THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: March 1, 2007 01:30 PM Thursday;
Millie meeting at UCSF begin 2nd cycle cetuximab treatment for IBC.
2...Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
3...Complex Patient History Knowledge Management Dilemma Issues Grow 40
4...Vitals Show Stable Medical Condition
5...Coordination Plan Divided Responsibilities Kaiser UCSF Referral
6...Collaboration Primary Care at Kaiser with UCSF Clinical Study Cetuximab
7...Communications Big Risk Feedback Accuracy Stressful Cognitive Overhead
8...Follow Up Feedback Resisted Avoid Stress Communications Biggest Risk
9...Vigilence Diligence Accuracy Continual Refining Emotionally Traumatic
10...Continual Improvement Continual Refinement of Accuracy Very Stressful
11...CA 15-3 Cancer Marker 36 Showing Significant Improvement
12...CA 15-3 36 Cancer Marker Strong Response to Treatment Cetuximab
13...Digestion Problems Increasing Relatively Infrequent Mild
14...Esophagitis Not Compared in Current PET Test with Prior Report
15...Left Arm Lymphedema Elevated Swelling No Lymphadenopathy
16...Axillary Left Arm No Lymphadenopathy Lymphedema Prominent
17...Lymphadenopathy Axillary Left Arm No Evidence Local Edema
18...Lymphedema Left Arm Remains Elevated Swelling No Cellulitis
19...IBC Expands Left Arm Responding to Treatment
20...Right Axillary Possible Involvement Red Rash Spreads Right Breast
21...Right Breast Red Rash Spreads Possible Involvement Right Axillary
22...Red Rash Right Breast Spreads Possible Involvement Right Axillary
23...IBC Right Arm New Minimal Red Rash Not Diagnosed IBC Today
24...Left Supraclavicular Examination PET Test Report Finding SUV 4.5
25...Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
26...Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
27...2 Scenarios Conflict IBC Expanding Intensity Subsides
28...IBC Rash Left Breast Stomach and Back Seems to Be Subsiding
29...Examination IBC Rash Subsiding Respoinding to Treatment Cetuximab
30...Cetuximab Effective Treatment IBC Subsiding Left Breast Stomach Back
31...Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
32...Local IBC Infection No Record Distant Metastasis Improves Chances
33...Prognosis Favorable No Lymphadenopathy 2006 No Distant Metastasis 5 Years
34...ANC 1.23 Blood Counts Drop Below Safe Level for Treatment with Cetuximab
35...Wicked Problem Expanding Disease Requires Increasing Treatment
36...Increasing Treatment Reduces Immune System Preventing Treatment
37...Weekly Carboplatin Chemotherapy Increase Difficulty Low Blood Counts
38...Neutropenia Chronic Low Blood Counts Prevents Chemotherapy
39...ANC Calculate Absolute Neutrophils
40...Severity Neutropenia Greatest with ANC Below 500 Mild Below 1000
41...Patient History Latent Effects Prior Chemotherapy Not Neutropenia
42...Cetuximab Treatment Approved Recover from Cancer Evaluate Blood Counts
43...Measurable Disease IBC Spreads from Left to Right Breast
44...Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
45...Measurable Disease IBC Observed with Tape Measure Photograph Pictures
46...CA 15-3 Diagnostic Measurable Disease IBC Not Meaured by Image Testing
47...Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
48...Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
49...Clinical Study Benefits from Biopsy of IBC Targeted Tissue
50...Biopsy Determine Biology of IBC and Guide Choice of Treatment
51...Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
52...CT Test Baseline Clinical Trial PE Expedite Collaborate with Kaiser
53...Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
54...Exercise Vigor Strength Engagement Ease Distress Living with Cancer
55...Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
56...Planning Case Management from Patient Profile Work Up
57...Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
58...Strategy Cetuximab Continued with Low ANC Expanding IBC Disease
59...Treatment 1st Cycle Cetuximab Carboplatin 070201 9th Cycle 3rd Relapse
60...9th Cycle Treatment IBC 3rd Relapse 2nd Cycle Cetuximab Clinical Study
61...Cetuximab 2nd Cycle 1st Treatment IBC 3rd Relapse Clinical Study Drug Trial
62...Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
63...Energy Strength Rising Minimal Side Effects Cetuximab Treatment
64...Facial Skin Dryness New Side Effect Cetuximab Curel Loation Prescribed
65...Curel Lotion Prescribed Facial Skin Dryness New Side Effect Cetuximab
66...Cetuximab UCSF Clinical Study Treatment Begins 070201
67...UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
68...Drug Trials UCSF Has Other Clinical Study Treatments May Help Millie
69...Schedule Treatment Start Cetuximab Carboplatin 070201
70...Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
71...Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
72...Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
73...INR 2.5 Blood Test Patient Stable for Coumadin Treatments Pulmonary Emboli
74...Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
75...Cor Pulmonale Heart Disorder Enlarged Right Ventricle
76...Heart Examination Not Ordered Investigate Enlarged Right Ventricle
77...Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
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Meeting Doctor Examination 12th Review Start Treatment #12 After Mas
1103 - ..
1104 - Summary/Objective
110501 - Follow up ref SDS L7 0000. ref SDS K1 0000.
110503 - Faced with conflicting evidence, the doctor made a difficult, decision
110504 - for treatment to continue unchanged. ref SDS 0 T85J It was later
110505 - validated by diagnostics which had been generated for decision
110506 - support, but could not be obtained today. ref SDS 0 GJ5M A week
110507 - later, on 070307 Millie's CA 15-3 cancer marker dropped to 36, the
110508 - lowest in over a year, ref SDS 0 087J, suggesting dramatic improvement
110509 - with cetuximab treatment. Over the past month during the 1st cycle of
110510 - treatment with cetuximab on the clinical study, IBC has seemed to
110511 - expand, raising concern today of failed treatment and peril.
110512 - Examination today confirmed expanding disease. ref SDS 0 4140 The
110513 - doctor and her team were, also, impressed by possible declining
110514 - intensity of IBC rash, indicating response to treatment. ref SDS 0
110515 - M68J Doctor Rugo considered changing the treatment protocol to
110516 - increase effectiveness by adding carboplatin, allowed within the study
110517 - protocol. ref SDS 0 AE3I Without CA 15-3 diagnostics, there was
110518 - uncertainty about measurable disease, ref SDS 0 M652, i.e., whether
110519 - expansion of disease was already underway before starting treatment on
110520 - 070201, and whether treament has brought improvement or worsening IBC.
110521 - ref SDS 0 NY7N Another problem was unexpected drop of ANC blood
110522 - counts below the level of safety for treatment. ref SDS 0 T85J These
110523 - conflicts were resolved today by approving treatment for one week, and
110524 - the doctor scheduling another meeting next week to further evaluate
110525 - ANC and CA 15-3. ref SDS 0 Q57O The doctor wants also another CT test
110526 - to evaluate progress starting the next cycle on 070329. ref SDS 0 UR9J
110527 - Millie has tolerated side effects of treatment well. Energy has been
110528 - elevated during this period compared to the past 6 months. However,
110529 - last week, after the 4th treatment with cetuximab, Millie has been
110530 - tired, possibly aligning with declining ANC blood counts. ref SDS 0
110531 - TQ6L Facial dryness is a new side effect. UCSF prescribed Curel
110532 - lotion. ref SDS 0 5V73 UCSF referral has developed patient care
110533 - coordination issues. ref SDS 0 RM4G Since the meeting was behind
110534 - schedule today, there was not enough time to review coordination
110535 - planning. ref SDS 0 O65N UCSF asked the patient to coordinate with
110536 - Kaiser. ref SDS 0 O67N
110538 - ..
110539 - [On 070306 UCSF called to schedule interim meeting with Doctor
110540 - Rugo on 070308 1000 to assess changing treatments based on ANC and
110541 - CA 15-3 blood test results. ref SDS N7 7Y5N
110543 - ..
110544 - [On 070306 Millie requested results of CA 15-3 tests on 070208 and
110545 - 070215 to support follow up meeting at UCSF on 070208. ref SDS N7
110546 - PY6N
110548 - ..
110549 - [On 070307 UCSF reports CA 15-3 36 for test today on 070301, which
110550 - is lowest level in 12 months, ref SDS N8 U85L; Kaiser submitted CA
110551 - 15-3 results for tests in February, showing consistent trend down
110552 - that align with impression from visual examination that intensity
110553 - of IBC rash is subsiding. ref SDS N8 IE5O
110555 - ..
110556 - [On 070308 since CA 15-3 36 indicates cetuxinab treatment is
110557 - effective, and since blood test showed ANC increased to the normal
110558 - range for cetuximab treatment, the doctor cancelled the meeting to
110559 - evaluate changing treatment. ref SDS N9 407N
110561 - ..
110562 - [On 070315 progress report submitted to primary care physician at
110563 - Kaiser on recovering from IBC 3rd relapse with treatment that
110564 - started 070201 under a clinical study for cetuximab at UCSF.
110565 - ref SDS O2 VP5N
110571 - ..
1108 - Progress
110901 - Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
110903 - Follow up ref SDS M2 SM6M, ref SDS L7 SM6M.
110905 - ..
110906 - Doctor Rugo met with Millie today at UCSF starting the 2nd cycle and
110907 - 5th treatment of IBC with cetuximab, as planned in the launch meeting
110908 - on 070130. ref SDS L7 WM7G This is a referral from Kaiser for a
110909 - clinical study drug trial ordered by the primary care physician on
110910 - 070105. ref SDS K1 PK68 It is the 12th physician meeting to start the
110911 - 9th chemotherapy cycle, since treatments began on 060711, ref SDS D6
110912 - SM6M, for the 3rd relapse of IBC. ref SDS D6 8Y8I This is the 2nd
110913 - meeting with Doctor Rugo, and follows meeting with the primary care
110914 - physician at Kaiser on 070202. ref SDS M2 0001 UCSF had a hectic
110915 - schedule today. The meeting scheduled for 1330 started at 1415; the
110916 - doctor reviewed findings at 1450, discussed strategy, and determined
110917 - treatment.
110919 - ..
110920 - Complete listing of treatments for 3rd relapse is reported in the
110921 - record of treatment following the meeting today. ref SDS N3 SG8I
110923 - ..
110924 - The agenda for the meeting at UCSF on 070130 provides a structure for
110925 - organizing results of the meeting.
110927 - 1. Coordination Plan.............................. ref SDS 0 RM4G
110928 - 2. CA 15-3 3 tests pending........................ ref SDS 0 GJ5M
110929 - 3. Breast exam IBC spreading...................... ref SDS 0 025H
110930 - 4. Measurable disease pictures tape measure....... ref SDS 0 M652
110931 - 5. Side effects facial dryness, rash, tired....... ref SDS 0 TQ6L
110932 - 6. CT test Jackie coordinating schedule........... ref SDS 0 EY5O
110933 - 7. Patient work up develop strategy............... ref SDS 0 K36G
110934 - 8. Treatment plan weekly clinical trial........... ref SDS 0 PF3O
110935 - 9. Pulmonary emboli severity right ventricle...... ref SDS 0 CV5L
110937 - ..
110938 - Scheduled next meeting for Thursday 070329. ref SDS 0 N96O
110940 - ..
110941 - The doctor was assisted by two aides...
110943 - 1. Brigid, Nurse Practitioner
110944 - 2. Jackie, Clinical Research Coordinator, coordinating
Complex Patient History 39 Issues Overwhelms Span of Attention Drive
150401 - ..
150402 - Complex Patient History Knowledge Management Dilemma Issues Grow 40
150404 - Follow up ref SDS L7 LU3J, ref SDS K1 LU3J.
150406 - Sampling of issues patient history diagnosis and treatment...
