician rash continues
750437 - on left arm, requests refill prescription antibiotic treatment for
750438 - cellulitus, Keflex. ref SDS D3 R66P
750440 - ..
750441 - [On 070222 Brigid investigated effects of tennis on lymphedema and
750442 - cellulitis in left arm, and determined that playing righ handed
750443 - makes this a manageable risk for restoring fitness to strengthen
750444 - the immune system. ref SDS D8 457F
Case Study Lymphedema Cellulitis Patient History Symptoms Diagnosis
Cellulitis Keflex Antibiotics Treatment Prescription Cellulitis Rela
800501 - ..
800502 - Lymphedema Cellulitis Case Study on Possible Causation Factors
800504 - Background on treatment for Cellulitis and lymphedema is shown in case
800505 - study on 061203. ref SDS A1 YT4M
800507 - ..
800508 - Patient history on causation of lymphedema and cellulitis shows...
800510 - 1. Surgery left breast lumptectomy
800511 - removeed tumor; lymph nodes left
800512 - axillary removed.................. 020312, ref SDS 1 7V61
800514 - ..
800515 - 2. Pathology surgery on 020312; 3 of
800516 - 3 lymph nodes positive for
800517 - metastatic disease left
800518 - axillary.......................... 020321, ref SDS 2 5O5F
800520 - ..
800521 - 3. Meeting primary care physician
800522 - recommends immediate surgery for
800523 - local control, makes no disclosure
800524 - risks lymphedema.................. 050913, ref SDS 56 5T4J
800526 - ..
800527 - 4. Meeting with surgeon to assess
800528 - Kaiser's recommendations for left
800529 - breast mastectomy makes no disclosure
800530 - of risks for post operation side
800531 - effects of lymphedema; surgon
800532 - asks for patient's
800533 - opinion........................... 050923, ref SDS 59 WI6K
800534 - surgeon asks again what patient
800535 - thinks about risks of approving
800536 - mastectomy........................ 050923, ref SDS 59 7K3J
800537 - surgeon warns mastectomy presents
800538 - high risks, no disclosure that
800539 - lymphedema and cellulitis will
800540 - cause chronic medical problems
800541 - with hospitalization.............. 050923, ref SDS 59 NT9G
800543 - ..
800544 - 5. Meeting primary care physician recommends
800545 - patient approve mastectomy surgery
800546 - for "palliation," no disclosure
800547 - risks for lymphedema.............. 051007, ref SDS 60 IV4G
800549 - ..
800550 - 6. Surgery left breast mastectomy
800551 - did not remove lymph nodes left
800552 - axillary in order to reduce risk
800553 - of lymphedema..................... 051021, ref SDS 61 QU5I
800555 - ..
800556 - 7. Surgeon confirms lymph nodes not
800557 - removed left axillary for left
800558 - breast mastectomy performed on
800559 - 051021............................ 051027, ref SDS 61 LI3K
800561 - ..
800562 - 8. Swelling, large bulge under left
800563 - axillary; diagnosis is
800564 - lymphadema........................ 060106, ref SDS 64 S164
800566 - ..
800567 - 9. Swelling reduced under left
800568 - axillary, referral to lymphedema
800569 - clinic............................ 060217, ref SDS 66 T56K
800571 - ..
800572 - 10. Lymphedema clinic examination finds
800573 - worsening lymphedema.............. 060306, ref SDS 67 G26O
800575 - ..
800576 - 11. Lymphedema rises, begin physical
800577 - therapy, and regimen of massage
800578 - to reduce swelling on entire
800579 - left arm and hand................. 060314, ref SDS 68 GE89
800581 - ..
800582 - 12. Therapyst finds improvement, says
800583 - removal of lymph nodes during surgery
800584 - on 051021 may have triggered
800585 - increased symptoms of
800586 - lymphedema........................ 060417, ref SDS 69 2Z9M
800588 - ..
800589 - 13. Measurements swelling patient
800590 - history lymphedema................ 060509, ref SDS 71 HO7F
800592 - ..
800593 - 14. Swelling increases, then recedes
800594 - somewhat; therapyst recommends
800595 - resuming using bandage on
800596 - entire left arm during
800597 - exercise.......................... 060515, ref SDS 72 Q05H
800599 - ..
800600 - 15. Lymphedema seems under
800601 - control........................... 060623, ref SDS 75 K75S
800603 - ..
800604 - 16. Physical therapyst ends treatment
800605 - for lymphedema.................... 060711, ref SDS 76 MW8J
800607 - ..
800608 - 17. Millie falls at BART breaks finger
800609 - left hand, left arm swells
800610 - complications from
800611 - lymphedema........................ 060914, ref SDS 87 ZQ5I
800613 - ..
800614 - 18. Lymphedema swelling left arm
800615 - suddenly increases................ 060922, ref SDS 88 0D5Y
800617 - ..
800618 - 19. Millie hospitalized 5 days temperature
800619 - 102.6 severe red rash envelops left
800620 - arm and shoulder; diagnosis cellulitis
800621 - complications of lymphedema, reaction
800622 - to tramua from fall and breaking
800623 - finger on 060914.................. 061027, ref SDS 96 V759
800625 - ..
800626 - 20. Cellulitis relapse left arm,
800627 - prescription Keflex
800628 - renewed........................... 061112, ref SDS 98 5K5G
800630 - ..
800631 - 21. Case study Cellulitis and lymphedema
800632 - indicates risks increase with exercise
800633 - after surgery removes lymph
800634 - nodes............................. 061203, ref SDS A1 YT4M
800636 - ..
800637 - 22. Cellulitis recurrence again, possibly
800638 - caused by cat bite, doctor renews
800639 - prescription for
800640 - Keflex............................ 061204, ref SDS A2 ZS5N
800642 - ..
800643 - 23. Cellulitis inflammation subsides,
800644 - swelling of lymphedema in left arm
800645 - remains significantly above
800646 - norms............................. 061208, ref SDS A3 CO7O
800648 - ..
800649 - 24. Cellulitis no evidence; lymphedema
800650 - swelling left arm and hand still
800651 - significant, preventing routine
800652 - exercise for
800653 - fitness........................... 070105, ref SDS B0 3Z9H
800655 - ..
800656 - 25. Rash left breast 2 scenarios,
800657 - erratic changes severity, expanding
800658 - from left breast toward stomach,
800659 - wrapping toward back expanding
800660 - to right breast could be
800661 - IBC compounded by
800662 - cellulitis........................ 070130, ref SDS 0 M68J
800664 - ..
800665 - 26. Rash upper left arm cited by primary
800666 - care physician similar to previous
800667 - condition diagnosed as
800668 - cellulitis........................ 070202, ref SDS D0 JP6F
800670 - ..
800671 - 27. Exercise case study correlation causing
800672 - Cellulitis and lymphedema after surgery
800673 - removed lymph nodes, reduces
800674 - capacity lymphatic
800675 - system............................ 070218, ref SDS D7 3M3J
800677 - ..
800678 - 28. Examination at UCSF indicates rash
800679 - on upper left arm more likely
800680 - expanding IBC, rather than
800681 - cellulitis........................ 070222, ref SDS D8 B64F
800683 - ..
800684 - 29. Exerecise tennis using right arm
800685 - minimizes harm compounding
800686 - lymphedema complications to
800687 - left arm.......................... 070222, ref SDS D8 IS5K
800689 - ..
800690 - 30. Lymphedema swelling left arm increases
800691 - significantly raising concerns about
800692 - exercising to strengthen immune system
800693 - that resists cancer and helps
800694 - manage emotional
800695 - stress............................ 070329, ref SDS E5 T87G
800697 - ..
800698 - 31. Cellulitis lymphedema recurrence during
800699 - treatment for cancer at UCSF; evident
800700 - cause increased exercise to stimulate
800701 - bone marrow that produces new blood
800702 - that maintains immune system essential
800703 - for chemotherapy treatments; exercise
800704 - further maintains physicial fitness
800705 - essential for aggressive chemotherapy
800706 - treatments to recover from
800707 - cancer............................ 070607, ref SDS E9 ZH6I
800709 - ..
800710 - 32. Cellulitis and lymphedema causation
800711 - discussed with UCSF; no evident
800712 - correlations that can help reduce
800713 - recurrence........................ 080501, ref SDS F6 9U5M
800715 - ..
800716 - 33. Lymphedema and Cellulitis risk declines
800717 - gradually after surgery remove cancerous
800718 - lymph nodes; lymphatic system gradually
800719 - becomes more robust because remaining
800720 - lymph nodes increase capacity so that
800721 - exercise can continue to maintain fitness
800722 - essential for aggressive chemotherapy
800723 - treatment to recover from cancer
800724 - reported by surgeon at
800725 - Kaiser............................ 080606, ref SDS F7 4P7L
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom
860401 - ..
860402 - Right Axillary Possible Involvement Red Rash Spreads Right Breast
860403 - Right Breast Red Rash Spreads Possible Involvement Right Axillary
860404 - Red Rash Right Breast Spreads Possible Involvement Right Axillary
860406 - Follow up ref SDS B0 3D6K, ref SDS A3 3D6K.
