THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: May 24, 2007 08:30 AM Thursday;
Millie meeting at UCSF 5th cycle 1st treatment cetuximab for IBC.
2...Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
3...Complex Patient History Knowledge Management Dilemma Issues Grow 45
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...CA 15-3 Cancer Marker 37 Shows Possible Progression of Disease
8...CA 15-3 37 Cancer Marker Rising Conflicts Favorable CT and Examination
9...Axillary Left Arm No Lymphadenopathy Lymphedema Prominent
10...Lymphadenopathy Axillary Left Arm No Evidence Local Edema
11...Lymphedema Cellulitis Complications Resolved Left Arm Swelling
12...Swelling Left Arm Lymphedema Cellulitis Complications Resolved
13...Left Arm Lymphedema Cellulitis Complications Resolved
14...Cellulitis Lymphedema Complications Resolved Left Arm Swelling
15...IBC Left Arm Stable Subsiding Responds Treatment Cetuximab Drug Trial
16...Left Arm IBC Stable Subsiding Responds Treatment Cetuximab Drug Trial
17...Right Axillary Possible Involvement Red Rash Spreads Right Breast
18...IBC Right Arm No IBC Red Rash or Cellulitis
19...Right Breast IBC Rash Intensity Subsides
20...Rash Right Breast Inflammation Intensity Subsides
21...Right Chest Rash Not Visible Above Breast and Port Catheter
22...Rash Above Port Catheter on Right Upper Chest Not Visible Today
23...Port Catheter Infection Blemish Right Chest Blood Culture Investigate
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 IBC Subsides Conflicts CA 15-3 37 Cancer Marker Rises 30%
28...IBC Rash Left Breast Stomach and Back Seems to Be Subsiding
29...Examination IBC Rash Subsiding Responding to Treatment Cetuximab
30...Cetuximab Effective Treatment IBC Subsiding Left Breast Stomach Back
31...Prognosis Good IBC Stable Cetuximab Clinical Study
32...Stable Low Intensity IBC Rash Very Good Response to Treatment
33...Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
34...Wicked Problems Good Management Looks Like Unnecessary Overkill
35...Communication Coordination Failure Perform Complex Wicked Problems
36...Comparison Evaluate Progression Lung Heart Disorders Side Effects
37...Unnecessary Overkill Evaluate Progression Disease Comparison CT Tests
38...Measurable Disease IBC No New Sites No Expansion Intensity Declines
39...Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
40...Measurable Disease IBC Observed with Tape Measure Photograph Pictures
41...CA 15-3 Diagnostic Measurable Disease IBC Not Measured by Image Testing
42...Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
43...Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
44...CT Test 070520 No Findings Metastatic Disease
........Test History No Evidence Distant Metastasis
........Distant Metastasis No Evidence 5 Years Imaging Tests
....History Missing Context Pulmonary Embolism Enlarged Right Ventricle
....Comparison: 070326 070131 061230 060930 Omitted Chronic Mistakes
....CT Scan Failed to Test for Pulmonary Embolism Cor Pulmonale
....Cancer No Findings Lymphadenopathy No Evidence Metastatic Disease
45...Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
46...Exercise Vigor Strength Engagement Ease Distress Living with Cancer
47...Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
48...Planning Case Management from Patient Profile Work Up
49...Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
50...Strategy Cetuximab Continued with Low ANC Expanding IBC Disease
51...Treatment IBC 3rd Relapse Start 5th Cycle Cetuximab Clinical Study
52...Cetuximab 5th Cycle Treatment IBC 3rd Relapse Clinical Study UCSF
53...Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
54...Energy Strength Rising Minimal Side Effects Cetuximab Treatment
55...Facial Skin Dryness New Side Effect Cetuximab Curel Lotion Prescribed
56...Curel Lotion Prescribed Facial Skin Dryness New Side Effect Cetuximab
57...Cetuximab UCSF Clinical Study Treatment Begins 070201
58...UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
59...Drug Trials UCSF Has Other Clinical Study Treatments May Help Millie
60...Schedule Treatment Start Cetuximab Carboplatin 070201
61...Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
62...Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
63...Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
64...INR 2.2 Blood Test Patient Stable for Coumadin Treatments Pulmonary Emboli
65...Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
66...Cor Pulmonale Heart Disorder Enlarged Right Ventricle
67...Heart Examination Not Ordered Investigate Enlarged Right Ventricle
68...Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
69...Dizziness Mild Symptoms Recur
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1...Gary H. Glover is the Director, Radiological Sciences Laboratory at
Meeting Examination Doctor Review Strategy Work Plan 5th Cycle 1st T
1403 - ..