150408 - 1. CA 15-3 monitors advance of cancer response to treatment
150409 - 2. Lymphedema complicated by mastectomy surgery
150410 - 3. Broken finger from minor fall complicates lymphedema
150411 - 4. Esophagitis reflux digestion issues
150412 - 5. Immune system chemotherapy increases risk of infection
150413 - Chemotherapy increase risk of infection
150414 - 6. Cat bites increase risk of infection complicates lymphedema
150415 - 7. Pneumonia chemotherapy increases risk of infection
150416 - 8. Metastatic cancer increases risk pulmonary embolism
150417 - 9. Lymphadenopathy left axilla local regional metastasis
150418 - 10. Lymphadenopathy right axilla distant metastasis
150419 - 11. Lymphadenopathy left supraclavicular diagnose metastatic cancer
150420 - 12. Breast cancer secondary IBC 3rd relapse left breast
150421 - 13. Cancer mutates slow response chemotherapy treatment
150422 - 14. Mastectomy surgery impact on treatment IBC relapse
150423 - 15. Blood vessels removed mastectomy slow chemotherapy treatments
150424 - 16. Treatment options, strategy, planning, schedule
150425 - 17. Drug trials increase declining pool chemotherapy agents
150426 - 18. UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
150427 - 19. Pulmonary embolism blood clots in lungs
150428 - 20. INR weekly adjustments Coumadin treatment blood clots
150429 - 21. Enlarged right ventricle heart problem core pulmonale
150430 - 22. Dizziness symptom enlarged right ventricle cor pulmonale
150431 - 23. Fatigue shortness breath side effect chemotherapy loss fitness
150432 - 24. Fatigue shortness breath symptom pulmonary embolism
150433 - 25. Shortness breath fatigue dizzy symptoms pulmonary embolism
150434 - 26. Coagulapathy hypercoagulable state work up genetic risks
150435 - 27. Testing resolution of errors (see Benz 2nd opinion 060821)
150436 - 28. Testing distant metastatic disease
150437 - 29. Testing pulmonary emoblism and heart disease
150438 - 30. Communication hectic schedule not enough time to manage details
150439 - 31. Emotional stress and well being
150440 - 32. Cellulitis inflammation temperature 102.6 on chemotherapy
150441 - 33. Urinary tract bladder infection
150442 - 34. IBC rash spreads to right breast
150443 - 35. Right breast rash may be "ring" infection, not cancer
150444 - 36. Lung cancer seems to be diagnosed in the Medical Chart
150445 - 37. IBC rash spreads to stomach and toward back
150446 - 38. IBC rash spreads to left arm
150447 - 39. Facial dryness
150448 - 40. Right arm evidence light red rash, may be IBC spreading
Vitals Submitted by Doctor UCSF Blood Pressure Pulse High Demonstrat
170401 - ..
170402 - Vitals Show Stable Medical Condition
170404 - Follow up ref SDS L7 KB5L, ref SDS K1 KB5L.
170406 - ..
170407 - Bld Prssr Pulse Temp Weight SaO2
170408 - ..
170409 - * 070301 1330............ [see treatment record, ref SDS N3 AW4L]
170410 - * 070130 1300............ 140 83 87 98
170411 - 070105 1040............
170412 - 061208 1226............ 152 90 76 97.8 147 99%
170413 - 061201 1430............ 123 76 76 97.5
170414 - 061110................. 136 83 73 97.0 150 98%
170415 - 061020 1534............ 140 79 67 99.8 151 97
170416 - 060929 1452............ 141 78 66 98.3
170417 - 060908 1335............ 139 79 73 98.1
170418 - 060814 1610............ 139 80 59 98.2
170419 - * 060808.................
170420 - 060711................. 172 87 54 97.5 147
170421 - 060623................. 141 87 71 98.0 147 99%
170422 - 060428................. 129 73 80 99.4 149 99%
170423 - 060217................. 153 81 61 98.6 150 99%
170425 - ..
170426 - * For some reason, vitals not submitted.
170428 - ..
170429 - High blood pressure reflects pressure on patient about effectivenss of
170430 - new treatment and arrangements between UCSF and Kaiser for timely
170431 - care, discussed below. ref SDS L7 Y642
Coordination Plan Communication UCSF Kaiser Collaboration Hectic Sch
480401 - ..
480402 - Coordination Plan Divided Responsibilities Kaiser UCSF Referral
480403 - Collaboration Primary Care at Kaiser with UCSF Clinical Study Cetuximab
480405 - Follow up ref SDS L7 RM4G.
480407 - Treatment by UCSF is on referral from Kaiser creating divided
480408 - responsibilities, discussed by the primary care physician at Kaiser
480409 - and Doctor Rugo in correspondence on 061230. ref SDS J8 3X6K Case
480410 - study on 070130 reviews referral work during January that shows
480411 - requirements for coordination planning to strengthen care. ref SDS L7
480412 - 4T5N
480414 - ..
480415 - On 070201 Jackie, UCSF Clinical Research Coordinator, submitted a
480416 - telephone number for patients to call for emergencies, and questions
480417 - on the clinical study. ref SDS M1 407N The record on 070202 meeting
480418 - at Kaiser the next day with the primary care physician reviewed need
480419 - for written coordination plan between Kaiser and UCSF with respect to
480420 - medication prescriptions and emergencies. ref SDS M2 2O5H
480422 - ..
480423 - On 070216 Jackie submitted a letter confirming instructions for
480424 - patients to call UCSF for emergencies. ref SDS M8 AM4N On 070217
480425 - Millie requested clarification of emergency care procedures, and
480426 - presented advantages of emergency treatment at Kaiser in this case.
480427 - ref SDS M9 AM4N
480429 - ..
480430 - A letter to Kaiser on 070218 cites confusion coordinating Kaiser and
480431 - UCSF on medication prescriptions and emergencies. ref SDS M7 VW6U
480432 - Similarly, review of the blood test today, shows numerous differences
480433 - between Kaiser and UCSF that require coordination to avoid medical
480434 - mistakes. ref SDS N3 HI6O Examples are INR analysis for prescribing
480435 - Coumadin to treat pulmonary embolism, ref SDS N3 SE6N, and ANC
480436 - diagnostics for approving cancer treatment. ref SDS N3 P560
480438 - ..
480439 - On 070222 Jackie discussed coordination planning to manage Millie's
480440 - care with responsibilities divided between Kaiser and UCSF.
480441 - ref SDS N1 VK5N Preliminary scope for coordination planning is
480442 - presented on 070222. ref SDS N1 KL5G
480444 - ..
480445 - Millie's letter yesterday on 070228 requested submission of a draft
480446 - coordination plan for discussion during the meeting today. ref SDS N2
480447 - LQ6R An example of current coordination is Millie facilitating
480448 - coordination on getting CA 15-3 reports for blood tests on 070208 and
480449 - 070215, also, cited in the letter on 070228. ref SDS N2 ED5H
480451 - ..
480452 - Today, the meeting started about an hour late, ref SDS 0 SM6M, so
480453 - there wasn't enough time to review coordination issues, except that
480454 - Jackie reported there wasn't enough time to coordinate with Kaiser to
480455 - get CA 15-3 diagnostics for the meeting today, per below. ref SDS 0
480456 - MP58
480458 - ..
480459 - Brigid said that some coordination has to be performed by USCF staff.
480460 - Examples are scheduling treatments and ordering tests. UCSF will
480461 - schedule the follow up blood test that Doctor Rugo wants for next week
480462 - to check ANC again, because ANC 1.23 in the test today is too low for
480463 - treatment, reported below, ref SDS 0 VF5M, and if this continues, then
480464 - remedial measures will be required, explained under strategy, also
480465 - below. ref SDS 0 T85J Brigid said the patient cannot order a blood
480466 - test, because this requires professional training and standing to
480467 - specify the scope and authorize the work.
480469 - [On 070302 Millie confirmed understandings that UCSF ordered a
480470 - follow up blood test on 070308. ref SDS N4 EZ6P
480472 - ..
480473 - [On 070308 the blood test had not been ordered; the nurse
480474 - placed the order based on patient coordination relating
480475 - patient history showing requirement for follow up blood test
480476 - to evaluate ANC. ref SDS N9 JG4G
480478 - ..
480479 - [On 070315 chemotherapy treatment in the Infusion Clinic had
480480 - not been scheduled, ref SDS O3 1M6H; treatment delayed for
480481 - pharmacy to perpare drugs. ref SDS O3 4N5M
480483 - ..
480484 - Brigid advised that coordinating communications with referral care
480485 - providers takes a lot of time. UCSF practice relies on patients to
480486 - coordinate communications, diagnostics, planning, and analysis between
480487 - Kaiser and UCSF for comprehensive care. She related that many
480488 - patients hand carry documents between UCSF and the primary care
480489 - provider. Best practices for medical professionals to coordinate
480490 - complex patient history in this case, shown above, ref SDS 0 LU3J,
480491 - were not discussed today, due to limited time.
480493 - [...below, Jackie asks Millie to coordinate with Kaiser to get
480494 - results on CA 15-3 for blood tests on 070208 and 070215.
480495 - ref SDS 0 2E5G
480497 - ..
480498 - [On 070307 case study on level of effort to coordinate
480499 - communications getting CA 15-3 diagnostics for blood tests
480500 - previously performed on 070208 and 070215. ref SDS N8 Q65K
480502 - ..
480503 - [On 070315 UCSF follows up requesting feedback on emotional toll
480504 - coping with everything flowing from having cancer. ref SDS O3 OR5K
480506 - ..
480507 - Brigid said an example of UCSF saving time and effort involving
480508 - patients in the coordination process is requesting Kaiser to schedule
480509 - the next CT test, discussed below, ref SDS 0 EY5O, and then follow up
480510 - to get feedback verifying a test is actually scheduled, and if not,
480511 - sending reminders in order to meet UCSF requirements. Avoiding
480512 - stressful coordination by asking others to verify accuracy of
480513 - performance aligns with research on 931130, and showing Drucker notes
480514 - that complexity increases stress, frustration, and delay that drives
480515 - people to give up on communication. ref SDS 1 3851
480517 - [On 070307 case study on level of effort to coordinate
480518 - communications getting CT test ordered to meet requirements of the
480519 - clinical study. ref SDS N8 G56L
480521 - ..
480522 - [On 070309 Arlette advised that email for coordination of
480523 - work on Kaiser's referral to UCSF should go to the primary
480524 - care physician, which does not support efficient common
480525 - distribution, rather than through Arlette, ref SDS O0 VP73,
480526 - which provides both efficient distribution, and a backup
480527 - for reminding the doctor of critical action items,
480528 - illustrated on 070307. ref SDS N8 9Z9N
480530 - ..
480531 - [On 070510 Jackie coordinated with Kaiser to schedule the next CT
480532 - test, which Kaiser set for 070514. ref SDS O7 DT8I
480534 - ..
480535 - [On 070610 primary care physician advises channels of
480536 - communication now established with UCSF for referral case
480537 - management. ref SDS O8 GV9G
480540 - ..
480541 - Communications Big Risk Feedback Accuracy Stressful Cognitive Overhead
480542 - Follow Up Feedback Resisted Avoid Stress Communications Biggest Risk
480543 - Vigilence Diligence Accuracy Continual Refining Emotionally Traumatic
480544 - Continual Improvement Continual Refinement of Accuracy Very Stressful
480546 - Many factors increase tension in communication causing people to avoid
480547 - coordination. Errors are endemic from meaning drift, explained in
480548 - POIMS, ref OF 2 049O, and become ticking time bombs, cited in POIMS.
480549 - ref OF 2 8844 Accurate communication, like freedom, requires
480550 - continual vigilence. However, cognitive overhead for diligence
480551 - explained in NWO. ref OF 4 3077, is extremely stressful, causing
480552 - anger, frustration, accusation, and reprisals. Therefore,
480553 - coordination to close the loop on pending issues is avoided....
480555 - 1. Calling entails stream-of-conscious conversation, which
480556 - must be transcribed to construct an object that controls
480557 - long term action, e.g., tomorrow, next week, next month.
480558 - People are busy, so 99% of calls are never transcribed,
480559 - which reduces management to guess and gossip, hunch and
480560 - hope that people will accurately remember complex
480561 - correlations, implications, and nuance. However, personal
480562 - memory is constantly buffetted by calls, meetings, and
480563 - other tasks that puts situational awareness under great
480564 - stress. Andy Grove at Intel explains that mental maps are
480565 - awfully forgiving of ambiguity, reviewed on 980307.
480566 - ref SDS 4 3668 When ambiguity manifests error, people
480567 - suffer pain, get mad, and lash out, pointing fingers in
480568 - accusation and blame because they cannot point to an
480569 - accurate record.
480571 - [On 070329 poor communication, bumbling management
480572 - create worry, stress, and emotional trauma, ref SDS O6
480573 - II7H; compounds difficulty sleeping that reduces
480574 - recovery from cancer. ref SDS O6 MR99
480576 - ..
480577 - 2. Coordination brings accountability for results. People
480578 - fear and hate accountability, reviewed on 980405,
480579 - ref SDS 5 5065, especially for coordinating, since there is
480580 - no authority for performing the work, and there is high
480581 - visibility for bringing up unpleasant tasks which others
480582 - often seek to avoid.
480584 - ..
480585 - 3. Effective communication requires metrics using feedback
480586 - loops to authenticate and verify accuracy by checking
480587 - alignment with original sources, called out in ISO and
480588 - other management standards, reported on 950721. ref SDS 2
480589 - 1740 People are very concerned about accuracy involving
480590 - their personal interests, but get easily frustrated doing
480591 - follow up on feedback to verify accuracy for others.
480593 - ..