860408 - Background on patient history of testing for lymphadenopathy in the
860409 - right axilla is reported in the record on 060929. ref SDS 89 3D6K
860411 - ..
860412 - On 061204 patient notifies Kaiser that IBC inflammation spread from
860413 - the left chest area infected with IBC across the sternum and slightly
860414 - onto the right breast. ref SDS A2 AE5I
860416 - ..
860417 - Patient has a long medical history of cancer associated with IBC rash
860418 - on the left breast and lymphadenopathy symptoms in the left axillary,
860419 - see case study on 040517. ref SDS 26 OW3I
860421 - ..
860422 - The doctor made careful and thorough examination of the left and right
860423 - breast areas.
860425 - ..
860426 - Examination of the right axillary yielded same results from examining
860427 - the left axilla, per above. ref SDS 0 VU6O
Left Supraclavicular Neck Lymphadenopathy Patient No Complaint Swell
940401 - ..
940402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
940403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
940404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
940406 - Follow up ref SDS B0 8R6M, ref SDS A3 8R6M.
940408 - During examination, the doctor asked about history of radiation to the
940409 - neck, and sequence of finding recurrence from Doctor Laio's biopsy
940410 - reported on 040309. ref SDS 23 0001
940412 - ..
940413 - Background of image testing, and consideration for radiation treatment
940414 - of left supraclavicular is reported on 060623. ref SDS 75 8R6M
940416 - ..
940417 - Like the left and right axillary locations, the doctor examined for
940418 - cancer in left supraclavicular region. There were no findings of
940419 - lumps which could indicate lymphadenopathy, as reported above.
940420 - ref SDS 0 VU6O
Examination IBC Red Rash Left Breast Spreads to Right Breast Toward
A30401 - ..
A30402 - Erratic Rash IBC Aligns Erratic CA 15-3 Results Case Study
A30403 - Case Study Erratic Changes IBC Rash Aligns Changes CA 15-3
A30404 - IBC Red Rash Left Breast Expands Toward Stomach Wraps Toward Back
A30405 - Examination Left Breast IBC Inflammation Expanding Stomach Back
A30407 - Follow up ref SDS B0 025H, ref SDS A3 025H.
A30409 - Background on prior relapse examinations is listed on 060711.
A30410 - ref SDS 76 8Y7O
A30412 - ..
A30413 - On 061204 Millie submitted a letter, ref DIP 1 I93X, notifying Kaiser
A30414 - that IBC spread from the left chest area to the right breast,
A30415 - ref SDS A2 I93X This was observed by the doctor during examination on
A30416 - 061208. ref SDS A3 RU6J Doctor's notes for examination on 070105
A30417 - describe erythema extending to the right breast. ref SDS B0 925L
A30419 - ..
A30420 - There has been steady expansion of rash beginning on the left chest
A30421 - area near the sternum since examination on 060623, ref SDS 75 025H,
A30422 - and since starting treatment with Taxotere and capecitabine on 060721.
A30423 - ref SDS 77 0001
A30425 - ..
A30426 - Erratic changes in severity/intensity and spreading of IBC rash are
A30427 - shown by case study in the record on 040517. ref SDS 26 2F4G Patient
A30428 - history since June of last year show changing severity of IBC rash
A30429 - during 3rd relapse. ref SDS 26 KR8O
A30431 - ..
A30432 - Changing intensity of rash generally tracks changes in CA 15-3 during
A30433 - treatment of 3rd relapse, shown above. ref SDS 0 087J This was cited
A30434 - by the primary care physician during a meeting on 061201 to discuss
A30435 - changing treatments. ref SDS A0 GJ5M The doctor further cited CA 15-3
A30436 - as a primary diagnostic for measurable disease in a letter to Doctor
A30437 - Rugo on 061230, ref SDS A7 PO3V, reflecting that IBC does not appear
A30438 - in image tests with PET and CT scan technology, unless there is
A30439 - related lymphadenopathy, which is not present at this time, reported
A30440 - above. ref SDS 0 VU6O
A30443 - ..
A30444 - Stomach Back IBC Rash Spreading
A30445 - IBC Progression Spreads Stomach and Back
A30446 - Progression IBC Disease Spreads Stomach and Back
A30448 - Examination today shows rash expanding on the left chest, and onto the
A30449 - right breast, as previously reported. Intensity of the rash seems
A30450 - much less severe today than prior examinations, based on patient
A30451 - comments. However, there is new and significant expansion of rash to
A30452 - the lower abdomen (stomach), and beginning to wrap toward the side and
A30453 - back. At this time, extension of rash toward the stomach and side,
A30454 - are light sprinkles of red dots, similar to when IBC relapse was
A30455 - observed near the sternum, above and below the mastectomy incision,
A30456 - reported on 060623. ref SDS 75 NE6G
A30458 - [On 070131 primary care physician at Kaiser notified examination
A30459 - today indicates rash has spread to stomach, and toward the back.
A30460 - ref SDS C8 6K6V
A30462 - ..
A30463 - [On 070201 rash severity continues to subside, shown by
A30464 - examination at UCSF to start treatment on 070201. ref SDS C9 6T6M
A30466 - ..
A30467 - [On 070202 rash observed on upper left arm reported by primary
A30468 - care physician during examination at Kaiser, similar to symptoms
A30469 - for IBC and/or cellulitus. ref SDS D0 6H6L
A30471 - ..
A30472 - [On 070216 UCSF schedules meeting to examine report new rash on
A30473 - left arm; proactive management may be spread of IBC. ref SDS D5
A30474 - VE3K
A30476 - ..
A30477 - [On 070222 examination at UCSF indicates rash on upper left arm
A30478 - likely expanding IBC. ref SDS D8 B64F
A30480 - ..
A30481 - [On 070301 new rash on upper right arm similar to IBC, but not
A30482 - diagnosed as IBC. ref SDS E0 H15M
A30484 - ..
A30485 - The doctor described rash and skin seems smooth to the touch, rather
A30486 - than rigid and pitted, as may occur with advanced IBC. The skin does
A30487 - not seem warm or hot, as also occurs when IBC becomes severe. Millie
A30488 - has previously noticed this area has been "hot" to the touch on
A30489 - occassion, but this has not occurred for a month or so.
A30491 - ..
A30492 - Biopsy has not been performed to affirmatively diagnose these new rash
A30493 - sites, and changes in intensity, per above, ref SDS 0 SE9O, and
A30494 - discussed again below. ref SDS 0 KT7J
A30496 - [On 070201 examination Brigid, Nurse Practitioner, prior to
A30497 - treatment, rash described similarly. ref SDS C9 LH5H
A30499 - ..
A30500 - This record indicates some response to treatment with Taxotere and
A30501 - capecitabine (Xeloda) having restrained and controlled advance of
A30502 - disease.
A30504 - ..
A30505 - May fit 2 scenario analysis on 060808, ref SDS 81 J16O, possibility
A30506 - expanding rash observed today is cellulitis which previously presented
A30507 - as initial light sprinkes of red dots, reported on 061027. ref SDS 95
A30508 - MS3Q This was reported in another record the same day. ref SDS 96
A30509 - HP52 In that case of cellulitis, Millie had elevated temperature,
A30510 - ref SDS 96 EX9L, reaching a high of 102.4. ref SDS 96 Q265 Physical
A30511 - correlation of connection between cellulitis on left arm, and IBC rash
A30512 - area on left chest was directly observed on 061027. ref SDS 96 V79M
A30514 - ..
A30515 - Since there is no temperature today, this may indicate the rash is not
A30516 - cellulitis, but IBC. Diagnosis seems indeterminate without a biopsy.
A30518 - ..
A30519 - [On 070202 doctor's examination at Kaiser, and progress notes,
A30520 - report cancer spreading toward the stomach, and around toward the
A30521 - back, ref SDS D0 368I, similar inflammation also occurred on the
A30522 - upper left arm, diagnosed as possible cellulitis; expanding rash
A30523 - beyond the left breast area could therefore be cellulitis from
A30524 - lymphedema. ref SDS D0 YK8O
A30528 - ..
A30529 - Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
A30531 - The doctor commented today that there is a good chance treatment with
A30532 - Cetuximab and Carboplatin will clear inflammation and rash observed
A30533 - today, as previously occurred in 2005 when Taxotere and capecitabine
A30534 - (Xeloda) were started to treat Millie for 2nd recurrence, illustrated
A30535 - by the report on 050520. ref SDS 50 025H
A30537 - [On 070301 subsiding rash and dramatic drop in CA 15-3 cancer
A30538 - marker after 4 treatments with cetuximab on clinical study at UCSF
A30539 - shows improving prospects. ref SDS E0 M645
A30542 - ..
A30543 - Local IBC Infection No Record Distant Metastasis Improves Chances
A30544 - Prognosis Favorable No Lymphadenopathy 2006 No Distant Metastasis 5 Years
A30546 - The doctor feels Millie is fortunate that 5 years of patient history
A30547 - image testing, listed recently on 070102, ref SDS A9 1Y8G, has not
A30548 - found distant metastatis. During all of 2006, there were no findings
A30549 - of swelled lymph nodes in the axillary regions, nor in the left
A30550 - supraclavicular where biopsy on 040309 reported a single incidence of
A30551 - cancer, which is is a symptom of IBC, reported on 040517. ref SDS 26
A30552 - N23J This gives Millie a good chance of arresting growth of cancer,
A30553 - if treatment accomplishes local control.