1404 - Summary/Objective
140501 - Follow up ref SDS 90 0000. ref SDS 87 0000.
140503 - Millie was approved to start the 5th cycle of treatment with
140504 - cetuximab. Examination today shows subsiding and stable IBC rash, and
140505 - no new sites, since treatment started on 070201 under a clinical study
140506 - of cetuximab alone. ref SDS 0 LB5L A few days after meeting with the
140507 - medical team today, UCSF reported CA 15-3 37 increased 30%.
140508 - ref SDS 0 087J Favorable examination, together with CT tests that
140509 - show no metastatic cancer present strong response to treatment,
140510 - ref SDS 0 EY5O, that supports starting cycle #5 today in the drug
140511 - trial. ref SDS 0 7X6N NEUTS (ANC) blood counts rising to safe levels
140512 - support approval for treatments. ref SDS 90 1R4H Pulmonary embolism
140513 - and enlarged right ventricle have not been tested nor compared for
140514 - progression of lung and heart disease with methods that discovered
140515 - preconditions. ref SDS 0 CV5L Progress communicating and
140516 - collaborating strengthen coordination of Kaiser referral to UCSF.
140517 - ref SDS 0 ZO6F Difficulty reporting patient history of lung and heart
140518 - disorders, ref SDS 0 GH5L, limits usefulness of CT scans by analysing
140519 - only 20% of test data. ref SDS 0 SY4K Wicked problems implementing
140520 - policies to save time and money for health care costs arise from
140521 - failure to perform comparisons to evaluate progression of pulmonary
140522 - embolism and enlarged right ventricle, ref SDS 0 0136, in the context
140523 - of patient history that requires increased scrutiney. ref SDS 0 VF5M
140524 - Stress rises from conflicts in communication and coordination for case
140525 - management to reduce cost and provide increased scrutiney. ref SDS 0
140526 - FR6J
140528 - ..
140529 - [On 070625 CA 15-3 30 improved 30% for blood test on 070621
140530 - aligns with clinical findings of IBC subsiding, indicating
140531 - response to treatment with cetuximab alone. ref SDS A5 PD4N
140536 - ..
1408 - Progress
140901 - Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
140903 - Follow up ref SDS 90 SM6M, ref SDS 87 SM6M.
140905 - ..
140906 - Millie met today with the medical team at UCSF starting the 5th cycle
140907 - and 17th treatment of IBC with cetuximab, as planned in the launch
140908 - meeting on 070130. ref SDS 56 WM7G Treatment at UCSF is on referral
140909 - from Kaiser for a clinical study drug trial ordered by the primary
140910 - care physician on 070105. ref SDS 51 PK68 This meeting starts the
140911 - 12th chemotherapy cycle since treatments began on 060711, ref SDS 27
140912 - SM6M, for the 3rd relapse of IBC. ref SDS 27 8Y8I
140914 - ..
140915 - Complete list of treatments for IBC 3rd relapse is reported in the
140916 - record of treatment today in the Infusion Clinic. ref SDS A0 PR8Q
140918 - ..
140919 - Case studies for Millie's patient history are listed on 061018.
140920 - ref SDS 38 0001
140922 - ..
140923 - Agenda for meeting at UCSF on 070419 provides a structure for planning
140924 - the meeting today...
140926 - 1. Coordination plan.............................. ref SDS 0 S58J
140927 - 2. CA 15-3 37 signals rising cancer............... ref SDS 0 GJ5M
140928 - 3. Lymphedema restricts exercise.................. ref SDS 0 4Y93
140929 - 4. Breast exam IBC stable subsides................ ref SDS 0 025H
140930 - 5. Measurable disease declines and rises.......... ref SDS 0 M652
140931 - 6. Side effects minimal........................... ref SDS 0 TQ6L
140932 - 7. CT no metestatic disease, no test PE........... ref SDS 0 EY5O
140933 - 8. Patient work up continue strategy.............. ref SDS 0 K36G
140934 - 9. Treatment plan weekly clinical trial........... ref SDS 0 7X6N
140935 - 10. Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
140936 - 11. Dizziness mild recurrence...................... ref SDS 0 PT4K
140938 - ..
140939 - Scheduled next meeting for Thursday 070524 0830, reported in the
140940 - record on 070315. ref SDS 73 159O
140942 - ..
140943 - The doctor could not support the meeting today; Millie met with two
140944 - (2) assistants...
140946 - 1. Brigid, Nurse Practitioner
140947 - 2. Jackie, Clinical Research Coordinator, coordinating
Complex Patient History 45 Issues Overwhelms Span of Attention Drive
230401 - ..