480594 - 4. People often hate feedback because verifying accuracy is a
480595 - risk management practice to prevent future mistakes by
480596 - managing a lot of very small details that seem like
480597 - unnecessary overkill, until someone gets killed. Sending
480598 - correspondence including email can seem intrusive to busy
480599 - people, who feel they do not have time to confirm
480600 - understandings either writing or reading correspondence,
480601 - because all of their time is consumed talking to people and
480602 - trying to find information on a computer. As a result,
480603 - very little of what is said between people and what is
480604 - entered into computers is ever verified, and much is
480605 - assumed because finding information on computers, in file
480606 - folders, and from memory is very hard. Without
480607 - verification of alignment meaning drift compounds over
480608 - time, which makes communication the biggest risk in
480609 - enterprise, as explained in POIMS. ref OF 2 049O
480611 - [On 070309 Arlette reports her schedule has changed, and
480612 - she can no longer support coordination as done
480613 - previously. ref SDS O0 VP4P
480615 - ..
480616 - 5. Anger and frustration is often vented during communications
480617 - even, when the immediate exhange involves no grounds for
480618 - controversy. Follow up to verify accuracy may occur in a
480619 - context of proximity with anger or simmering anger from
480620 - others, totally apart from the instant communication. An
480621 - immediate exchange is merely the "straw that breaks the
480622 - camel's back," causing someone to explode in anger and lash
480623 - out. People then refuse to cooperate, ignore, or actively
480624 - disrupt to avenge perceived afronts or other grievances
480625 - which do not actually exist.
480627 - ..
480628 - 6. Desire to avoid controversy results in avoiding feedback to
480629 - verify accuracy, which then causes errors, conflict and
480630 - calamity, as set out in NWO. ref OF 4 2670 But since
480631 - mistakes from failed communication occur downstream in the
480632 - future, and usually impact others, there is no experience
480633 - gained to encourage and support feedback. Since people are
480634 - consumed with fixing problems caused by other people at an
480635 - earlier time, there is no awareness they are creating new
480636 - problems for others to fix at a later time.
480638 - ..
480639 - 7. Coordinating often entails reminding people to take action,
480640 - either by direct discussion, or forwarding correspondence.
480641 - Reminding, however, is sometimes resisted and resented by
480642 - perception that others are interferring in the work, even
480643 - though coordinating and follow up are critical to getting
480644 - things done correctly and on time. Since reprisals and
480645 - recriminations create controversey, people resent and
480646 - ignore requests for coordination, until an emergency occurs
480647 - that cannot be avoided.
480649 - ..
480650 - 8. Coordination reminding people to take action at a future
480651 - time often fails because people cannot manage action items
480652 - for planning work hours, days, weeks, and months in the
480653 - future. Providing multiple notices risks reprisals for
480654 - harrassment, or reprisals for failing to follow up because
480655 - the coordinator cannot manage action items. Sometimes
480656 - reprisals occur merely from a "kill the messenger" syndrome
480657 - when people are asked to do difficult tasks, and simply
480658 - strike out at the closest target. When there is a lot
480659 - going on, remembering critical details becomes harder for
480660 - everyone due to limited span of attention, reviewed on
480661 - 990303. ref SDS 6 HE4N
480663 - ..
480664 - This makes coordination a high risk task that is avoided in order to
480665 - avoid emotional trauma of controversy.
480667 - [On 070329 poor communication, bumbling management
480668 - create worry, stress, and emotional trauma, ref SDS O6
480669 - II7H; compounds difficulty sleeping that reduces
480670 - recovery from cancer. ref SDS O6 MR99
480672 - ..
480673 - Another example of coordination avoided in this case was discussion
480674 - during the meeting that the report on the blood test today showing INR
480675 - 2.5, should be submitted to Gloria at the Kaiser Coagulation Control
480676 - Clinic in Martinez, CA, who manages Coumadin treatments for Millie's
480677 - pulmonary embolism. INR 2.5 indicates favorable and stable blood
480678 - conditions for several weeks in the middle of the normal range, and
480679 - therefore reduces requirements for near term INR testing and changing
480680 - treatment protocols. There wasn't enough time during the meeting to
480681 - verify this diagnostic on the computer, but everyone remembered seeing
480682 - 2.5 earlier in the day on their computer. Rather than UCSF submit the
480683 - record to Kaiser, there was discussion that the patient would call
480684 - Kaiser and verbally convey results of the blood test today, and that
480685 - Kaiser would rely on that form of communication to decide treatment
480686 - for pulmonary embolism.
480688 - ..
480689 - Subsequent review, indicates UCSF lists INR 2.5, as remembered in the
480690 - meeting; however, the normal range for INR is .9 to 1.2. Therefore,
480691 - 2.5 is more than double the specified norm, indicating immediate
480692 - adjustment is requird to Coumadin treatment for pulmonary embolism in
480693 - order to avoid hemorraging. ref SDS N3 SE6N
480695 - ..
480696 - This suggests that managing blood test results may be an important
480697 - part of a coordination plan for comprehensive care listed on 070222.
480698 - ref SDS N1 KL5G
480700 - [...below, coordination on INR blood tests requires complex
480701 - notices due to delays and differences in test reporting standards.
480702 - ref SDS 0 4K42
480704 - ..
480705 - [On 070305 Millie requested that Gloria coordinate directly
480706 - with UCSF on interpreting the UCSF blood test report for
480707 - prescribing Coumadin to treat pulmonary embolism, and
480708 - reminded that UCSF has ordered another blood test on
480709 - 070308, so that INR can be tested again if needed.
480710 - ref SDS N5 3A6S
480712 - ..
480713 - [On 070305 Brigid clarified interpreting "normal" range for INR
480714 - blood test results to manage Coumadin treatments for pulmonary
480715 - embolism, and did not include Kaiser in the distribution, perhaps
480716 - relying on UCSF policy for patients to coordinate communcations.
480717 - ref SDS N5 2C7K
480719 - ..
480720 - [On 070306 Millie requests feedback from Gloria to verify accuracy
480721 - of understandings that Kaiser is satisfied with UCSF blood test on
480722 - INR for prescribing Coumadin to treat pulmonary embolism, and
480723 - advises current regimen will continue until further notice.
480724 - ref SDS N6 FJ9K
480726 - ..
480727 - [On 070510 Jackie coordinated with Kaiser to schedule the
480728 - next CT test, which Kaiser set for 070514. ref SDS O7 DT8I
CA 15-3 36 Falls Dramatically Consistently through February Cancer M
590401 - ..
590402 - CA 15-3 Cancer Marker 36 Showing Significant Improvement
590404 - Follow up ref SDS L7 087J, ref SDS K1 087J.
590406 - Millie had a blood test at Kaiser on 070208 and another on 070215. A
590407 - week after the meeting today, on 070307 Kaiser advised in a letter
590408 - that these tests were 55 and 52. Also, on 070307 CA 15-3 dropped to
590409 - 36 for the blood test today,
590411 - ..
590412 - Test Date Date Received
590413 - 070301......... 36 H............. 070307, ref SDS N3 A16M
590414 - 070215......... 52 H............. 070307, ref SDS M6 ER5O
590415 - 070208......... 55 H............. 070307, ref SDS M6 ER5O
590416 - 070201.....cetuximab begins...... 070201, ref SDS M1 G68I
590417 - 070131......... 56 H............. 070202, ref SDS M2 087J
590418 - 070123......... 52 H............. 070202, ref SDS M2 087J
590419 - 070118......... 68 H............. 070123, ref SDS L1 GK5B
590420 - 070104......... 56 H............. 070110, ref SDS K3 087J
590421 - 061218......... 74 H............. 061227, ref SDS J6 6P9F
590422 - 061214......... 63 H............. 061227, ref SDS J6 6P9F
590423 - 061201....Pause treatments..... . 061201, ref SDS I9 GJ5M
590424 - 061130......... 67 H............. 061201, ref SDS I9 087J
590425 - 061116......... 66 H............. 061201, ref SDS I9 087J
590426 - 061110......... 56 H............. 061201, ref SDS I9 087J
590427 - 061109......... 61 H............. 061110, ref SDS I3 087J
590428 - 061026......... 57 H............. 061110, ref SDS I3 087J
590429 - 061019......... 56 H............. 061020, ref SDS H2 087J
590430 - 060928......... 51 H............. 060929, ref SDS G4 087J
590431 - 060907......... 68 H............. 060929, ref SDS G4 087J
590432 - 060813......... 73 H............. 060817, ref SDS F8 U24M
590433 - 060809......... 87 H............. 060810, ref SDS F6 2N5J
590434 - 060721..Taxotere capecitabine.... 060721, ref SDS E1 0001
590435 - 060708......... 71 H............. 060711, ref SDS D6 087J
590436 - 060616......... 63 H............. 060623, ref SDS D4 UQ5Q
590437 - 060522......... 59 H............. 060605, ref SDS C9 UQ5Q
590438 - 060501......... 49 H............. 060522, ref SDS C6 MC4F
590439 - 060421......... 44 H............. 060428, ref SDS B8 087J
590440 - 060330......... 40 H............. 060428, ref SDS B8 087J
590441 - 060303......... 36............... 060428, ref SDS B8 087J
590442 - 060210......... 33............... 060217, ref SDS A7 087J
590443 - 060109......... 34............... 060126, ref SDS A6 KV59
590444 - 051223......... 34............... 060106, ref SDS A5 087J
590445 - 051202......... 28............... 060106, ref SDS A5 087J
590446 - 051116......... 31............... 051121, ref SDS A3 087J
590447 - 051109......... 30............... 051121, ref SDS A3 087J
590448 - 051102......... 34............... 051121, ref SDS A3 087J
590449 - 051021..Mastectomy surgery....... 051021, ref SDS A0 0001
590450 - 050916...end treatment........... 050916, ref SDS 91 407N
590451 - 050909......... 45 H............. 051007, ref SDS 97 087J
590452 - 050826......... 45 H............. 050913, ref SDS 90 087J
590453 - 050819......... 45 H............. 050913, ref SDS 90 087J
590454 - 050812......... 39 .............. 050819, ref SDS 83 3K6L
590455 - 050729......... 45 H............. 050819, ref SDS 83 EA5G
590456 - 050708......... 46 H............. 050729, ref SDS 82 087J
590457 - 050701......... 37 .............. 050729, ref SDS 82 087J
590458 - 050617......... 45 H............. 050729, ref SDS 82 087J
590459 - 050527......... 56 H............. 050610, ref SDS 79 087J
590460 - 050512......... 67 H............. 050520, ref SDS 77 087J
590461 - 050506......... 80 H............. 050520, ref SDS 77 087J
590462 - ..
590463 - 050415.........105 H............. 050422, ref SDS 74 087J
590464 - 050415..Taxoter capecitabie begin 050415, ref SDS 73 407N
590465 - 050325.........100 H............. 050329, ref SDS 72 087J
590466 - 050318.........101 H............. 050325, ref SDS 71 2N5J
590467 - 050304......... 88 H............. 050311, ref SDS 69 087J
590468 - 050225......... 95 H............. 050308, ref SDS 68 0001
590469 - 050211......... 78 H............. 050214, ref SDS 67 02BB
590470 - 050128......... 67 H............. 050204, ref SDS 65 087J
590471 - 050104...AC start treatment...... 050104, ref SDS 64 407N
590472 - 041228......... 56 H............. 041230, ref SDS 63 087J
590473 - 041204......... 43 H............. 041210, ref SDS 62 087J
590474 - 041021...Taxol bevciz ends....... 041021, ref SDS 57 0001
590475 - 041007......... 39............... 041104, ref SDS 58 087J
590476 - 040923......... 49 H............. 041005, ref SDS 52 087J
590477 - 040908......... 44 H............. 040909, ref SDS 51 087J
590478 - 040825......... 47 H............. 040909, ref SDS 51 087J
590479 - 040811......... 42 H............. 040812, ref SDS 50 087J
590480 - 040728......... 43 H............. 040729, ref SDS 48 2N5J
590481 - 040712......... 47 H............. 040713, ref SDS 47 087J
590482 - 040614......... 55 H............. 040615, ref SDS 46 PX6X
590483 - 040517......... 78 H............. 040601, ref SDS 44 2N5J
590484 - 040420..Taxol becizam starts..... 040420, ref SDS 40 9Z5J
590485 - 040311......... 70 H............. 040318, ref SDS 35 SM6M
590486 - 040205......... 60 H............. 040211, ref SDS 33 SM6M
590487 - 031201......... 62 H............. 031205, ref SDS 32 SM6M
590488 - 030912......... 66 H............. 030915, ref SDS 31 SM6M
590489 - 030708......... 68 H............. 030710, ref SDS 30 SM6M
590490 - 030503......... 54 H............. 030508, ref SDS 28 SM6M
590491 - 030403......... 45 H............. 030508, ref SDS 28 SM6M
590492 - 030215......... 46 H............. 030220, ref SDS 27 5E6L
590493 - 030106......... 37 H............. 030109, ref SDS 26 SM6M
590494 - 021204..Adjuvant chemo ends...... 021204, ref SDS 25 SQ5I
590495 - 021202......... 41 H?............ 021204, ref SDS 25 SP5G
590496 - 021111......... 36 H?............ 021113, ref SDS 24 Y65I
590497 - 021023......... 33 H?............ 021023, ref SDS 23 SQ5I
590498 - 020930......... 33 H?..39........ 021002, ref SDS 22 SQ5I
590499 - 020917......... 36 H?............ 020924, ref SDS 21 SQ5I
590500 - 020717......... 59 H?............ 020726, ref SDS 20 YN5K
590501 - 020629......... 75 H ............ 020705, ref SDS 18 UX6I
590502 - 020608........ 67 H ............ 020614, ref SDS 16 0001
590503 - 020603........ 108 H ............ 020607, ref SDS 15 X67F
590504 - 020511........ 117 H ............ 020603, ref SDS 14 PJ4J
590505 - 020419......... 81 H ............ 020430, ref SDS 12 7N5H
590506 - 020321......... 85 H ............ 020405, ref SDS 11 6T8K
590512 - ..