Measurable Disease IBC Spreads from Left to Right Breast Photographs
A50401 - ..
A50402 - Measurable Disease IBC Spreads from Left to Right Breast
A50403 - Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
A50404 - Measurable Disease IBC Observed with Tape Measure Photograph Pictures
A50405 - CA 15-3 Diagnostic Measurable Disease IBC Not Meaured by Image Testing
A50407 - Follow up ref SDS A8 4Q6K.
A50409 - On 061230 Doctor Rugo asked in a letter to Kaiser about measurable
A50410 - disease in Millie's case. The primary care physician cited rising CA
A50411 - 15-3, ref SDS A7 PO3V, which has tracked expanding IBC rash and
A50412 - intensity, discussed above. ref SDS 0 SE5J Measurable disease was
A50413 - cited again in follow up correspondence reviewed on 070101, At that
A50414 - time, a case study lists patient history considering use of diagrams
A50415 - and photographs to measure advance and improvement treating IBC,
A50416 - because image testing with CT and PET scan technologies are not
A50417 - effective for IBC. ref SDS A8 4Q6K
A50419 - ..
A50420 - Today, the doctor used a tape measure to obtain dimensions of the
A50421 - current rash. This is a little difficult because the rash spreads
A50422 - unevenly in all directions. Seemed like the doctor used the stermun
A50423 - as a base point, where IBC was initially concentrated following
A50424 - relapse, reported on 060711. ref SDS 76 T86N Infected skin tissue
A50425 - measures 1 - 2 inches from the sternum onto the right breast.
A50426 - Measurement was also made of rash extending approximately 5 inches
A50427 - from the sternum on the left side above and below the mastectomy
A50428 - incision wound. The doctor also measured vertically about 4 inches
A50429 - left of the sternum from above and and extending below the incision
A50430 - line, toward the stomach to a location which the doctor described as
A50431 - significant rash.
A50433 - ..
A50434 - Jackie plans to take pictures of IBC infected area on the first day of
A50435 - treatment, to compare with subsequent pictures taken every 4 weeks
A50436 - starting a new cycle, as discussed on 070116 for determining
A50437 - measurable disease. ref SDS B3 JS5G Background considering
A50438 - photographic records for diagnostics to assess progress of "measurable
A50439 - disease" treating IBC was reviewed in a case study on 070101, when
A50440 - this issue was raised in correspondence between UCSF and Kaiser.
A50441 - ref SDS A8 4Q6K
A50443 - [On 070201 Jackie took pictures of infected IBC tissue with a tape
A50444 - measure held in various angles to assess measurable disease.
A50445 - ref SDS C9 6T6M
Lung Cancer No Discussion Metastatic Disease Lymph Nodes Doctor's Pr
A90401 - ..
A90402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
A90403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
A90405 - Follow up ref SDS B0 G25K, ref SDS A3 G25K.
A90407 - Primary care physician Progress Notes in the Medical Chart for 070105
A90408 - shows under Impressions...
A90410 - Metastatic breast cancer (IBC)lung and lymph node; chest wall
A90411 - recurrence. ref SDS B0 1248
A90413 - ...which repeats an entry in the Medical Chart for the meeting on
A90414 - 061208. ref SDS A3 1248 Review on 061208 notes there is no record of
A90415 - disclosure to the patient on lung cancer, and nothing in patient
A90416 - history over the past 5 years that hints nor diagnoses lung cancer.
A90417 - ref SDS A3 LP6K
A90419 - ..
A90420 - There was no discussion at Kaiser on 061208, because the Medical Chart
A90421 - was received after the meeting. This matter was not reviewed with the
A90422 - doctor during the meeting on 070105 because at that time, the doctor
A90423 - was focused on getting Millie started with treatment at UCSF.
A90424 - ref SDS B0 PK7L and ref SDS B0 MA8O
A90426 - ..
A90427 - Lung cancer seems like a matter that could effect clinical study
A90428 - issues, and so may warrant review by UCSF.
A90430 - ..
A90431 - On 070112 Millie asked Kaiser to explain support for notation of lung
A90432 - cancer in the Medical Chart. ref SDS B2 NM6G On 070117 the primary
A90433 - care physician cited several CT tests over the past few years report
A90434 - small pulmonary nodules involving the right lung, which are smaller
A90435 - than 5 mm, and so do not appear in PET scan tests. ref SDS B5 TS8G
A90436 - Case study on patient history confirms that CT tests beginning in 2002
A90437 - report nodules in the both right and left lungs; none are identified
A90438 - as cancer, and none show growth common to cancer. ref SDS B5 4Q46
A90439 - Unless Kaiser pathology reports have been audited with further review
A90440 - of scan files, and changed to reflect further findings, there is no
A90441 - evident basis for diagnosis of lung cancer.
A90443 - ..
A90444 - On 070105 the primary care physician further indicated that Millie may
A90445 - have suffered permanent lung damage from pulmonary embolism, which
A90446 - seems related, but different from lung cancer. ref SDS B0 3Q5J
A90448 - ..
A90449 - There was no discussion of this issue today, so that attention could
A90450 - be focused on starting Millie's treatment to stop progression of IBC
A90451 - metastatic disease.
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea
AG0401 - ..
AG0402 - Pockets of Resistance to Treatment of IBC Red Rash Left Breast
AG0403 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
AG0404 - Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
AG0405 - Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
AG0407 - Follow up ref SDS B0 EH3F, ref SDS A3 EH3F.
AG0409 - Background on slow response to treatment and impending progression of
AG0410 - disease due to mastectomy surgery on 051021 was reviewed in the record
AG0411 - for the meeting on 061020, ref SDS 94 EH3F, and again on 061110.
AG0412 - ref SDS 97 EH3F Case study considering mastectomy surgery for Millie
AG0413 - is reported on 041210. ref SDS 38 657F
AG0415 - ..
AG0416 - On 041117 Doctor Benz recommended there is no role for surgery in
AG0417 - Millie's case. ref SDS 37 OU4U On 050311 Kaiser oncology ordered
AG0418 - examination by the surgery department for mastectomey to remove
AG0419 - "pockets of resistance" to chemotherapy in the left breast.
AG0420 - ref SDS 43 XQ41 On 050324 the surgeon observed IBC spreading toward
AG0421 - the neck provided, which prevented surgery because there was no
AG0422 - evident boundary for surgery. ref SDS 44 YY7F On 050329 oncology
AG0423 - changed treatment to Taxotere and capecitabine, which started on
AG0424 - 050415. ref SDS 47 407N On 050727 surgeon observed IBC rash was no
AG0425 - longer visible. ref SDS 52 YY7F On 050729 Kaiser oncology recommended
AG0426 - mastectomy surgery. ref SDS 53 BZ56 On 050811 Millie asked UCSF about
AG0427 - Kaiser's proposal for surgery, and on 050823 UCSF referred the issue
AG0428 - to Doctors Bailey and Grissom. ref SDS 55 AI8N
AG0430 - ..
AG0431 - Doctor Grissom recommended on 050922 continuing chemotherapy for local
AG0432 - control, and that mastectomy could be considered, but that risks of
AG0433 - distant metastasis are high. ref SDS 57 XL6S Similarly, 2nd opinion
AG0434 - from Doctor Bailey received on 050922, cautioned against surgery,
AG0435 - ref SDS 58 XD6U, and that, if mastectomy was performed, then Millie's
AG0436 - patient history of no distant metastasis and IBC spreading toward the
AG0437 - neck, indicated that breast reconstruction of a very wide mastectomy
AG0438 - should be considered to avoid recurrence by removing previously
AG0439 - infected tissue. ref SDS 58 XD8P
AG0441 - ..
AG0442 - On 051007 Kaiser proposed deferring breast replacement, ref SDS 60
AG0443 - 635M, explaining that tissue harvested for reconstruction may have
AG0444 - poor blood vessels due to prior surgery, and this could reduce
AG0445 - delivery and therefore effectiveness of chemotherapy drugs in the
AG0446 - event of relapse. ref SDS 60 KO49
AG0448 - ..
AG0449 - Today, the doctor seemed to comment that slow, and erratic response to
AG0450 - treatment the past several months, including evident progression of
AG0451 - disease, cited in the study above, ref SDS 0 SE9O, is not likely
AG0452 - caused by "pockets of resistance" to treatment because mastectomy
AG0453 - surgery interrupted the blood vessel system slowing delivery of
AG0454 - chemotherapy drug agents to this region, as considered in the record
AG0455 - on 061110. ref SDS 97 5E5I The doctor described this theory as new to
AG0456 - oncology practice at the UCSF Cancer Center.
AG0458 - ..
AG0459 - The doctor further indicated today that mastectomy was reasonable
AG0460 - treatment with a 20% chance of long term success for Millie's patient
AG0461 - history, but that IBC presents an aggressive disease that is difficult
AG0462 - to treat. There was no discussion of palliation, i.e., how mastectomy
AG0463 - aided patient comfort from failing treatment. Case study on 051027
AG0464 - reviews mastectomy for palliation in relation to increasing local
AG0465 - control. ref SDS 62 F25H
AG0467 - ..
AG0468 - The doctor indicated today that breast reconstruction has not been an
AG0469 - effective solution at UCSF for IBC patients. UCSF has seen the worst
AG0470 - IBC relapse occur with breast reconstruction.
Biopsy Left Right Breasts Start Clinical Study Treatment IBC Cetuxim
AU0401 - ..
AU0402 - Clinical Study Benefits from Biopsy of IBC Targeted Tissue
AU0403 - Biopsy Determine Biology of IBC and Guide Choice of Treatment
AU0404 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
AU0406 - Follow up ref SDS B0 KT7J, ref SDS A3 KT7J.
AU0408 - ..
AU0409 - Biopsy for patient work up to treat 3rd IBC relapse was originally
AU0410 - discussed on 060711, ref SDS 76 K36G, and more recently on 061020?
AU0411 - ref SDS 94 KH6H Further review on 061110 presents objectives and
AU0412 - rationale based on evidence of cancer mutating. ref SDS 97 448F
AU0413 - Biopsy was reviewed at Kaiser on 070105 to evaluate rash spreading
AU0414 - from left to the right breast, ref SDS B0 WZ5J, and based on patient
AU0415 - history discovering IBC with a biopsy on 040419. ref SDS 25 789F
AU0417 - ..
AU0418 - Status change can be reviewed with biopsy, which could increase
AU0419 - treatment options for Millie.
AU0421 - ..
AU0422 - During the meeting today, Millie agreed to several biopsy samples of
AU0423 - rash infected areas observed during examination, per above,
AU0424 - ref SDS 0 M68J, in order to support clinical study objectives, set out
AU0425 - in the consent form reviewed on 070116. ref SDS B3 0348
AU0427 - ..
AU0428 - Consent form was signed and initialed during the meeting today
AU0429 - authorizing UCSF to share patient health care data on biopsy tissue
AU0430 - with clinical study personnel. This supplements consent documents
AU0431 - signed on 070119 authorizing UCSF to share blood, test, and other
AU0432 - data. ref SDS B7 1G3K
AU0434 - ..
AU0435 - Biopsy can provide more definitive diagnosis of new rash sites and
AU0436 - erratic changes in rash intensity, reported in case study today, also,
AU0437 - per above. ref SDS 0 5N6L
AU0439 - ..
AU0440 - The doctor identified several locations where biopsy would cause
AU0441 - least discomfort.
AU0443 - [On 070131 doctor consults with surgeon and decides Millie's
AU0444 - treatment with Coumadin for pulmonary embolism presents elevated
AU0445 - risk of bleeding (hemoraging); decides not to do biopsies.
AU0446 - ref SDS C8 6E3J
AU0448 - ..
AU0449 - [On 070201 Jackie explains that biopsy diagnostics and pathology
AU0450 - are not reported to the doctor for patient diagnosis and
AU0451 - treatment; therefore, even though Millie has experienced minimal
AU0452 - bleeding while on Coumadin the past few months, there is no
AU0453 - benefit to balance risk to the patient for performing biopsies
AU0454 - that only support research. ref SDS C9 IH6H
CT Scan Test Ordered 070131 Baseline New Treatment Clinical Study Dr
B90401 - ..
B90402 - CT Test Baseline Clinical Trial PE Expedite Collaborate with Kaiser
B90404 - Follow up ref SDS B0 EY5O, ref SDS A3 EY5O.
B90406 - PET/CT test on 061227 received on 070102. ref SDS A9 XT4M
B90408 - ..
B90409 - Test history listed in the same record on 070102, shows no evidenece
B90410 - of regional nor distant metastasis. ref SDS A9 1Y8G
B90412 - ..
B90413 - On 070125 Jackie advised that UCSF wants another CT test because delay
B90414 - on referral authorization issues, delayed start of clinical trial
B90415 - beyond the protocol period for using the last test on 061227.
B90416 - ref SDS C1 Z24H
B90418 - ..
B90419 - Jackie reported today during the meeting that UCSF has requested
B90420 - Kaiser advance the CT test one day, from 070201 to 070131, i.e., from
B90421 - Thursday to Wednesday, as discussed earlier this morning, when Jackie
B90422 - called. ref SDS C4 JM4J Advancing the test enables Millie's treatment
B90423 - to start on 070201, rather than on Friday, 070202, so that Doctor Rugo
B90424 - can supervise Millie's first day of treatment. Apparently, Doctor
B90425 - Rugo will not be available on Friday, so advancing treatment is
B90426 - critical to avoid scheduling conflicts, and revises UCSF planning from
B90427 - yesterday. ref SDS C3 TD3O
B90429 - [On 070201 Doctor Rugo was consulted on issues to support start of
B90430 - treatment. ref SDS C9 7835
B90432 - ..
B90433 - Jackie seemed to indicate that discussion today with Arlette at Kaiser
B90434 - showed that the original order for the CT test prepared by a
B90435 - substitute doctor on 070126, while Millie's primary care physician was
B90436 - on vacation, ref SDS C2 G29I, did not include specified scope to
B90437 - evaluate pulmonary embolism and enlarged right ventricle, in order to
B90438 - help the doctor distinguish side effects of Cetuximab, which are
B90439 - similar to symptoms of pulmonary embolism, reported below. ref SDS 0
B90440 - MO7K
B90442 - ..
B90443 - Evidently, today the primary care physician was on site at Kaiser,
B90444 - back from vacation. Jackie relayed something along the lines that
B90445 - Millie can only get a "regular" CT test tomorrow at Kaiser's
B90446 - Pleasanton facility, because they do not have the equipment to perform
B90447 - CT tests that detect pulmonary embolism. Jackie said there are two
B90448 - time slots available for Millie to be tested in Pleasenton: OA 1030
B90449 - and OA 1130.
B90451 - ..
B90452 - Jackie further indicated that the primary care physician may be able
B90453 - to order the form of the CT test that evaluates pulmonary embolism, at
B90454 - Kaiser's Walnut Creek offices, but the earliest this can be done is on
B90455 - 070201. Under this scenario, treatment cannot start until the
B90456 - following day, and, as noted, this would prevent Doctor Rugo from
B90457 - supervising Millie's first treatment, due to a prior schedule
B90458 - commitment on 070202, as noted above. ref SDS 0 M882
B90460 - [On 070131 technician giving Millie CT test at Pleasenton seemed
B90461 - to indicate that testing for pulmonary embolism and enlarged right
B90462 - ventricle is supported. ref SDS C8 KM4F
B90464 - ..
B90465 - Jackie will ask Kaiser later today to consider performing the CT test
B90466 - at Walnut Creek tomorrow, rather than waiting until Thursday, so that
B90467 - the scope can include analysis of pulmonary embolism, and will also
B90468 - fit Doctor Rugo's schedule.
B90470 - ..
B90471 - If this cannot be accomplished, then Kaiser will be asked to give the
B90472 - CT test in Pleasanton tomorrow without scope to evalate pulmonary
B90473 - embolims and enlarged right ventricle. The primary goal at this time
B90474 - is to perform the CT test tomorrow so that Doctor Rugo can monitor
B90475 - Millie's first treatment on Thursday, rather than delay treatment to
B90476 - Friday, when the doctor will not be available to manage the work.
Emotional Trauma Increases Stress Pulse 87 Complex Medical Profile 3
BE0401 - ..
BE0402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
BE0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
BE0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
BE0406 - Follow up ref SDS B0 Y642, ref SDS A3 Y642.
BE0408 - Medical issues create an emotional roller coaster that increase
BE0409 - patient stress and trauma listed in the record on 070105. ref SDS B0
BE0410 - Y642
BE0412 - ..
BE0413 - Millie's vitals were very high today, e.g., pulse 87, ref SDS 0 KB5L,
BE0414 - where normally her resting heart beat is plus or minus 60, reported on
BE0415 - 061201. ref SDS 99 AW4L
BE0417 - ..
BE0418 - Millie related during the meeting being very concerned about how the
BE0419 - meeting today would go, and whether there would even be a meeting,
BE0420 - which caused her to leave town last Wednesday on 070124. ref SDS C0
BE0421 - KX9H
BE0423 - ..
BE0424 - Recent progress through collaboration between Kaiser and UCSF relieves
BE0425 - stress and anxiety, reported by Jackie this morning scheduling the
BE0426 - meeting with Doctor Rugo today, and expediting required testing so
BE0427 - that Doctor Rugo can supervise the work, per above. ref SDS 0 M85Q
BE0429 - ..
BE0430 - There was reassurance during the meeting that proposed treatment has a
BE0431 - good chance of stopping advance of disease, and possibly clearing the
BE0432 - rash currently spreading from the left chest area. There was further
BE0433 - reassurance that side effects that cause acne-like face rash will most
BE0434 - likely be controlled with medication.
BE0436 - ..