5908 - Analysis
590901 - CA 15-3 36 Cancer Marker Strong Response to Treatment Cetuximab
590903 - Follow up ref SDS L7 GJ5M, ref SDS K1 GJ5M.
590905 - CA 15-3 for the blood test today was not available in time for the
590906 - meeting, as shown in another record reporting treatment at 1500 in the
590907 - Infusion Clinic. ref SDS N3 2N5J Subsequently in a call on 070307 to
590908 - the Infusion Clinic, UCSF reported CA 15-3 was 36 for the test on
590909 - 070301, as shown above. ref SDS 0 087J Dramatic improvement of the
590910 - cancer marker dropping to the lowest level in over a year, indicates
590911 - that, despite expanding cancer for several months while off treatment,
590912 - shown below, ref SDS 0 LB5L, Doctor Rugo's assessment of clinical
590913 - improvement with subsiding intensity of IBC rash was correct.
590914 - ref SDS 0 M68J
590916 - ..
590917 - [On 070307 Catherine reported CA 15-3 blood test on 070301
590918 - dropped dramatically to 36, the lowest level in over a year.
590919 - ref SDS N8 U85L
590921 - ..
590922 - [On 070328 research on 070328 indicates advances in cancer
590923 - biomarker technology for improving patient care, including
590924 - recognizing response to treatment. ref SDS O5 FN6I
590926 - ..
590927 - However, this was not known at the time of the meeting today, and so
590928 - Doctor faced elevated CA 15-3 56 and spreading disease, seeming to
590929 - indicate no response to treatment, per dilemma below. ref SDS 0 1T4O
590931 - [On 070308 meeting at UCSF cancelled because blood test on
590932 - 070301 reported CA 15-3 36 shows dramatic improvement, and ANC
590933 - blood counts increased to a safe level for treatment.
590934 - ref SDS N9 FO6H
590936 - ..
590937 - [On 071023 UCSF explains cancer marker applied to look more
590938 - carefully and does not signal consideration of treatment change
590939 - based on a cut off diagnostic of 80 (using Kaiser Lab
590940 - calibration methods). ref SDS O9 V63L
590942 - ..
590943 - A letter to UCSF yesterday on 070228 discussed coordinating with
590944 - Kaiser to obtain results on CA 15-3 for blood tests on 070208 and on
590945 - 070215, and in order to help assess response to treatment. ref SDS N2
590946 - ED5H Jackie indicated during the meeting today that a hectic schedule
590947 - did not have enough time for coordinating with Kaiser to get CA 15-3
590948 - diagnostics on measurable disease to complement phyisical examination
590949 - showing expanding disease, presented below. ref SDS 0 LB5L Work up on
590950 - a coordination plan, discussed above, ref SDS 0 HH7H, may improve
590951 - communication on CA 15-3 needed to assess strategy on changing
590952 - treatments, as discussed below. ref SDS 0 NY7N
590954 - [On 070302 Millie reported UCSF taking decisions on continuing
590955 - current treatment without CA 15-3 test results. ref SDS N4 EY5W
590957 - ..
590958 - [On 070306 Millie requested results of CA 15-3 tests on 070208
590959 - and 070215 to support follow up meeting at UCSF on 070208.
590960 - ref SDS N7 PY6N
590962 - ..
590963 - Today, during the meeting, Jackie advised that CA 15-3 was not ordered
590964 - because reasoning in the letter on 070228, ref SDS N2 LQ5X, conflicts
590965 - with UCSF policy to order CA 15-3 monthly. She explained that, since
590966 - 2 tests were performed by Kaiser during February, then, even though
590967 - there wasn't enough time to get results of the tests, noted above,
590968 - ref SDS 0 MP58, doing another CA 15-3 test today to start the new
590969 - treatment cycle appears conflicting with policy. Brigid seemed to
590970 - indicate that the context of patient history showing expanding disease
590971 - observed at UCSF on 070222, ref SDS N1 B64F, requires another CA 15-3
590972 - test that sets a baseline with UCSF laboratory standards, and so she
590973 - ordered CA 15-3 for the blood test this morning.
590975 - ..
590976 - Patient history in the record today shows CA 15-3 closely tracks
590977 - progresssion of disease, and so supports diagnosis and treatment.
590978 - ref SDS 0 087J For example, on 061201 the primary care physician at
590979 - Kaiser relied on CA 15-3 diagnostics to change treatments, which led
590980 - to current care arrangements for Millie at UCSF. ref SDS I9 GJ5M
590981 - Earlier, Doctor Benz relied on CA 15-3 patient history for 2nd opinion
590982 - review at UCSF on 060821, ref SDS F9 GJ5M, which was later relied on
590983 - by Kaiser to make a referral to UCSF.
Digestion Problems GERD Subside No Examination Nor Consideration PET
630401 - ..
630402 - Digestion Problems Increasing Relatively Infrequent Mild
630403 - Esophagitis Not Compared in Current PET Test with Prior Report
630405 - Follow up ref SDS L7 JP6K, ref SDS K1 JP6K.
630407 - Background is reported in the meeting on 061201. ref SDS I9 JP6K
630408 - During the meeting on 061208, the doctor requested comparison between
630409 - PET scan test scheduled for 061227, and prior PET test on 060120,
630410 - which was reviewed on 060126, ref SDS A6 DH4O, and CT test on 060505,
630411 - reviewed on 060523, ref SDS C6 4O8P, to clarify diagnosis and plan
630412 - treatment of esophagitis or other malady that may be causing increased
630413 - digestion problems. Kaiser's medical chart for the meeting on 061208
630414 - shows GERD worse. ref SDS J2 1248 The medical chart for the meeting
630415 - on 070105 makes no reference to GERD. ref SDS K1 1248
630417 - ..
630418 - There was no discussion of this issue today.
Left Axillary Lymphadenopathy Patient No Complaint of Swelling Disco
750401 - ..
750402 - Left Arm Lymphedema Elevated Swelling No Lymphadenopathy
750403 - Axillary Left Arm No Lymphadenopathy Lymphedema Prominent
750404 - Lymphadenopathy Axillary Left Arm No Evidence Local Edema
750405 - Lymphedema Left Arm Remains Elevated Swelling No Cellulitis
750407 - Follow up ref SDS L7 MW8J, ref SDS K1 MW8J.
750409 - Patient has a long history of IBC on the left breast and associated
750410 - lymphadenopathy symptoms in the left axillary, see case study on
750411 - 040517. ref SDS 43 OW3I
750413 - ..
750414 - Brigid examined the left axilla. Clinical palpation made no findings
750415 - of lumps or other indications of cancer, including swelled lymph nodes
750416 - that might indicate lymphadenopathy. The patient made no complaint of
750417 - lumps or discomfort from swelling under the left arm. A CT test on
750418 - 070131 shows no findings of lymphadenopathy, as reviewed at Kaiser on
750419 - 070202. ref SDS M2 013T
750421 - ..
750422 - Lymphedema in the left arm is reported in a case study on 070131.
750423 - ref SDS L7 VX6F
750425 - ..
750426 - The arm today has reduced swelling from lymphedema. Measurement below
750427 - the elbow is 10.75" stable since 070130, shown in case study on
750428 - 060509. ref SDS C3 HO7F Improvement to stable condition at near
750429 - normal measurement has occurred with increased activity and stress on
750430 - the arm from working out in the gym, reported on 070204, ref SDS M3
750431 - HF5H, and from playing tennis, reported on 070218. ref SDS N0 N05H On
750432 - 070222 Brigid verified that Millie plays tennis right handed, which
750433 - reduces stress on the left arm that could cause complications of
750434 - lymphedema.
750437 - ..
750438 - IBC Expands Left Arm Responding to Treatment
750440 - On 070202 a new rash on the upper left arm was observed by the primary
750441 - care physician during examination at Kaiser. ref SDS M2 6H6L On
750442 - 070214 Millie cited this new condition in a letter to Kaiser and UCSF.
750443 - Brigid concluded during examination at UCSF on 070222 that the rash
750444 - looks more like IBC than cellulitis. ref SDS N1 B64F
750446 - ..
750447 - There was a general impression today by Doctor Rugo, Brigid, and the
750448 - patient that the rash seems less intense today after 4 treatments with
750449 - cetuximab than when observed earlier, similar to improvement on the
750450 - left and right breast areas, discussed below. ref SDS 0 025H At the
750451 - time of examination today, dramatic improvement in CA 15-3 test
750452 - diagnostic was not known. Subsequent reports of testing this past
750453 - month, including today showing CA 15-3 has dropped to 36, ref SDS 0
750454 - GJ5M, seems to align with observing that IBC on the upper left arm is
750455 - subsiding.
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom
830401 - ..
830402 - Right Axillary Possible Involvement Red Rash Spreads Right Breast
830403 - Right Breast Red Rash Spreads Possible Involvement Right Axillary
830404 - Red Rash Right Breast Spreads Possible Involvement Right Axillary
830406 - Follow up ref SDS L7 3D6K, ref SDS K1 3D6K.
830408 - Background on patient history testing for lymphadenopathy in the right
830409 - axilla is reported in the record on 060929. ref SDS G4 3D6K
830411 - ..
830412 - Examination of the right axillary yielded same results from examining
830413 - the left axilla, per above. ref SDS 0 VU6O
830415 - ..
830416 - On 061204 IBC inflammation spread from the left chest area infected
830417 - with IBC across the sternum and slightly onto the right breast.
830418 - ref SDS J1 AE5I
830420 - ..
830421 - Examination of the right breast shows reduced intensity of IBC rash,
830422 - and there is no spreading of the rash, suggesting favorable response
830423 - to treatment. At the time of examination today, CA 15-3 was not
830424 - known. Subsequently, report of testing this past month, including
830425 - today showing CA 15-3 has dropped to 36, ref SDS 0 GJ5M, seems to
830426 - align with observing that IBC on the right breast is subsiding.
830429 - ..
830430 - IBC Right Arm New Minimal Red Rash Not Diagnosed IBC Today
830432 - New evidence today presented 5 - 10 barely visible light red dots
830433 - dispersed on the upper, inner right arm running generally along the
830434 - bicep. This is similar to initial appearance on the left breast area
830435 - reported on 060623, ref SDS D4 NE6G, which later increased and was
830436 - diagnosed as IBC on 060711. ref SDS D6 025H Dispersed red dots on the
830437 - upper, inner right arm seem somewhat similar to the rash on the
830438 - stomach, which Doctor Rugo noticed on 070130 and identified as
830439 - progression of IBC. ref SDS L7 M68J Similarly, slight rash on the
830440 - lower left arm reported in the morning of 061027, ref SDS H5 3N83, and
830441 - then increased into severe inflammation of the entire left arm by
830442 - 1728, ref SDS H5 WO6N, and was diagnosed as cellulitis OA 2020.
830443 - ref SDS H5 V65J Later on 070202 the primary care physician at Kaiser
830444 - noticed slight rash on the upper left arm. ref SDS M2 JP6F UCSF was
830445 - notified and on 070222 Brigid diagnosed IBC has spread to the left
830446 - arm. ref SDS N1 B643
830448 - ..
830449 - Initial assessment today is that slight rash or blemishes is not IBC,
830450 - as was diagnosed on the left arm on 070222, ref SDS N1 FO6H, and
830451 - examined again today, per above. ref SDS 0 527G Brigid seemed to
830452 - indicate there are several possibilities to explain the rash besides
830453 - expanding IBC.
830455 - ..
830456 - There is the possibility this is IBC and is responding to treatment,
830457 - as with IBC in other areas, per below. ref SDS 0 4140
830459 - [On 070315 examination still results in not diagnosing rash on the
830460 - right arm as IBC. ref SDS O3 FO6H
830462 - [On 070322 Millie asked Catherine in the Infusion Clinic to
830463 - look at the right arm, and at that time there was no
830464 - discernable pattern of rash. ref SDS O4 LI4M
Left Supraclavicular Neck Lymphadenopathy Patient No Complaint Swell
910401 - ..