BE0437 - [On 070204 Kaiser and UCSF notified no initial side effects of 1st
BE0438 - treatment with cetuximab; energy has increased, Millie worked out
BE0439 - in the gym 2 days in a row, and for the first time in 6 months;
BE0440 - planning for CT test to evaluate pulmonary embolism. ref SDS D1
BE0441 - JJ7O
Strategy IBC 3rd Relapse Treatment Plan UCSF Clinical Study Drug Tri
Strategy CT Test Evaluate Aggressive Treatment IBC Cetuximab Clinica
BR0501 - ..
BR0502 - Patient History Presented for Profile Work Up Planning and Strategy
BR0503 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
BR0504 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
BR0506 - Follow up ref SDS B0 K36G, ref SDS A3 K36G.
BR0508 - Background on requirements and obstacles to planning and proactive
BR0509 - management in time for action to be effective is reported on 060825.
BR0510 - ref SDS 86 K36G
BR0512 - ..
BR0513 - Review of treatment history is listed on 061208. ref SDS A3 5Q5I
BR0515 - ..
BR0516 - There was no discussion today on the role of the Tumor Board process
BR0517 - to support strategy and planning, considered on 061208. ref SDS A3
BR0518 - P69G
BR0520 - ..
BR0521 - Doctor Rugo's assistant, Doctor So-Rosillo, developed a summary of
BR0522 - patient history from reviewing the record, aided by Millie's primary
BR0523 - care physician at Kaiser submitting a summary of the case to UCSF on
BR0524 - 061228. ref SDS A6 NP8G
BR0526 - ..
BR0527 - Jackie advised that Doctor Benz 2nd opinions were examined for
BR0528 - comprehensive understanding of Millie's condition, reported on 041117,
BR0529 - ref SDS 37 OS7P, and for the more recent consultation at UCSF on
BR0530 - 060821, which was received from Kaiser on 060929. ref SDS 90 WP4V
BR0532 - ..
BR0533 - Millie was again questioned on details of medical care over the past 5
BR0534 - years, begining on 020208, and which are listed chronologically in the
BR0535 - record on 050812. ref SDS 54 6L4M This took about 40 minutes today,
BR0536 - following the practice at UCSF on 060821, ref SDS 85 TQ4X, and earlier
BR0537 - on 041018. ref SDS 34 EN63
BR0539 - ..
BR0540 - The assistant then briefed the doctor for about 20 minutes. During
BR0541 - this briefing in another room, Jackie provided more information about
BR0542 - working with the Clinical Research Department under Doctor Rugo's
BR0543 - leadership.
BR0546 - ..
BR0547 - Referral Authorization Resolution
BR0549 - After Doctor So-Rosillo's briefing, Doctor Rugo came into the
BR0550 - examination room and introduced herself. The doctor initially noted
BR0551 - emotional relief to finally work on medicine, rather than shuffle
BR0552 - paperwork for complex communications coordinating referral that has
BR0553 - dominated efforts the past few months, beginning on 061208,
BR0554 - ref SDS A3 WR6G, reported on 070101, ref SDS A8 YP8O, and complicated
BR0555 - on 070123. ref SDS B9 0001
BR0557 - [On 070906 Millie's letter to UCSF reports not having been
BR0558 - notified about coinsurance charges. ref SDS F3 KC8S
BR0562 - ..
BR0563 - Examination Initial Patient Work Up Starting Cetuximab Treatments
BR0565 - The doctor made a thorough examination to complement initial work up
BR0566 - on patient history per above. ref SDS 0 LC49 Doctor So-Rosolli,
BR0567 - assisting today, took notes to capture the record of examination,
BR0568 - following the practice at Stanford Medical Center, reported on 041019.
BR0569 - ref SDS 35 5W6H
BR0571 - ..
BR0572 - During this time, Jackie briefly examined patient history on the
BR0573 - computer, previously reviewed by Margaret Rubino on 060809.
BR0574 - ref SDS 82 I73H There was discussion of difficulty transforming from
BR0575 - traditional printed documents, to computer records that support
BR0576 - precision access, noted by Margaret on 060821, ref SDS 85 TQ5F, when
BR0577 - the 2nd opinion consultation repeated past practices relying on
BR0578 - printed documents.
BR0580 - ..
BR0581 - Jackie commented on difficulty preparing for the meeting today from
BR0582 - wading through several folders of papers UCSF has on file for Millie's
BR0583 - case. This aligns with experience at UCSF on 060821 during
BR0584 - consultation with Doctor Benz. ref SDS 85 TQ7I
BR0586 - ..
BR0587 - Case studies on 40 issues from Millie's care are listed on 061018.
BR0588 - ref SDS 93 0001
BR0590 - ..
BR0591 - Patient history (chronology) from inception on 020208 to 051020 prior
BR0592 - to mastectomy surgery is listed in a case study on 050812. ref SDS 54
BR0593 - 6L4M
BR0595 - ..
BR0596 - Patient history after mastectomy on 051021 to the present is listed on
BR0597 - 060722. ref SDS 79 6L4M
BR0599 - ..
BR0600 - The doctor explained that patients who get both drugs are on a 4 week
BR0601 - cycle. Cetuximab is given every week continuously without breaks.
BR0602 - Carboplatin is given for 3 weeks, and then there is a week off until
BR0603 - the next cycle starts again on the 4th week, as set out in the consent
BR0604 - documents reviewed on 070116. ref SDS B3 5U7S
BR0606 - ..
BR0607 - Strategy is to continue treatment with a particular drug until disease
BR0608 - progresses, then change to another protocol. If Millie is randomized
BR0609 - to get only cetuximab in the drug trial program, then if, at some
BR0610 - point, disease gets worse and spreads, the doctor will add carboplatin
BR0611 - to increase strength and effectiveness of treatment, discussed further
BR0612 - below. ref SDS 0 NI6K
BR0614 - [On 070201 Millie was randomized to get only Cetuximab.
BR0615 - ref SDS C9 XR3M
BR0617 - ..
BR0618 - [On 070301 IBC spreads, ref SDS E0 LB5L; doctor considered
BR0619 - changing treatment by adding carboplatin, but decision is
BR0620 - complicated by falling ANC blood counts below the level that
BR0621 - allows treatment without increasing risk of contracting other
BR0622 - lethal diseases from prolonged exposure with weakened immune
BR0623 - system. ref SDS E0 V95M
BR0626 - ..
BR0627 - Patients can remain in the program indefinitely until there is
BR0628 - evidence of disease progression, as previously noted from the Consent
BR0629 - document reviewed on 070116. ref SDS B3 5U7S
Strategy Treatment Plan Surgery Remove Pockets of Resistance to Chem
BW0401 - ..
BW0402 - Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
BW0404 - Follow up ref SDS B0 ZZ5F, ref SDS A3 ZZ5F.
BW0406 - Surgery to treat "pockets of resistance" to chemotherapy was discussed
BW0407 - briefly on 061208, ref SDS A3 ZZ5F, citing prior considerations
BW0408 - reported on 040416. ref SDS 38 657F
BW0410 - ..
BW0411 - Surgery to remove infected tissue and rebuild the breast for better
BW0412 - response to chemotherapy in the event of relapse was postponed by the
BW0413 - Surgery Department on 051007, and then considered again to treat
BW0414 - relapse on 060711. ref SDS 76 X54L
BW0416 - ..
BW0417 - Doctor Rugo seemed to support Millie's primary care physician at
BW0418 - Kaiser indicating today that breast reconstruction is not a good
BW0419 - course for Millie's condition of IBC.
Treatment IBC 8th Cycle 3rd Relapse 1st Cycle 1st Treatment Chemothe
C00401 - ..
C00402 - Treatment 1st Cycle Cetuximab Carboplatin 070201 8th Cycle 3rd Relapse
C00403 - 8th Cycle Treatment 3rd Relapse 1st Cycle Cetuximab Carboplatin
C00404 - Drug Trial Clinical Study Protocol Side Effects Randomized Cetuximab
C00405 - Cetuximab Carboplatin Randomize Patient Can Still Get Carboplatin
C00407 - Follow up ref SDS B0 PF3O, ref SDS A3 PF3O.
C00409 - UCSF will submit Millie's case to randomize treatment for both
C00410 - cetuximab and carboplatin, or only cetuximab.
C00412 - [On 070201 Millie randomized for treatment with only cetuximab;
C00413 - provides additional treatment with carboplatin, if needed.
C00414 - ref SDS C9 XR3M
C00416 - ..
C00417 - Since at this time, diagnostics in image test history indicates
C00418 - evidence of only local disease, discussed above, ref SDS 0 EY5O, and
C00419 - since clinical examination today seems to find moderate, though
C00420 - expanding IBC, ref SDS 0 M68J, Millie might be better to get initial
C00421 - treatment with cetuximab, and if that is effective, then additional
C00422 - treatment with the study protocol would not be needed, and could be
C00423 - available later if disease progresses.
C00425 - [On 070202 primary care physician at Kaiser indicated starting
C00426 - treatment with cetuximab gives Millie another treatment option
C00427 - in the event that disease progresses. ref SDS D0 QO6O
C00429 - ..
C00430 - [On 070419 IBC subsiding; Millie fortunate responding to
C00431 - treatment with cetuximab alone, clinical study changes protocol
C00432 - eliminating this option because not enough patients getting
C00433 - favorable response with cetuximab alone. ref SDS E7 Q665
C00435 - ..
C00436 - As noted, UCSF wants Millie to get treatment on Thursday, 070201, so
C00437 - that Doctor Rugo can monitor the work for the first cycle. This
C00438 - requires getting CT testing done on Wednesday, 070131, a day before
C00439 - treatment begins. Jackie is coordinating with Arlette to get Kaiser's
C00440 - support, per above. ref SDS 0 M85Q Blood work previously performed on
C00441 - 070123 seems to be adquate for Millie to get treatment, per above.
C00442 - ref SDS 0 MP4H
C00444 - ..
C00445 - Doctor Rugo confirmed understandings from the study consent documents
C00446 - reviewed on 070116 that, if initial treatment is only with cetuximab,
C00447 - and Millie does not respond well, UCSF can switch to try both
C00448 - cetuximab and carboplatin together for a stronger treatment regimen.
C00449 - ref SDS B3 NL7I This flexibility in the study protocol fits the
C00450 - doctor's strategy for Millie's treatment plan discussed above.
C00451 - ref SDS 0 N13L
C00453 - ..
C00454 - [On 070201 Millie randomized to cetuximab. ref SDS C9 XR3M
C00456 - ..
C00457 - [On 070202 primary care physician notices new rash on upper left
C00458 - arm, which is a symptom of cellulitis, ref SDS D0 JP6F but may
C00459 - progression of IBC. ref SDS D0 JP6L
C00461 - ..
C00462 - [On 070222 examination at UCSF indicates new rash likely
C00463 - progression of IBC. ref SDS D8 B64F
C00465 - ..
C00466 - [On 070301 IBC progression to left arm, evident rise CA 15-3
C00467 - cancer marker presents prognosis of failed response to
C00468 - treatment, requiring increasing prescription from cetuximab
C00469 - alone to add carboplatin. ref SDS E0 OL5M
C00471 - ..
C00472 - [On 070524 CA 15-3 37 cancer marker rises 30% signals
C00473 - effectiveness of treatment with cetuximab alone may be
C00474 - ending; since IBC continues to subside, and CT tests
C00475 - shown no progression of disease, decided to continue
C00476 - with cetuximab alone now. ref SDS E8 357I
Side Effects Cetuximab Similar Symptoms Pulmonary Embolism Fatigue W
C20401 - ..
C20402 - Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
C20404 - Follow up ref SDS B4 QM7I, ref SDS B3 7Y4H.
C20406 - Side effects of fatigue, weakness cause loss of fitness with shortness
C20407 - of breath disclosed in the clinical study consent form, ref DRP 1
C20408 - HW54, reviewed on 070116, ref SDS B3 RT7K, are similar to symptoms of
C20409 - pulmonary embolism, discussed below, ref SDS 0 MO7K, and to symptoms
C20410 - of heart disorder Cor Pulmonale also described as enlarged right
C20411 - ventricle, is also discussed below. ref SDS 0 L56L
C20413 - ..
C20414 - Millie asked if rash and inflammation side effects of cetuximab,
C20415 - listed in UCSF letter ton 070116, ref SDS B3 MH4Q, can be mistaken for
C20416 - Cellulitis, or otherwise conceal progression of IBC by mistaking the
C20417 - rash for side effects of cetuximab? This issue was presented in
C20418 - Millie's letter to UCSF on 070117, ref SDS B4 HT3Q, asking for comment
C20419 - on questions in the record on 070116 reviewing cetuximab side effects,
C20420 - ref SDS B3 MH4Q, including skin reacations in relation to IBC...
C20422 - Will Cetuximab rash side effects compound IBC rash?
C20424 - ..
C20425 - How will Cetuximab side effects be distinguished from IBC?
C20427 - ..
C20428 - The doctor explained today that cetuximab acne-like rash side effects
C20429 - only occur to the face, and that other skin reactions to cetuximab
C20430 - have not previously been mistaken for IBC rash nor otherwise caused
C20431 - conflicting diagnosis.
C20433 - [On 070330 rising severity of rash and inflammation on
C20434 - the upper left arm the day after treatment with cetuxiab
C20435 - at UCSF, ref SDS E6 T87G, was diagnosed as recurrent
C20436 - Cellulitis, ref SDS E6 7C5F, and later was discovered to
C20437 - be a side effect of cetuximab. ref SDS E6 N75M
C20439 - ..
C20440 - Doctor Rugo said that UCSF will prescribe medication as part of the
C20441 - clinical study protocol to treat side effects, as the need arises. In
C20442 - some case, this is minimal. She seemed to indicate that patients
C20443 - react differently to treatments of cetuximab side effects. In some
C20444 - cases several treatments may be needed to fully suppress acne-like
C20445 - side effects. This generally aligns with Jackie's report on 070117.
C20446 - ref SDS B4 QM7I
C20448 - ..
C20449 - This aligns with Jackie's comments when she called on 070117.
C20450 - ref SDS B4 QM7I
C20452 - ..
C20453 - [On 070201 Brigid advised during follow up examination to
C20454 - start treatment at UCSF that medication to control
C20455 - acne-like side effects is provided a week after the 1st
C20456 - treatment, and if shown by examination to be required.
C20457 - ref SDS C9 FO66
C20459 - ..
C20460 - [On 070208 Millie requested treatment for the rash on her
C20461 - face that is a side effect of cetuximab chemotherapy;
C20462 - this was deferred for 2 weeks to the start of the next
C20463 - cycle on 070301. ref SDS D2 FO66
C20465 - ..
C20466 - Consent documents reviewed on 070116 say in part...
C20468 - Approximately 100 patients from around the country are
C20469 - expected to participate in the study, including
C20470 - approximately 20 subjects from UCSF. ref SDS B3 1H3O
C20472 - ...which seems fairly limited experience for evaluating effectivenss,
C20473 - and side effects.
Strategy Other Treatments After Cetuximab Carboplatin Clinical Study
CI0401 - ..
CI0402 - Strategy Other Treatments After Cetuximab Carboplatin Clinical Study
CI0403 - Other Treatments after Cetuximab Carboplatin Clinical Study
CI0404 - Treatments Millie Qualifies for Other UCSF Clinical Trial Studies
CI0405 - UCSF Other Treatments Clinical Study Drug Trials May Help Millie
CI0407 - Follow up ref SDS B0 P256.
CI0409 - Doctor Rugo explained strategy to extend patient quality of life by
CI0410 - switching to other drugs and medications, when cancer progresses.
CI0412 - ..
CI0413 - This aligns with planning on 070105 at Kaiser. ref SDS B0 P256
CI0415 - ..
CI0416 - At that time on 070105, Kaiser could not find new treatments for
CI0417 - Millie's triple negative status. Millie requested Kaiser perform due
CI0418 - diligence review of UCSF clinical study proposals. ref SDS B0 1R5J
CI0419 - Kaiser then prescribed the cetuximab Carboplatin clinical study as the
CI0420 - best course of treatment for Millie, because triple negative status is
CI0421 - a qualifying asset. ref SDS B0 PK7L
CI0423 - ..
CI0424 - Progression of disease monitored by examination and testing...
CI0426 - 1. Examination taking measurements and photographs of IBC
CI0427 - inflammation areas.
CI0429 - 2. Cancer marker CA 15-3 blood testing every 4 weeks to start
CI0430 - a new cycle.
CI0432 - ..
CI0433 - 3. CT scan tests every 8 weeks.
CI0435 - ..
CI0436 - Doctor Rugo further advised during discussion today on strategy and
CI0437 - planning that, in the event cancer progresses during treatment with
CI0438 - cetuximab and Carboplatin, Millie qualifies for treatment with other
CI0439 - chemotherapy drugs in clinical study at UCSF, noted by Doctor Benz in
CI0440 - a letter dated 060821, and reviewed at Kaiser on 060929. ref SDS 90
CI0441 - UI9K This was discussed again at Kaiser on 061208, ref SDS A3 P256,
CI0442 - leading to referral to UCSF on 061230. ref SDS A7 PN5X
CI0444 - ..
CI0445 - One example is Avastin with abraxane, also cited in the doctor's
CI0446 - letter to Kaiser on 061230. ref SDS A7 PO3Q
CI0448 - [On 080712 Millie asks about other treatments after labs at
CI0449 - Kaiser report CA 15-3 142, ref SDS F9 K15P, even though test
CI0450 - sample may have been hemolyzed, ref SDS F8 05YW, and this
CI0451 - affects results, reported on 080708. ref SDS F8 L74K
CI0453 - ..
CI0454 - The doctor seemed to indicate today that Millie's pulmonary embolism
CI0455 - in 2004, may not have been caused by Avastin (bevacizumab), but rather
CI0456 - was more related to family genetics. There was further discussion
CI0457 - that the Avastin abraxane treatment could be designed to arrest growth
CI0458 - of disease in Millie's case without increased risks of blood clots and
CI0459 - heart damage. This analysis relates to comments at Kaiser on 041104.