910402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
910403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
910404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
910406 - Follow up ref SDS L7 8R6M, ref SDS K1 8R6M.
910408 - During examination on 070130, Doctor Rugo asked about history of
910409 - radiation to the neck, and sequence of finding recurrence from Doctor
910410 - Laio's biopsy reported on 040309. ref SDS 34 0001 Background of image
910411 - testing, and consideration for radiation treatment of left
910412 - supraclavicular is reported on 060623. ref SDS D4 8R6M
910414 - ..
910415 - Like the left and right axillary locations, examination today for
910416 - cancer in left supraclavicular region found no evidence of lumps or
910417 - other indications of lymphadenopathy, as reported above. ref SDS 0
910418 - VU6O
Examination IBC Rash Left Breast Spreads to Right Breast Stomach Bac
990401 - ..
990402 - 2 Scenarios Conflict IBC Expanding Intensity Subsides
990403 - IBC Rash Left Breast Stomach and Back Seems to Be Subsiding
990404 - Examination IBC Rash Subsiding Respoinding to Treatment Cetuximab
990405 - Cetuximab Effective Treatment IBC Subsiding Left Breast Stomach Back
990407 - Follow up ref SDS L7 025H, ref SDS K1 025H.
990409 - Since 060623, IBC has expanded from near the sternum, ref SDS D4 025H,
990410 - and during treatment with Taxotere and capecitabine started on 060721,
990411 - ref SDS E1 0001, and ending on 061201. ref SDS I9 GJ5M Case study on
990412 - 070130 shows erratic changes in severity/intensity of IBC rash which
990413 - led to referral to UCSF. ref SDS L7 5N6L
990415 - ..
990416 - Cetuximab treatment, started at UCSF on 070201, ref SDS M1 G68I, was
990417 - delayed 4 weeks, reported in case study on 070130, ref SDS L8 2W58,
990418 - which increased opportunity for stage IV cancer to spread.
990420 - ..
990421 - Examination today confirmed understandings on 070222 that IBC has
990422 - significantly expanded, most prominently to the left arm, ref SDS N1
990423 - B64F, creating concern about cancer cascading out of control with CA
990424 - 15-3 56 cancer marker seemingly unchanged and possibly increased,
990425 - while getting treatments so far, discussed again below, ref SDS 0
990426 - QN3F; yet, intensity of IBC rash seems to be subsiding...
990428 - right breast...................... 061204, ref SDS J1 AE5I
990429 - stomach........................... 070130, ref SDS L7 M68J
990430 - back.............................. 070130, ref SDS L7 M68J
990431 - left arm.......................... 070202, ref SDS M2 6Q5N
990432 - Right arm??....................... 070301, ref SDS 0 H15M
990434 - [On 070315 examination still results in not diagnosing rash
990435 - on the right arm as IBC. ref SDS O3 FO6H
990437 - ..
990438 - [On 070329 rash on right chest above port catheter and
990439 - above the right breast reported during treatment on 070315
990440 - was not observed during examination on 070329. ref SDS O6
990441 - 583G
990443 - ..
990444 - [On 070329 examination shows continued clinical
990445 - improvement; no new IBC sites, and subsiding intensity of
990446 - rash; aligns with continuing decline of CA 15-3 33 cancer
990447 - marker. ref SDS O6 M68J
990449 - ..
990450 - Expanding IBC rash indicates progression of disease. On 070130 the
990451 - plan for treating progression of cancer in this case is to increase
990452 - the level of treatment from cetuximab alone by adding carboplatin,
990453 - discussed further under strategy, shown below. ref SDS 0 1T4O
990455 - ..
990456 - Examination today shows intensity of IBC rash seems to be subsiding.
990457 - Doctor Rugo recalled today seeing rash on the left arm during
990458 - examination on 070130; and new rash on the right arm has not yet been
990459 - diagnosed IBC, per above. ref SDS 0 H15M As a result, there has been
990460 - no expansion of IBC with cetuximab treatment on the clinical study.
990461 - At the time of examination today, CA 15-3 was not known, see above.
990462 - ref SDS 0 MP58
990464 - [On 070307 new CA 15-3 36 test results seem to align with visual
990465 - examination showing disease expanding, likely before starting
990466 - treatment on 070201, and now with subsiding intensity. ref SDS N8
990467 - U85L
990469 - ..
990470 - [On 070307 CA 15-3 test results received from Kaiser for February
990471 - present consistent trend down, supporting inference of subsiding
990472 - IBC disease. ref SDS N8 IE5O
990474 - ..
990475 - Conflicting scenarios of expanding disease and declining intensity
990476 - observed by examination today, ref SDS 0 LB5L, was analysed by the
990477 - doctor in light of missing CA 15-3 test data to formulate treatment
990478 - strategy, discussed below. ref SDS 0 1T4O The doctor scheduled
990479 - another examination next week to validate the strategy, also, set out
990480 - below. ref SDS 0 NY7N
990482 - [On 070315 Millie submitted to primary care physician at
990483 - Kaiser progress report on recovering from IBC 3rd relapse
990484 - with treatment starting on 070201 clinical study cetuximab
990485 - at UCSF. ref SDS O2 VP5N
990488 - ..
990489 - Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
990491 - Follow up ref SDS L7 M645.
990493 - Subsequently, on 070307 report of testing this past month, including
990494 - today showing CA 15-3 has dropped to 36, ref SDS 0 GJ5M, seems to
990495 - align with observing IBC rash subsiding. Dramatic reduction of CA
990496 - 15-3 cancer marker after switching treatments and starting with
990497 - cetuximab on a clinical study fits prior patient history of improving
990498 - prospects by changing treatments, reported on 050520. ref SDS 77 025H
990499 - This aligns with understandings from meeting with Doctor Rugo on
990500 - 070130. ref SDS L7 M645.
990502 - [On 070307 Catherine reported CA 15-3 blood test on 070301
990503 - dropped dramatically to 36, the lowest level in over a year.
990504 - ref SDS N8 U85L
990506 - ..
990507 - [On 070328 research on 070328 indicates advances in cancer
990508 - biomarker technology for improving patient care, including
990509 - recognizing response to treatment. ref SDS O5 FN6I
990512 - ..
990513 - Local IBC Infection No Record Distant Metastasis Improves Chances
990514 - Prognosis Favorable No Lymphadenopathy 2006 No Distant Metastasis 5 Years
990516 - Follow up ref SDS L7 FF4H.
990518 - There is no evidence of distant metastasis in internal organs,
990519 - unchanged from meeting at Kaiser on 070202, when CT test on 070131 was
990520 - reviewed. ref SDS M2 013T
990522 - ..
990523 - IBC expanded during December and January, ref SDS 0 4140, presents a
990524 - grave concern, which seems now to be coming under control again.
ANC 1.23 Blood Counts Below Safe Level for Treatment Cetuximab Weekl
A80401 - ..
A80402 - ANC 1.23 Blood Counts Drop Below Safe Level for Treatment with Cetuximab
A80404 - During the meeting today, Brigid showed the report on the blood test
A80405 - earlier this morning. For convenience, the report is listed in the
A80406 - record on getting treatment today. ref SDS N3 075H
A80408 - ..
A80409 - Brigid explained ANC is presented in the UCSF blood test report as
A80410 - "NEUTS," and has dropped to 1.23, well below 1.8 listed as safe for
A80411 - chemotherapy. ref SDS N3 P560 ANC 1.23 corresponds to 1230 in
A80412 - Kaiser's scheme, and so is also below Kaiser's criteria of 1500 for
A80413 - permitting chemotherapy treatments. ref SDS N3 A27K
A80415 - ..
A80416 - Brigid further explained that, even though the UCSF laboratory report
A80417 - for blood tests lists 1.80 as the low value of the target range, UCSF
A80418 - uses 1.5 that Kaiser uses to evaluate safe chemotherapy treatments,
A80419 - since UCSF test reports for NEUTS are multiplied by 1000 to convrt to
A80420 - Kaiser units of measure...
A80422 - UCSF NEUTS 1.5 = 1500 ANC at Kaiser
A80424 - ..
A80425 - [On 070308 ANC increased to 1.51 within the normal range for
A80426 - cetuximab treatments. ref SDS N9 P560
A80429 - ..
A80430 - Wicked Problem Expanding Disease Requires Increasing Treatment
A80431 - Increasing Treatment Reduces Immune System Preventing Treatment
A80432 - Weekly Carboplatin Chemotherapy Increase Difficulty Low Blood Counts
A80434 - Falling ANC blood counts without getting chemotherapy indicate that
A80435 - weekly chemotherapy treatments with Carboplatin may not provide enough
A80436 - time for bone marrow to replenish blood that maintains the immune
A80437 - system. Prolonged weakened immune system increases risk of infection
A80438 - by other lethal diseases, reported on 030606. ref SDS 29 JP7G This
A80439 - was reviewed again a year later on 040614. ref SDS 45 6T7F
A80441 - ..
A80442 - Since IBC disease has expanded significantly, per above, ref SDS 0
A80443 - 4140, the obvious solution is to change treatment by adding
A80444 - Carboplatin, allowed by the clinical study protocol, reported on
A80445 - 070130. ref SDS L7 NI6K
A80447 - ..
A80448 - Doctor Rugo commented today that, since carboplatin chemotherapy
A80449 - reduces blood counts more than cetuximab, ANC blood counts falling
A80450 - below a safe level for treatment today with only cetuximab then
A80451 - maintaining ANC at a safe level for weekly treatments required by the
A80452 - study protocol will be even harder, if carboplatin is added to
A80453 - increase effectiveness of treatment. This presents a "wicked
A80454 - problem." Either expanding cancer will cascade out of control; or,
A80455 - increasing treatment to prevent cancer from expanding will weaken the
A80456 - immune system by lowering blood counts, which exposes the patient to
A80457 - worse diseases than cancer.
A80459 - [On 080313 Carboplatin added to Millie's treatment for rising
A80460 - symptoms of IBC. ref SDS P0 TZ8I
A80462 - ..
A80463 - [On 080403 blood counts falling from adding Carboplatin
A80464 - chemotherapy, so UCSF orders Neupogen treatments to restore
A80465 - strength of immune system so that Millie can continue getting
A80466 - treatments to recover from growing cancer. ref SDS P1 6Y9K
Neutropenia Research Emedicine Article 00809 Chronic Low Blood Coun
AG0401 - ..
AG0402 - Neutropenia Chronic Low Blood Counts Prevents Chemotherapy
AG0404 - Neutropenia that weakens the immune system occurs when the bone marrow
AG0405 - system cannot replace blood counts between treatments, per above,
AG0406 - ref SDS 0 D24M, explained in an article published by Emedicine on
AG0407 - 060809...
AG0409 - ..
AG0410 - http://www.emedicine.com/MED/topic1640.htm
AG0412 - ..
AG0413 - Effects of age, exercise, fitness, and chemotherapy on weakening the
AG0414 - immune system, which then prevents getting chemotherpy treatments to
AG0415 - recover from cancer was explained by the primary care physician at
AG0416 - Kaiser on 030606, including benefits of exercise that maintain fitness
AG0417 - which enables robust treatment. ref SDS 29 JP7G
AG0420 - ..
AG0421 - ANC Calculate Absolute Neutrophils
AG0423 - The author describes neutropenia...
AG0425 - Neutropenia is a decrease in circulating neutrophils in the
AG0426 - peripheral blood. The absolute neutrophil count (ANC) number
AG0427 - defines neutropenia. An abnormal ANC value contains fewer than
AG0428 - 1500 cells per mm3. African Americans may have a lower but
AG0429 - normal ANC value of 1000 cells per mm3 with a normal total WBC
AG0430 - count. The ANC is calculated by multiplying the percentage of
AG0431 - bands and neutrophils (segmented neutrophils or granulocytes)
AG0432 - on a CBC differential times the total white WBC count.
AG0433 - ref OF 7 TI7N
AG0435 - ..
AG0436 - Calculating ANC is shown in the record getting treatment at Kaiser on
AG0437 - 060810. ref SDS F6 GL4M This was clarified on 060814. ref SDS F7 C56L
AG0440 - ..
AG0441 - Severity Neutropenia Greatest with ANC Below 500 Mild Below 1000
AG0444 - Research neutropenia continues...
AG0446 - Severity of neutropenia is mild when the ANC is 1000-1500 cells
AG0447 - per mm3, moderate when the ANC is 500-1000 cells per mm3, and
AG0448 - severe when the ANC is less than 500 cells per mm3. The risk
AG0449 - of bacterial infection is related to both the severity and
AG0450 - duration of neutropenia. ref OF 7 1V9M
AG0452 - ..