CI0460 - ref SDS 36 RZ4I
CI0462 - ..
CI0463 - Correlations between starting treatment with Avastin on 040420, and
CI0464 - Millie's symptoms of pulmonary embolism starting on 040517, and
CI0465 - continuing until treatment was ended with Avastin, reported on 041230,
CI0466 - shown in case study on 060722, ref SDS 78 6G6O, and was further
CI0467 - supported by CT test on 041218 that reported no visualization of
CI0468 - pulmonary embolism, as reviewed on 041230. ref SDS 39 PW3K
CI0470 - ..
CI0471 - Doctor Rugo discussed strategy to use CT tests for monitoring Millie's
CI0472 - risk for pulmonary embolism lung disease, which is compounded by Cor
CI0473 - Pulmonale (enlarged right ventricle) heart disease. Both are also
CI0474 - possible side effects of cetuximab treatments, presenting a "wicked
CI0475 - problem," disucssed further below. ref SDS 0 MO7K
Schedule Treatment Cetuximab 070201 Start Clinical Study Drug Trial
CL0401 - ..
CL0402 - Schedule Treatment Start Cetuximab Carboplatin 070201
CL0403 - Cetuximab UCSF Clinical Study Treatment Begins 070201
CL0404 - UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
CL0406 - Follow up ref SDS B0 N96O, ref SDS A3 N96O.
CL0408 - The doctor proposed starting treatment as soon as possible in order to
CL0409 - recover from severe progression of IBC since Millie's last treatment
CL0410 - at Kaiser 2 months ago on 061201. Progression of disease increased
CL0411 - the past 4 weeks because treatment was delayed waiting for referral
CL0412 - coordination with Kaiser, reported by case study in another record
CL0413 - today. ref SDS C5 RM4G
CL0415 - ..
CL0416 - Millie cannot get treatment today, because delay performing referral
CL0417 - coordination with Kaiser makes test diagnostics required for standard
CL0418 - of care and the clinical trial, and previously performed to start
CL0419 - treatment on 070119, ref SDS B7 AS96, are now outdated. As a result,
CL0420 - Millie needs new tests before getting treatment.
CL0422 - ..
CL0423 - The doctor schedule the first treatment for 070201.
CL0425 - ..
CL0426 - UCSF will coordinate with Kaiser to perform CT testing so that Millie
CL0427 - can start treatment on 070201, which will enable Doctor Rugo to
CL0428 - supervise the work, per above. ref SDS 0 PF3O
CL0430 - ..
CL0431 - Meetings and treatments will continue on Thursdays, so the next
CL0432 - meeting at Kaiser will be on 070208.
CL0434 - [On 070201 initial order for treatment with cetuximab is for 8
CL0435 - weeks. ref SDS C9 5564
Pulmonary Emboli Blood Clots Lungs Enlarged Right Ventricle Heart Di
CR0401 - ..
CR0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
CR0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
CR0404 - Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
CR0406 - Follow up ref SDS B0 CV5L, ref SDS A3 CV5L.
CR0408 - Background on pulmonary embolism recurrence is reported in the record
CR0409 - for the meeting on 061020. ref SDS 94 CV5L The record was updated on
CR0410 - 061201 showing symptoms of chronic fatigue, cough, shortness of
CR0411 - breath, clearing of throat, which continue under a Coumadin regimen.
CR0412 - ref SDS A0 CV5L Treatment with Procrit for anemia was ended when
CR0413 - hemoglobin blood count increased to the normal range, yet symptoms of
CR0414 - pulmonary embolism continued. ref SDS A0 2P9F
CR0416 - ..
CR0417 - A factor driving further inquiry is failure of pulmonary embolism to
CR0418 - recover after months of treatment beginning on 061002, which contrasts
CR0419 - sharply with prior experience in 2004. Previously, Millie recovered
CR0420 - former energy and relief from symptoms within a few months after
CR0421 - starting treatment on 041104, as reported on 041230. ref SDS 39 RZ4I
CR0423 - ..
CR0424 - At that time, a follow up CT test on 041217 reported findings reviewed
CR0425 - on 041230, that stated in part...
CR0427 - Previous noted right pulmonary arterial emboli are no
CR0428 - longer visiualized. ref SDS 39 PW3K
CR0430 - ..
CR0431 - Since Millie relapsed after this finding, reported on 061012,
CR0432 - ref SDS 92 294Q, and since relapse carries a high risk of death for
CR0433 - pulmonary embolism, reported on 060722, ref SDS 78 BI5J, increased
CR0434 - scrutiny is required to manage elevated risk of further pulmonary
CR0435 - embolism.
CR0437 - ..
CR0438 - The doctor plans vigorous testing to monitor Millie's reaction from
CR0439 - treatment with cetuximab and carboplatin in the clinical study that
CR0440 - could complicate and compound preconditions of pulmonary embolisma and
CR0441 - Cor Pulmonale (enlarged right ventricle).
CR0443 - ..
CR0444 - Doctor Rugo advised today that fatigue, shortness of breath, and
CR0445 - weakness that occur from Millie's preconditions of pulmonary embolism
CR0446 - and heart disorders, can be compounded by treatment with cetuximab, as
CR0447 - listed in Consent documents for the clinical study received from UCSF
CR0448 - on 070116. ref SDS B3 I75I, The Consent documents also cite
CR0449 - interstitial lung disease (ILD) that results in inflammation, scarring
CR0450 - and hardening of the lungs. Interstitial lung disease has been
CR0451 - reported in fewer than 1% of patients treated with cetuximab.
CR0452 - Patients are directed to notify the doctor immediately if shortness of
CR0453 - breath occurs while receiving cetuximab. ref SDS B3 0256
CR0455 - ..
CR0456 - This presents a "wicked problem" distinguishing between expected side
CR0457 - effects of cancer treatment, which are not lethal and eventually
CR0458 - dissipate after treatment ends, reported on 030606, ref SDS 18 RY5J,
CR0459 - from rising symptoms of pulmonary embolism which can turn lethal
CR0460 - quickly, previously reviewed on 060722. ref SDS 78 346F
CR0462 - ..
CR0463 - Today, the doctor carefully reviewed patient history to distinguish
CR0464 - symptoms of lung disease, pulmonary embolism, and heart disease,
CR0465 - enlarged right ventricle, discussed below, ref SDS 0 VJ4J, from side
CR0466 - effects of treatment with cetuximab that could complicate and compound
CR0467 - Millie's preconditions.
CR0469 - ..
CR0470 - Case study on 060722 shows patient history of pulmonary embolism
CR0471 - symptoms. ref SDS 78 ZV41
CR0473 - ..
CR0474 - Millie began having shortness of breath, fatigue and weakness in late
CR0475 - August associated with normal exertion walking up stairs at home, at
CR0476 - BART, and walking to her office at 2 Embacadero Center in San
CR0477 - Francisco. On 060914 she fell at the BART station. ref SDS 87 ZQ5I
CR0478 - At that time, attention focused on her swelled left hand and arm,
CR0479 - which eventually cascaded into cellulitus that landed Millie in the
CR0480 - hospital for a week beginning on 061027. ref SDS 96 V77F During the
CR0481 - meeting on 060929, the doctor ordered a CT test for pulmonary embolism
CR0482 - to investigate rising symptoms. ref SDS 89 B56N The test was
CR0483 - expedited and performed the next day on 060930. Two days later, on
CR0484 - 061002 the doctor reported findings of pulmonary embolism recurrence.
CR0485 - ref SDS 91 MI5I The doctor ordered treatments resumed, which were
CR0486 - previously ended on 051007. ref SDS 60 XN7K Test report reviewed on
CR0487 - 061012 showed new findings of enlarged right ventricle, discussed
CR0488 - below. ref SDS 0 VJ4J
CR0490 - ..
CR0491 - Side effects of cetuximab that make patients tired and weak, can be
CR0492 - distinguished from symptoms of pulmonary embolism by applying the
CR0493 - practice in 2004 using CT tests to determine if conditions reported on
CR0494 - 060930 have improved, stabalized, or worsened. If conditions are
CR0495 - worse or stable relative to conditions on 060930, this points to
CR0496 - symptoms of continuing pulmonary embolism. If comparison shows
CR0497 - pulmonary conditions have improved or are no longer present, as
CR0498 - occurred previusly in 2004, per above, ref SDS 0 GX60, then low
CR0499 - energy, tiredness, and weakness can be reasonably attributed to side
CR0500 - effects of cetuximab treatments.
CR0502 - ..
CR0503 - Since the most recent image test on 061227 was a combination PET/CT
CR0504 - test, which does not support analysis of pulmonary embolism, Kaiser
CR0505 - was unable to make comparison with the test on 060930 with respect to
CR0506 - pulmonary embolism, as shown in record on 070102 that reviewed the
CR0507 - recent report. ref SDS A9 AK9H
CR0509 - ..
CR0510 - The doctor asked Millie how she is feeling today?
CR0512 - ..