AG0453 - Case study today seems to indicate Millie has suffered mild
AG0454 - neutropenia with ANC 1000 - 1500, shown in the record getting
AG0455 - treatment later today. ref SDS N3 AZ8H
AG0457 - ..
AG0458 - Case study on 060810 shows Millie has routinely been treated with
AG0459 - chemotherapy with ANC below 1500 because she has maintained a high
AG0460 - level of fitness. ref SDS F6 HV45
AG0462 - [On 081205 Millie's ANC 624 very low, required Neupogen
AG0463 - treatments on 081205 and 081206. ref SDS P3 CH40
AG0465 - ..
AG0466 - [On 081210 Kaiser indicated standards and practices of
AG0467 - giving Neupogen treatment when ANC falls below 1000.
AG0468 - ref SDS P4 H46J
AG0470 - ..
AG0471 - Research neutropenia continues...
AG0473 - Morbidity usually involves infections during severe, prolonged
AG0474 - episodes of neutropenia. Serious medical complications occur
AG0475 - in 21% of patients with cancer and neutropenic fever.
AG0476 - Mortality correlates with the duration and severity of
AG0477 - neutropenia and the time elapsed until the first dose of
AG0478 - antibiotics is administered for neutropenic fever. ref OF 7
AG0479 - 5M3A
AG0481 - ..
AG0482 - Neupogen
AG0484 - Do not use 12-24 h before or 24 h after administering
AG0485 - cytotoxic chemotherapy because will increase sensitivity of
AG0486 - rapidly dividing myeloid cells to cytotoxic chemotherapy;
AG0487 - obtain CBC before therapy and monitor twice weekly during
AG0488 - therapy to avoid excessive leukocytosis; rarely, cutaneous
AG0489 - vasculitis is reported with long-term use in severe chronic
AG0490 - neutropenia, ref OF 7 IF5K
AG0492 - [On 080821 Doctor Rugo recommends getting Neupogen
AG0493 - treatment at Kaiser 24 hours after chemotherapy at UCSF.
AG0494 - ref SDS P2 4B4L
Default Null Subject Account for Blank Record
AH0401 - ..
AH0402 - Patient History Latent Effects Prior Chemotherapy Not Neutropenia
AH0403 - Cetuximab Treatment Approved Recover from Cancer Evaluate Blood Counts
AH0405 - The doctor noted today that patient history shows ANC has been on a
AH0406 - long, steady decline since starting treatment with Taxotere and
AH0407 - capecitabine on 060721, listed in a case study for the record getting
AH0408 - treatment later today. ref SDS N3 AZ8H Therefore the current fall to
AH0409 - 1.23 could reflect latency effects of prior conventional chemotherapy
AH0410 - treatments, rather than caused by cetuximab. The doctor decided that
AH0411 - scheduled treatment for today with cetuximab should be performed, (see
AH0412 - strategy below, ref SDS 0 T85J), and that another blood test will be
AH0413 - done next week to see if ANC recovers, as expected, or declines
AH0414 - further, and so requires treatment to aid recovery necessary for
AH0415 - weekly treatments, as discussed further under strategy. ref SDS 0 1T4O
AH0417 - ..
AH0418 - Jackie will coordinate with the Infusion Clinic to perform another
AH0419 - blood test next week on 070308. Coordination is required, because on
AH0420 - 070201 blood tests were scheduled only once every 4 weeks under the
AH0421 - clinical study protocol for patients randomized to be treated with
AH0422 - only cetuximab. ref SDS M1 XR40
AH0424 - [On 070302 confirmed understandings for a blood test on 070308.
AH0425 - ref SDS N4 EZ6P
AH0427 - ..
AH0428 - [On 070308 for some reason the blood test was not ordered,
AH0429 - ref SDS N9 Q659; the Infusion Clinic performed a blood test on
AH0430 - notice by the patient, ref SDS N9 XA9I; ANC increased from 1.23 to
AH0431 - 1.51 that meets requirements for cetuximab treatments.
Measurable Disease IBC Spreads from Left to Right Breast Stomach Bac
AJ0401 - ..
AJ0402 - Measurable Disease IBC Spreads from Left to Right Breast
AJ0403 - Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
AJ0404 - Measurable Disease IBC Observed with Tape Measure Photograph Pictures
AJ0405 - CA 15-3 Diagnostic Measurable Disease IBC Not Meaured by Image Testing
AJ0407 - Follow up ref SDS L7 M652, ref SDS J9 4Q6K.
AJ0409 - Background on measurable disease for IBC using cancer biomarker CA
AJ0410 - 15-3 and photographic records showing spread of cancer is reported in
AJ0411 - a case study on 070101. ref SDS J9 4Q6K
AJ0413 - ..
AJ0414 - There wasn't enough time today to get CA 15-3 test results to evaluate
AJ0415 - progression of disease, per above. ref SDS 0 MP58 Subsequently, a
AJ0416 - week later on 070307, test results from Kaiser on previous tests, and
AJ0417 - UCSF results for the blood test today indicate substantial effect by
AJ0418 - cetuximab treatment, cited in the examination. ref SDS 0 M68J
AJ0420 - ..
AJ0421 - Jackie and Brigid took pictures again today for the clinical study
AJ0422 - protocol to show measurable disease of IBC expanding rash, following
AJ0423 - work on 070222, ref SDS N1 6T6M, and previously on 070201. ref SDS M1
AJ0424 - 6T6M
Lung Cancer No Discussion Metastatic Disease Lymph Nodes Doctor's Pr
AN0401 - ..
AN0402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
AN0403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
AN0405 - Follow up ref SDS L7 G25K, ref SDS K1 G25K.
AN0407 - Background is reported on 070130 in the record meeting with Doctor
AN0408 - Rugo at UCSF. ref SDS L7 G25K
AN0410 - ..
AN0411 - There was no discussion of this issue today, so that attention could
AN0412 - focus on assessing Millie's response to treatment for IBC.
Biopsy Left Right Breasts Start Clinical Study Treatment IBC Cetuxim
B10401 - ..
B10402 - Clinical Study Benefits from Biopsy of IBC Targeted Tissue
B10403 - Biopsy Determine Biology of IBC and Guide Choice of Treatment
B10404 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
B10406 - Follow up ref SDS L7 KT7J, ref SDS K1 KT7J.
B10408 - On 070131 Doctor Rugo consulted with a surgeon and discussed Millie's
B10409 - treatment with Coumadin for pulmonary embolism presents elevated risk
B10410 - of bleeding (hemoraging). As a result, the decision on 070130 to
B10411 - perform biopsies for the clinical study, ref SDS L7 M840, was changed
B10412 - on 070131, and so biopsies were not performed in this case.
B10413 - ref SDS M0 6E3J
B10415 - ..
B10416 - There was no discussion today of taking biopsies to verify diagnosis
B10417 - of rash on the left arm. ref SDS 0 527G The rash on the right arm
B10418 - was also not biopsied. ref SDS 0 H15M
CT Scan Test Ordered Before 070328 Start Cycle 3 Cetuximab Correct M
BF0401 - ..
BF0402 - CT Test Baseline Clinical Trial PE Expedite Collaborate with Kaiser
BF0404 - Follow up ref SDS L7 EY5O, ref SDS K1 EY5O.
BF0406 - PET/CT test on 070131 received on 070202. ref SDS M2 1Y8G Test
BF0407 - history listed in the same record on 070202, shows no evidenece of
BF0408 - regional nor distant metastasis. ref SDS M2 GB8J
BF0410 - ..
BF0411 - Jackie related that on 070202 the primary care physician at Kaiser
BF0412 - requested a 4-week notice on the next CT test so that the order for
BF0413 - the test can be written to include special requirements that test for
BF0414 - pulmonary embolism and enlarged right ventricle. ref SDS M2 T85K On
BF0415 - 070204 the patient sent a letter confirming understandings that Kaiser
BF0416 - requests a month notice on the date when the next CT test is needed
BF0417 - for the clinical study. ref SDS M3 4L4T Planning for implementation
BF0418 - was discussed during the meeting at UCSF on 070208. ref SDS M4 PR5L
BF0420 - ..
BF0421 - The doctor advised today that a CT test is needed for the clinical
BF0422 - study to start the 3rd cycle of treatment that begins on 070329.
BF0423 - Brigid prepared a form...
BF0425 - Department of Radiology Outpatient Request
BF0427 - ...and requested the next CT test before 070328.
BF0429 - ..
BF0430 - Brigid gave the form to Millie and asked her to transmit the UCSF
BF0431 - request to Kaiser, and coordinate to verify the test is scheduled at
BF0432 - Kaiser in time to accomplish requirements for the drug trial, and to
BF0433 - further test for pulmonary embolism, explained below. ref SDS 0 N19I
BF0435 - ..
BF0436 - Millie asked about UCSF coordinating with Kaiser directly. Brigid
BF0437 - cited UCSF policy to rely on patients for managing communications with
BF0438 - originating referral provider, per above, ref SDS 0 O67N, rather than
BF0439 - UCSF staff, per above. ref SDS 0 CI9L
BF0441 - [On 070302 Millie submitted a letter to Kaiser presenting
BF0442 - results of the meeting today, and conveying UCSF request for CT
BF0443 - test before 070328, and specifying testing for pulmonary
BF0444 - embolism. ref SDS N4 EZ6T
BF0446 - ..
BF0447 - [On 070306 follow up letter to Kaiser reminding to order CT
BF0448 - test in time for starting next cycle on 070329, and to order
BF0449 - test for pulmonary embolism. ref SDS N7 HS3X
BF0451 - ..
BF0452 - [On 070307 Arlette reminded the doctor to order the CT test.
BF0453 - ref SDS N8 9Z9N
BF0455 - ..
BF0456 - [On 070309 Kaiser scheduled test for 070328 0845.
BF0457 - ref SDS O0 VP5N
BF0459 - ..
BF0460 - [On 070314 Millie requested that Kaiser change the schedule for
BF0461 - the test to 070326 at 2000, providing time for preparing
BF0462 - analyst's report, and distribution in time to prepare for
BF0463 - meeting at UCSF on 070329. ref SDS O1 VP5N
BF0465 - ..
BF0466 - [On 070314 Millie notified UCSF CT test is scheduled for
BF0467 - 070326. ref SDS O1 DT4I
Emotional Trauma Increases Stress Pulse Well Above 80 Complex Medica
BK0401 - ..
BK0402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
BK0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
BK0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
BK0406 - Follow up ref SDS L7 Y642, ref SDS K1 Y642.
BK0408 - Medical issues create an emotional roller coaster explained on 070105.
BK0409 - ref SDS K1 Y642 Stress and trauma are compounded with rising
BK0410 - complexity of case history, listed above. ref SDS 0 LU3J
BK0412 - ..
BK0413 - Millie's vitals are very high again today, e.g., pulse well above 80,
BK0414 - where normally her resting heart beat is plus or minus 60, reported in
BK0415 - patient history for treatment today after meeting with Doctor Rugo.
BK0416 - ref SDS N3 AW4L
BK0418 - ..
BK0419 - Expanding IBC reported on 070222, ref SDS N1 B64F, and worry about new
BK0420 - rash on the right arm today, per above, ref SDS 0 H15M, causes
BK0421 - increased alarm. Finding that intensity of the rash seems to be
BK0422 - subsiding, and later learning that CA 15-3 dropped to 36 with
BK0423 - treatment on the cetuximab clinical study, per above, ref SDS 0 4140,
BK0424 - has a powerfully satisfying effect.
BK0426 - ..
BK0427 - Increased energy and fitness with rising exercise from reduced side
BK0428 - effects, discussed below, ref SDS 0 TQ6L, moderates emotional swings
BK0429 - and worry.
BK0431 - ..
BK0432 - Since there wasn't enough time to get CA 15-3 test reports for the
BK0433 - meeting today, there was a lot of tension during the meeting about
BK0434 - whether Millie would get treatment today, because ANC is below the
BK0435 - standard for treatment, discussed below. ref SDS 0 1T4O There was
BK0436 - further concern about expanding treatment to include carboplatin.
BK0437 - This caused greater emotional stress, because adding carboplatin would
BK0438 - put downward pressure on ANC, threatening treatment to recover from
BK0439 - IBC, and/or required adding additional treatment to increase blood
BK0440 - counts. ref SDS 0 OL5M Uncertainty on resolving complex choices can
BK0441 - greatly increase emotional trauma.
BK0443 - [On 070307 CA 15-3 36 dramatic improvement after concern that
BK0444 - IBC expanded during December and January, another emotional
BK0445 - roller coaster. ref SDS N8 046S
BK0447 - ..
BK0448 - [On 070309 Arlette advised that email for coordination of
BK0449 - work on Kaiser's referral to UCSF should go to the primary
BK0450 - care physician, which does not support efficient common
BK0451 - distribution, rather than through Arlette, ref SDS O0 VP73,
BK0452 - which provides both efficient distribution, and a backup
BK0453 - for reminding the doctor of critical action items,
BK0454 - illustrated on 070307. ref SDS N8 9Z9N
BK0456 - ..
BK0457 - [On 070315 Millie asked about coping emotionally with major
BK0458 - changes in assessment of treatment on the cetuximab clinical
BK0459 - study, ref SDS O3 6A7J; review impact of complex communications
BK0460 - that increase stress, causing vitals to rise. ref SDS O3 OR5K
Strategy 3 Issues ANC High IBC Expanding Intensity Subsiding Should
BS0401 - ..
BS0402 - Planning Case Management from Patient Profile Work Up
BS0403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
BS0404 - Strategy Cetuximab Continued with Low ANC Expanding IBC Disease
BS0406 - Follow up ref SDS L7 K36G, ref SDS K1 K36G.
BS0408 - Background on requirements and obstacles to planning and proactive
BS0409 - management in time for action to be effective is reported on 060825.
BS0410 - ref SDS G0 K36G
BS0412 - ..
BS0413 - Review of treatment history is listed on 061208, leading to strategy
BS0414 - for referral to UCSF. ref SDS J2 5Q5I Chronology on patient history
BS0415 - along with case studies for critical issues were cited on 070130.
BS0416 - ref SDS L7 GG7I CA 15-3 history listed with changes in treatment is
BS0417 - listed at the top of this record for a summary of the case.
BS0418 - ref SDS 0 087J
BS0420 - ..
BS0421 - There was no discussion today on the role of the Tumor Board process
BS0422 - to support strategy and planning, considered on 061208. ref SDS J2
BS0423 - P69G
BS0425 - ..
BS0426 - Challenges coordinating with Kaiser and limited time due to hectic
BS0427 - schedules that delayed submission of CA 15-3 diagnostics, per above,
BS0428 - ref SDS 0 HH7H, reflect Jackie's report on 070130 that preparing for
BS0429 - meetings requires wading through several folders of papers UCSF has on
BS0430 - file for Millie's case, ref SDS L7 LD39, and citing experience at UCSF
BS0431 - on 060821 during consultation with Doctor Benz. ref SDS F9 TQ7I
BS0432 - Finding time to prepare for meetings was cited in a study of poor
BS0433 - productivity, reviewed on 960205. ref SDS 3 5902
BS0435 - ..
BS0436 - Strategy issues today were...
BS0438 - 1. Should Millie get treatment today with ANC 1.23 dropping below
BS0439 - UCSF's standard of 1.8, and also below Kaiser's standard of
BS0440 - 1.5, reported in the blood test today, discussed above.
BS0441 - ref SDS 0 VF5M
BS0443 - ..
BS0444 - 2. Should treatment be upgraded at this time to add carboplatin to
BS0445 - the regimen, as planned on 070130, ref SDS L7 NI6K, and in
BS0446 - light of spreading disease, cited during examination today,
BS0447 - ref SDS 0 4140, and uncertainty of cancer marker CA 15-3 56 due
BS0448 - to delays getting test results from Kaiser, per above.
BS0449 - ref SDS 0 464O
BS0451 - [On 071023 UCSF explains cancer marker applied to look more
BS0452 - carefully and does not signal consideration of treatment
BS0453 - change based on a cut off diagnostic of 80 (using Kaiser
BS0454 - Lab calibration methods). ref SDS O9 V63L
BS0456 - ..
BS0457 - 3. How to avoid "wicked problem" of ignorning relatively benign
BS0458 - side effects of fatigue, weakness, shortness of breath from
BS0459 - treatment for cancer with cetuximab, without also ignoring
BS0460 - similar symptoms of pulmonary embolism and enlarged right
BS0461 - ventrical, a heart disorder called Cor Pulmanele, which
BS0462 - requires immediate treatment to prevent symptoms from
BS0463 - escalating into a lethal event.
BS0465 - ..
BS0466 - Strategy for distinguishing side effects of cetuximab from symptoms of
BS0467 - pulmonary embolism and Cor Pulmonale is discussed below. ref SDS 0
BS0468 - CV5L
BS0470 - ..
BS0471 - The doctor decided treatment should continue today with ANC 1.23 blood
BS0472 - counts below UCSF standard of 1.8 for giving treatment, because there
BS0473 - is concern that disease is expanding. ref SDS 0 LB5L Maintaining a
BS0474 - steady level of chemotherapy drug is a common strategy to treat
BS0475 - expanding cancer. Giving treatment with ANC below target levels
BS0476 - aligns with patient history listed on 060810 showing Millie has been
BS0477 - treated routinely when ANC falls below Kaiser's standard of 1500,
BS0478 - ref SDS F6 HV45, and further chemotherapy has been given in this case
BS0479 - with ANC in the range of 1230 (converted to Kaiser's standard),
BS0480 - reported in the test today, ref SDS N3 P560, e.g., see 050916.
BS0481 - ref SDS 91 R43M Additionally, WBC 4.1, which is a primary component
BS0482 - of ANC, is within the normal range (see blood test reported for
BS0483 - treatment today, ref SDS N3 075H), and Millie's energy has elevated
BS0484 - under treatment with cetuximab, allowing increased exercise that
BS0485 - strengthens the immune system, reviewed below. ref SDS 0 TQ6L
BS0487 - ..
BS0488 - The doctor decided to continue treatment today with cetuximab alone,
BS0489 - rather than add carboplatin at this time. Patient history indicates
BS0490 - expanding IBC occurred prior to starting treatment with cetuximab, per
BS0491 - above study. ref SDS 0 4140 Examinations indicate subsiding intensity
BS0492 - of IBC rash at all infection sites. ref SDS 0 M68J Decision support
BS0493 - was hampered without results of CA 15-3 tests this past month to
BS0494 - cross-check impressions from visual examination of declining disease.
BS0495 - ref SDS 0 MP58 The most recent CA 15-3 fell favorably from 68 to 56,
BS0496 - reported on 070202 for the test on 070131. ref SDS M2 GJ5M While
BS0497 - these results occurred prior to starting treatment with cetuximab on
BS0498 - 070201 and were erratic, noted in the meeting with Doctor Rugo on
BS0499 - 070130, ref SDS L7 S58L, this is the best evidence available. Since
BS0500 - adding carboplatin risks increasing downward pressure on ANC that
BS0501 - would make weekly treatments problematic, a strategy of continuing the
BS0502 - current regimen for at least another week was adopted.
BS0504 - ..
BS0505 - Doctor Rugo ordered another blood test to evaluate ANC next week. She
BS0506 - plans to examine Millie again prior to treatment on 070308, and assess
BS0507 - treatment strategy. By then CA 15-3 test data for the blood test
BS0508 - today should be available, as well as for tests on 070208 and 070215.
BS0509 - This additional test data will supplement visual examination to
BS0510 - evaluate response to treatment, and support deciding on changing the
BS0511 - treatment by adding carboplatin.
BS0513 - [On 070306 Millie requested results of CA 15-3 tests on 070208
BS0514 - and 070215 to support follow up meeting at UCSF on 070208.
BS0515 - ref SDS N7 PY6N
BS0517 - ..
BS0518 - If CA 15-3 56 is rising, ref SDS 0 OL5M, it aligns with expanding IBC
BS0519 - disease, notably to the left arm, discussed above, ref SDS 0 LB5L, and
BS0520 - so may require adding carboplatin to increase strength and
BS0521 - effectiveness of treatment. similar to issue at Kaiser on 020603.
BS0522 - ref SDS 14 4X5K In that case, if NEUTS (ANC at Kaiser) remains below
BS0523 - criteria for safe treatment, as reported today, per above, ref SDS 0
BS0524 - V95M, then remedial measures will be required. e.g., Neupogen ordered
BS0525 - on 050415. ref SDS 73 KX49 If, on the other hand, CA 15-3 shows a
BS0526 - clear trend downward, this will align with the doctor's impression
BS0527 - that despite IBC having begun to expand prior to starting treatment on
BS0528 - 070201, treatments have been effective reducing the intensity of the
BS0529 - rash, per above. ref SDS 0 M68J
BS0531 - ..
BS0532 - Days later on 070307 a clear trend that CA 15-3 36 falling
BS0533 - significantly during treatment with cetuximab, further supports the
BS0534 - decision today to contiue treatment with cetuximab alone.
BS0536 - [On 070308 meeting at UCSF cancelled because blood test on
BS0537 - 070301 reported CA 15-3 36 shows dramatic improvement, and ANC
BS0538 - blood counts increased to a safe level for treatment.
BS0539 - ref SDS N9 FO6H
BS0541 - ..
BS0542 - [On 070329 examination shows continued clinical improvement,
BS0543 - with no new IBC sites, and subsiding intensity of rash, and
BS0544 - aligns with continuing decline of CA 15-3 33 cancer marker.
BS0545 - ref SDS O6 M68J
Treatment IBC 9th Cycle 3rd Relapse 2nd Cycle 1st Treatment Chemothe
BW0401 - ..
BW0402 - Treatment 1st Cycle Cetuximab Carboplatin 070201 9th Cycle 3rd Relapse
BW0403 - 9th Cycle Treatment IBC 3rd Relapse 2nd Cycle Cetuximab Clinical Study
BW0404 - Cetuximab 2nd Cycle 1st Treatment IBC 3rd Relapse Clinical Study Drug Trial
BW0406 - Follow up ref SDS L7 PF3O, ref SDS K1 PF3O.
BW0408 - The doctor approved Millie to start cycle #2 treatment with cetuximab
BW0409 - alone today, in accordance with strategy, discussed above. ref SDS 0
BW0410 - T85J She will meet with Millie next week to assess changing treatment
BW0411 - strategy based on blood test results for ANC and CA 15-3, under
BW0412 - analysis above. ref SDS 0 1T4O
BW0414 - [On 070306 UCSF called to schedule meeting with Doctor Rugo on
BW0415 - 070308 1000. ref SDS N7 7Y5N
BW0417 - ..
BW0418 - [On 070306 Millie requested results of CA 15-3 tests on 070208
BW0419 - and 070215 to support follow up meeting at UCSF on 070208.
BW0420 - ref SDS N7 PY6N
BW0422 - ..
BW0423 - [On 070308 meeting with Doctor Rugo was cancelled because
BW0424 - diagnostics show patient responding to treatment. ref SDS N9
BW0425 - 407N
BW0427 - ..
BW0428 - Following the meeting with the doctor, treatment was given today at
BW0429 - 1500 in the Infusion Clinic, reported in another record, ref SDS N3
BW0430 - 1M6H, and additional blood vials were drawn for the drug trial
BW0431 - research. ref SDS N3 O56V
Side Effects Cetuximab Acne-like Rash Face Controlled Prescribed Med
BZ0401 - ..
BZ0402 - Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
BZ0403 - Energy Strength Rising Minimal Side Effects Cetuximab Treatment
BZ0404 - Facial Skin Dryness New Side Effect Cetuximab Curel Loation Prescribed
BZ0405 - Curel Lotion Prescribed Facial Skin Dryness New Side Effect Cetuximab
BZ0407 - Until the past few days following the 4th treatment with cetuximab,
BZ0408 - Millie's energy has been elevated compared to the past 8 months. She
BZ0409 - reported starting to work out in the gym on 070204, ref SDS M3 HF5H,
BZ0410 - which has been a goal for a long time, discussed at Kaiser on 070105.
BZ0411 - ref SDS K1 MA9K At that time, the primary care physician commented
BZ0412 - that pulmonary embolism and enlarged right ventrical may have caused
BZ0413 - permenant lung damage that will never permit vigorous exercise to
BZ0414 - strengthen the immune system to help resist cancer, and enable
BZ0415 - aggressive chemotherapy treatments. ref SDS K1 WR4J
BZ0417 - ..
BZ0418 - On 070218, Millie also reported playing tennis for the first time in
BZ0419 - many years, further indicating she is tolerating treatments with
BZ0420 - cetuximab well. ref SDS N0 N05H Higher energy from reduced side
BZ0421 - effects of cancer treatments enables regular exercise that increases
BZ0422 - fitness. Exercise and better fitness moderates emotional trauma
BZ0423 - confronting big changes in disease progression and response to
BZ0424 - treatment, per above. ref SDS 0 Y642
BZ0426 - ..
BZ0427 - Recent history of significantly increased energy seems conflicting
BZ0428 - with ANC falling to such a low count of 1.23, reported for the record
BZ0429 - on treatment today. ref SDS N3 P560
BZ0431 - ..
BZ0432 - Today, Millie feels tired after 4 treatments with cetuximab. Whether
BZ0433 - rising fatigue and weakness reflect falling blood counts, e.g., ANC
BZ0434 - 1.23, well below UCSF 1.8 criteria for giving treatment, and reported
BZ0435 - by Brigid today, per above, ref SDS 0 VF5M, or other short term
BZ0436 - factors that may be correctable is not clear in the record at this
BZ0437 - time.