CR0513 - Millie's letter to Kaiser on 061227 reported continuing symptoms of
CR0514 - pulmonary embolism: tired, weak, heavy chest, shortness of breath with
CR0515 - routine effort. ref SDS A5 B987
CR0517 - ..
CR0518 - Millie reported today that energy and strength seem improved over the
CR0519 - past few weeks. She is starting to feel like getting back in the gym
CR0520 - to resume regular exercise, as discussed with the primary care
CR0521 - physician at Kaiser on 061208. ref SDS A3 HZ39
CR0523 - ..
CR0524 - The doctor indicated that feeling higher energy and strength aligns
CR0525 - with ending Taxotere and capecitabine chemotherapy treatments 2 months
CR0526 - ago on 061201, ref SDS 99 407N, particularly in light of reports on
CR0527 - 050516 that treatment with Taxotere and capecitabine (Xeloda) was
CR0528 - extremely debilitating. ref SDS 49 AQ6G This suggests conditions of
CR0529 - fatigue, weakness, heavy chest, and shortness of breath were mostly
CR0530 - attributed to accumulating side effects of chemotherapy, discussed by
CR0531 - the primary care physician on 030606. ref SDS 18 O44J
CR0533 - ..
CR0534 - Case study on 060722 shows Millie's patient history requires a special
CR0535 - form of test using thin slice spiral CT technology to discover
CR0536 - pulmonary embolism and enlarged right ventricle.
CR0538 - ..
CR0539 - UCSF will ask Kaiser to perform CT tests to evaluate progression of
CR0540 - lung and heart disorders by comparing with past findings, as specified
CR0541 - by the primary care physician at Kaiser on 061208, ref SDS B0 Q93H,
CR0542 - and to follow prior practice at Kaiser reported on 041230 developing
CR0543 - test results with affirmative findings that former signs of pulmonary
CR0544 - embolism are "no longer visible" in the CT test scan files, per above.
CR0545 - ref SDS 0 RS9O
CR0547 - ..
CR0548 - Jackie will coordinate with Kaiser on ordering the correct test, per
CR0549 - above. ref SDS 0 M84R
CR0551 - [On 070131 technician warns about internal bleeding from needle
CR0552 - penetration for blood draws; need plan to minimize using needles,
CR0553 - use Millie's port to reduce risk of bleeding while on Coumadin
CR0554 - (warfarin) for pulmonary embolism. ref SDS C8 E87I
CR0556 - ..
CR0557 - [On 070131 doctor consults with surgeon and decides Millie's
CR0558 - treatment with Coumadin for pulmonary embolism presents elevated
CR0559 - risk of bleeding (hemoraging); decides not to do biopsies.
CR0560 - ref SDS C8 6E3J
CR0562 - ..
CR0563 - [On 070202 meeting with primary care physician at Kaiser disclosed
CR0564 - that CT test for pulmonary embolism was not peformed on 070131;
CR0565 - the doctor indicated this should be corrected for reasons
CR0566 - discussed with Doctor Rugo at UCSF today on 070130, ref SDS 0
CR0567 - 915J, and requested a months notice from UCSF to order the next CT
CR0568 - test required by the cetuximab protocol so that the correct order
CR0569 - can be placed to test for pulmonary embolism and enlarged right
CR0570 - ventricle. ref SDS D0 M15I
CR0572 - ..
CR0573 - [On 070204 UCSF notified no initial side effects of treatment,
CR0574 - energy has increased, Millie worked out in the gym 2 days in a
CR0575 - row, and for the first time in 6 months; planning for CT test to
CR0576 - evaluate pulmonary embolism. ref SDS D1 JJ7O
CR0578 - ..
CR0579 - [On 070218 Millie experienced further increase in energy, playing
CR0580 - tennis for several days, and for the first time in 5 years.
CR0581 - ref SDS D7 N05H
Examination Stethoscope No Findings Enlarged Right Ventricle Heart S
CY0401 - ..
CY0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
CY0404 - Follow up ref SDS B0 Q35O, ref SDS A3 Q35O.
CY0406 - The doctor examined Millie with a stethoscope today. This included
CY0407 - multiple locations on her back and on the chest. There were no
CY0408 - findings of cardio pulmonary issues from clinical examination.
CY0410 - ..
CY0411 - UCSF did not comment today on SaO2 99% diagnostic for oxygenated
CY0412 - blood, which as been cited at Kasier to indicate there is no alarm of
CY0413 - danger, shown by the report on 061208, ref SDS B0 1E5G, that Millie is
CY0414 - not suffering from loss of cardio-pulmonary functioning due to
CY0415 - pulmonary embolism, including enlarged left ventricle.
Enlarged Right Ventricle Heart Disorder Cor Pulmonale Examples Sympt
D40401 - ..
D40402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
D40403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
D40404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
D40406 - Follow up ref SDS B0 VJ4J, ref SDS A3 VJ4J.
D40408 - Background is reported on 061110, ref SDS 97 VJ4J Severity of
D40409 - enlarged right ventricle was discussed on 061020. ref SDS 94 VJ4J
D40410 - During the meeting at Kaiser on 061208, Millie requested examination
D40411 - by a heart specialist. The primary care physician indicated
D40412 - diagnostics are not severe enough yet for referral to cardiologist.
D40413 - ref SDS A3 HZ39, citing vitals Sa O2 99% test diagnostic, ref SDS A3
D40414 - KB5L, and examination with a stethoscope, ref SDS A3 Q35O, indicates
D40415 - strong cardio pulmonary functioning, rather than diminished capacity
D40416 - that signals severe impact of enlarged right ventricle. ref SDS A3
D40417 - VV4H
D40419 - ..
D40420 - At that time, on 061208 the doctor modified the order for the PET scan
D40421 - test specifying that the analyst compare prior tests on 041103, and on
D40422 - 060930, with the new test scheduled on 061227 to report severity of
D40423 - enlarged right ventricle. ref SDS A3 Y77J
D40425 - ..
D40426 - On 061218 Millie again requested examination by heart specialist for
D40427 - clearance to resume exercise in the gym and restore fitness.
D40428 - ref SDS A4 HX6V The primary care physician at Kaiser responded that
D40429 - heart disorder of enlarged right ventricle diagnosed in the CT test on
D40430 - 060929, and reviewed on 061012, ref SDS 92 7E5L, most likely is not
D40431 - clinically relevant because symptoms Cor Pulmonale take years to
D40432 - become life threatening. ref SDS A4 XQ5H On 061227 Millie requested
D40433 - examination by a heart specialist to backup up first impression that
D40434 - Cor Pulmonale requires no treatment beyond Coumadin at this time.
D40435 - Millie reported continuing symptoms chronic fatigue, shortness of
D40436 - breath, and heavy chest. ref SDS A5 645I
D40438 - ..
D40439 - On 070102 review of the report for the CT test on 061227 showed that
D40440 - Kaiser did not perform the doctor's order on 061208 to compare with
D40441 - prior tests and provide trend analysis on pulmonary embolism and
D40442 - enlarged right ventricle. ref SDS A9 AK9H
D40444 - ..
D40445 - During the follow up meeting at Kaiser on 070105, the primary care
D40446 - physician advised that Millie's cardio pulmonary system may be so
D40447 - severely damaged that former active life of regular exercise cannot be
D40448 - restored.
D40450 - [On 070204 Kaiser and UCSF notified no initial side effects of 1st
D40451 - treatment with cetuximab; energy has increased, Millie worked out
D40452 - in the gym 2 days in a row, and for the first time in 6 months;
D40453 - planning for CT test to evaluate pulmonary embolism. ref SDS D1
D40454 - JJ7O
D40456 - ..
D40457 - Today, the doctor asked for examples of symptoms.
D40459 - ..
D40460 - Patient history on 061110 presents symptoms, ref SDS 97 VD4G, which
D40461 - are similar to pulmonary embolism, discussed above that are further
D40462 - similar to side effects of treatment with cetuximab, per above.
D40463 - ref SDS 0 MO7K
D40465 - ..
D40466 - As noted, Millie's energy seems to be edging up in the past few weeks,
D40467 - which reflect ending chemotherapy on 061201, and therefore indicates
D40468 - possible recovery from enlarge right ventricle, also, noted above.
D40469 - ref SDS 0 RT6I
D40471 - ..
D40472 - Besides doing a follow up CT test, discussed above, ref SDS 0 R16N,
D40473 - the doctor seemed to suggest today examination by a cardiologist and
D40474 - perhaps a treadmill test may be helpful to better understand this
D40475 - issue.
D40477 - [On 070202 meeting with primary care physician, there was no
D40478 - report of coordination from UCSF on this issue. ref SDS D0 UN9F
D40480 - ..
D40481 - [On 070204 Kaiser and UCSF notified no initial side effects of 1st
D40482 - treatment with cetuximab; energy has increased, Millie worked out
D40483 - in the gym 2 days in a row, and for the first time in 6 months;
D40484 - planning for CT test to evaluate pulmonary embolism. ref SDS D1
D40485 - JJ7O
D40487 - ..
D40488 - [On 070218 Millie experienced further increase in energy, playing
D40489 - tennis for several days, and for the first time in 5 years.
D40490 - ref SDS D7 N05H