BZ0439 - [On 070308 ANC increased to 1.51 within the normal range for
BZ0440 - cetuximab treatments. ref SDS N9 P560
BZ0442 - ..
BZ0443 - Facial dryness needs treatment in addition to treatment prescribed on
BZ0444 - 070222, ref SDS N1 FO66, as reported to UCSF in Millie's letter
BZ0445 - yesterday on 070228. ref SDS N2 LR4S
BZ0447 - ..
BZ0448 - Brigid presescribed Curel lotion to reduce facial dryness caused by
BZ0449 - cetuximab treatments.
BZ0451 - ..
BZ0452 - On the way home after treatment, Millie stopped at Long's Drugs on
BZ0453 - Treat street in Concord and purchased the lotion.
BZ0455 - [On 070308 Millie reported Curel treatment has brought some
BZ0456 - relief to facial dryness. ref SDS N9 JS6M
BZ0458 - [On 070329 Millie looks great, and feels fortunate to have
BZ0459 - avoided severe skin rash side effects of cetuximab by applying
BZ0460 - treatment prescribed by Brigid. ref SDS O6 N49K
BZ0462 - ..
BZ0463 - Side effects of fatigue, weakness cause loss of fitness with shortness
BZ0464 - of breath disclosed in the clinical study consent form, ref DRP 1
BZ0465 - HW54, reviewed on 070116, ref SDS K5 RT7K, are similar to symptoms of
BZ0466 - pulmonary embolism, discussed below, ref SDS L7 MO7K, and to symptoms
BZ0467 - of heart disorder Cor Pulmonale also described as enlarged right
BZ0468 - ventricle, is also discussed below. ref SDS L7 L56L
Cetuximab Clinical Study UCSF Drug Trial Expanding IBC Metastatic Di
C80401 - ..
C80402 - Cetuximab UCSF Clinical Study Treatment Begins 070201
C80403 - UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
C80404 - Drug Trials UCSF Has Other Clinical Study Treatments May Help Millie
C80406 - Follow up ref SDS L7 ZJ9N, ref SDS K1 P256.
C80408 - Background on Kaiser referral to UCSF for treatment on clincial study
C80409 - is reported on 070105. ref SDS K1 P256 Purpose of referral is to
C80410 - improve patient care with new treatment. ref SDS K1 PK7L Case study
C80411 - on Kaiser and UCSF collaborating to expedite treatment is listed
C80412 - above. ref SDS L7 4T5N
C80414 - ..
C80415 - Consideration of upgrading treatment by adding carboplatin to increase
C80416 - effectiveness of current treatment with cetuximab alone was deferred
C80417 - today under strategy discussed above. ref SDS 0 NY7N
Schedule Treatment Cetuximab 070301 Clinical Study Drug Trial 2nd Cy
CC0401 - ..
CC0402 - Schedule Treatment Start Cetuximab Carboplatin 070201
CC0404 - Follow up ref SDS L7 N96O, ref SDS K1 N96O.
CC0406 - Millie will coordinate with Kaiser to schedule a CT test before
CC0407 - 070328, per planning above, ref SDS 0 5Z6L, and implementing Brigid's
CC0408 - request for the patient to coordinate communications with Kaiser,
CC0409 - ref SDS 0 CI9L, including outstanding CA 15-3 test results to support
CC0410 - meeting next week with Doctor Rugo on assessing changes to treatment,
CC0411 - per above. ref SDS 0 PF3O
CC0413 - [On 070314 Millie notified UCSF CT test is scheduled for
CC0414 - 070326. ref SDS O1 DT4I
CC0416 - ..
CC0417 - Jackie will schedule Millie for treatments with cetuximab alone during
CC0418 - the next cycle, per strategy above. ref SDS 0 NY7N
CC0420 - ..
CC0421 - Jackie asked Millie to coordinate with Kaiser to get CA 15-3 results
CC0422 - for blood tests on 070208 and 070215 in time for meeting with Doctor
CC0423 - Rugo next week on 070308, as discussed with Brigid above. ref SDS 0
CC0424 - O67N
CC0426 - ..
CC0427 - Jackie will schedule a blood test to evaluate ANC prior to treatment
CC0428 - next week on 070308, ref SDS 0 VF6O, and will schedule a follow up
CC0429 - meeting with Doctor Rugo on 070308 to further evaluate treatment
CC0430 - strategy, per above, ref SDS 0 1T4O, and based on ANC and CA 15-3
CC0431 - cancer marker results from blood tests. ref SDS 0 MP58
CC0433 - [On 070306 UCSF called to schedule meeting with Doctor Rugo on
CC0434 - 070308 1000. ref SDS N7 7Y5N
CC0436 - ..
CC0437 - [On 070306 Millie requested results of CA 15-3 tests on 070208
CC0438 - and 070215 to support follow up meeting at UCSF on 070208.
CC0439 - ref SDS N7 PY6N
CC0441 - ..
CC0442 - [On 070308 Noral, the Infusion Clinic receptionist, reported
CC0443 - that Millie was not scheduled for a blood test; a blood test
CC0444 - was performed on Millie's request that results are needed for
CC0445 - Doctor Rugo to assess ANC for approving treatment. ref SDS N9
CC0446 - 1M6H
CC0448 - ..
CC0449 - Meetings and treatments continue on Thursdays, so the next meeting at
CC0450 - Kaiser will be on 070308.
Pulmonary Emboli Blood Clots Lungs Enlarged Right Ventricle Heart Di
CN0401 - ..
CN0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
CN0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
CN0404 - Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
CN0406 - Follow up ref SDS L7 CV5L, ref SDS K1 CV5L.
CN0408 - Background on pulmonary embolism recurrence and correlation with IBC
CN0409 - treatment at UCSF is reported in the record meeting with Doctor Rugo
CN0410 - on 070130, ref SDS L7 CV5L, presenting a "wicked problem" to avoid
CN0411 - ignorning needed treatment. ref SDS L7 MO7K
CN0413 - ..
CN0414 - Strategy for overcoming "wicked problems" differentiating side effects
CN0415 - of cetuximab treatment for IBC, from symptoms of pulmonary embolism,
CN0416 - which can quickly escalate into lethal events, ref SDS 0 HL6H, is CT
CN0417 - testing, reported on 070130. ref SDS L7 R16N On 070202, the primary
CN0418 - care physician at Kaiser requested a months notice from UCSF to order
CN0419 - the next CT test required by the cetuximab protocol, so that the test
CN0420 - can, also, test evaluate pulmonary embolism and enlarged right
CN0421 - ventricle. ref SDS M2 M15I UCSF
CN0423 - ..
CN0424 - On 070204 Millie notified Kaiser and UCSF there were no noticable
CN0425 - initial side effects of 1st treatment with cetuximab; energy has
CN0426 - increased, Millie worked out in the gym 2 days in a row, and for the
CN0427 - first time in 6 months; planning for CT test to evaluate pulmonary
CN0428 - embolism. ref SDS M3 JJ7O On 070218 energy increases, shortness of
CN0429 - breath, fatigue, weakness subside 10 weeks after ending treatment for
CN0430 - 3rd relapse of IBC with Taxotere and cacecitabine; exercising in the
CN0431 - gym and playing tennis 2 days her pulse reached 144. ref SDS N0 N05H
CN0433 - ..
CN0434 - On 070204 Millie sent a letter facilitating communications between
CN0435 - Kaiser and UCSF on coordinating this issue. ref SDS M3 4L5Q
CN0437 - ..
CN0438 - Today, Brigid advised that UCSF prefers that the patient coordinate
CN0439 - communications with Kaiser on scheduling and scope for the CT test,
CN0440 - ref SDS 0 UR9J, rather than UCSF medical professionals coordinate the
CN0441 - work, per above. ref SDS 0 CI9L
CN0445 - ..
CN0446 - INR 2.5 Blood Test Patient Stable for Coumadin Treatments Pulmonary Emboli
CN0448 - Brigid advised that the blood test this morning shows INR 2.5 for
CN0449 - Millie, which needs to be submitted to Gloria at Kaiser's Coagulation
CN0450 - Control Clinic in Martinez, CA to prescribe Coumadin treatments for,
CN0451 - pulmonary embolism, as set out Millie's letter to UCSF yesterday on
CN0452 - 070228. ref SDS N2 LQ6W
CN0454 - ..
CN0455 - Earlier, when the meeting began, Brigid explained UCSF policy for
CN0456 - patients to coordinate medical diagnostics with Kaiser, see above.
CN0457 - ref SDS 0 O67N Jackie indicated Millie should submit INR results from
CN0458 - the UCSF blood test to Gloria. ref SDS 0 0U8K
CN0460 - ..
CN0461 - [On 070302 Gloria at the Kaiser Coagulation Control Clinic
CN0462 - in Martinez, CA called and left a message saying that since
CN0463 - Kaiser did not receive results of the blood test at UCSF
CN0464 - the day before on 070301, Millie should get a blood test
CN0465 - for INR the following week on 070308 to evaluate Coumadin
CN0466 - treatments for pulmonary embolism. ref SDS N4 U24Y
CN0468 - ..
CN0469 - [On 070302 Millie called back and left a message for Gloria at
CN0470 - the Kaiser Coagulation Control Clinic in Martinez, CA, and
CN0471 - Millie sent a letter to Arlette in the doctor's office at
CN0472 - Kaiser's oncology clinic in Walnut Creek; copies were sent to
CN0473 - Gloria, and to Jackie, the Clinical Research Coordinator at
CN0474 - UCSF confirming the telephone message to Gloria that reported
CN0475 - the blood test on 070301 shows INR 2.5, ref SDS N4 K14H, and so
CN0476 - testing for INR would occur with the next blood test on 070329
CN0477 - for the next cycle of cetuximab treatment for IBC. ref SDS N4
CN0478 - X84G
CN0480 - ..
CN0481 - After Millie met with Doctor Rugo, Brigid, and Jackie in the Breast
CN0482 - Care Center on the 2nd floor, Pauline in the Infusion Clinic submitted
CN0483 - the blood test report at the end treatment. Subsequent review showed
CN0484 - that the normal range for INR in UCSF blood test reports is different
CN0485 - from the range Kaiser uses to manage Coumadin treatments for pulmonary
CN0486 - embolism. ref SDS N3 SE6N
CN0488 - [On 070305 entering results of the blood test on 070301 showed
CN0489 - a big difference in the way UCSF and Kaiser set the "normal"
CN0490 - range for INR, ref SDS N3 SE6N, Millie wrote a letter notifying
CN0491 - Jackie at UCSF with copies to Arlette and Gloria at Kaiser,
CN0492 - ref SDS N5 XG5H; and asking UCSF for clarification to
CN0493 - facilitate managing Millie's Coumadin treatments for pulmonary
CN0494 - embolism. ref SDS N5 3A4Y
CN0496 - ..
CN0497 - [On 070305 Millie requested that Gloria coordinate directly
CN0498 - with UCSF on interpreting the UCSF blood test report for
CN0499 - prescribing Coumadin to treat pulmonary embolism, and
CN0500 - reminded that UCSF has ordered another blood test on
CN0501 - 070308, so that INR can be tested again if needed.
CN0502 - ref SDS N5 3A6S
CN0504 - ..
CN0505 - [On 070305 Brigid advised INR 2 - 3 is the correct range for
CN0506 - prescribing Coumadin to treat Millie for pulmonary embolism,
CN0507 - despite being 100% over the normal range in the report for the
CN0508 - UCSF blood test on 070301. ref SDS N5 SN5O
CN0510 - ..
CN0511 - [On 070305 UCSF did not make distribution to coorindate
CN0512 - communciations with Kaiser; Millie sent a letter thanking
CN0513 - Brigid for timely response to INR question, and sent copies
CN0514 - thanking Jackie for timely coordination, and also copies to
CN0515 - Arlette at Kaiser in Walnut Creek, and to Gloria in
CN0516 - Kaiser's Coagulation Control Clinic in Martinez, CA for
CN0517 - managing Coumadin that treats Millie's pulmonary embolism.
CN0518 - ref SDS N5 B18H
CN0520 - ..
CN0521 - [On 070306 Millie requests feedback from Gloria to verify
CN0522 - accuracy of understandings that Kaiser is satisfied with
CN0523 - UCSF blood test on INR for prescribing Coumadin to treat
CN0524 - pulmonary embolism, and advises current regimen will
CN0525 - continue until further notice. ref SDS N6 FJ9K
Examination Stethoscope No Findings Enlarged Right Ventricle Heart S
CU0401 - ..
CU0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
CU0404 - Follow up ref SDS L7 Q35O, ref SDS K1 Q35O.