230402 - Complex Patient History Knowledge Management Dilemma Issues Grow 45
230404 - Follow up ref SDS 90 LU3J, ref SDS 87 LU3J.
230406 - Sampling of issues patient history diagnosis and treatment...
230408 - 1. CA 15-3 monitors advance of cancer response to treatment
230409 - 2. Lymphedema complicated by mastectomy surgery
230410 - 3. Broken finger from minor fall complicates lymphedema
230411 - 4. Esophagitis reflux digestion issues
230412 - 5. Immune system chemotherapy increases risk of infection
230413 - Chemotherapy increase risk of infection
230414 - 6. Cat bites increase risk of infection complicates lymphedema
230415 - 7. Pneumonia chemotherapy increases risk of infection
230416 - 8. Metastatic cancer increases risk pulmonary embolism
230417 - 9. Lymphadenopathy left axilla local regional metastasis
230418 - 10. Lymphadenopathy right axilla distant metastasis
230419 - 11. Lymphadenopathy left supraclavicular diagnose metastatic cancer
230420 - 12. Breast cancer secondary IBC 3rd relapse left breast
230421 - 13. Cancer mutates slow response chemotherapy treatment
230422 - 14. Mastectomy surgery impact on treatment IBC relapse
230423 - 15. Blood vessels removed mastectomy slow chemotherapy treatments
230424 - 16. Treatment options, strategy, planning, schedule
230425 - 17. Drug trials increase declining pool chemotherapy agents
230426 - 18. UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
230427 - 19. Pulmonary embolism blood clots in lungs
230428 - 20. INR weekly adjustments Coumadin treatment blood clots
230429 - 21. Enlarged right ventricle heart problem core pulmonale
230430 - 22. Dizziness symptom enlarged right ventricle cor pulmonale
230431 - 23. Fatigue shortness breath side effect chemotherapy loss fitness
230432 - 24. Fatigue shortness breath symptom pulmonary embolism
230433 - 25. Shortness breath fatigue dizzy symptoms pulmonary embolism
230434 - 26. Coagulapathy hypercoagulable state work up genetic risks
230435 - 27. Testing resolution of errors (see Benz 2nd opinion 060821)
230436 - 28. Testing distant metastatic disease
230437 - 29. Testing pulmonary embolism and heart disease
230438 - 30. Communication hectic schedule not enough time to manage details
230439 - 31. Emotional stress and well being
230440 - 32. Cellulitis inflammation temperature 102.6 on chemotherapy
230441 - 33. Urinary tract bladder infection
230442 - 34. IBC rash spreads to right breast
230443 - 35. Right breast rash may be "ring" infection, not cancer
230444 - 36. Lung cancer seems to be diagnosed in the Medical Chart
230445 - 37. IBC rash spreads to stomach and toward back
230446 - 38. IBC rash spreads to left arm
230447 - 39. Dry skin face chest arm
230448 - 40. Right arm evidence light red rash, may be IBC spreading
230449 - 41. Rash right upper right chest near port catheter
230450 - 42. Restless legs side effect Benadryl pre-treatment
230451 - 43. Sleeping difficulty side effect cetuximab
230452 - 44. Rash intense .5" round rash about .75" above port catheter
230453 - 45. Sleep nap after cetuximab treatments fatigue accumulating
Vitals Submitted by Doctor UCSF Blood Pressure Pulse Normal Low Anxi
300401 - ..
300402 - Vitals Show Stable Medical Condition
300404 - Follow up ref SDS 90 KB5L, ref SDS 87 KB5L.
300406 - Conversion Celsius to Farhenheit...
300408 - http://www.wbuf.noaa.gov/tempfc.htm
300410 - Blood
300411 - Date Time Pressure Pulse Temperture Weight So2
300412 - .
300413 - 070524 1235..... 134 75 61 36.6c 97.88f 99
300414 - 070524 1145..... 119 69 58 37.1c 98.78f 98
300415 - 070524 standing.......... 67 ................
300416 - 070524 0945..... 132 80 56 37.0c 98.60f 98
300417 - 070517 1120..... 126 72 56 36.7c 98.06f 100
300418 - 070517 1020..... 140 75 54 36.6c 97.88f 98
300419 - 070517 0940..... 140 75 54 36.1c 96.98f 99
300420 - 070510 1145..... 145 86 54 35.9c 96.62f 100
300421 - 070510 1045..... 149 82 69 37.0c 98.60f 97
300422 - 070510 0900..... 132 75 62 36.8c 98.24f 99
300423 - 070503 1150..... 113 67 59 36.8c 98.24f 98
300424 - 070503 1055..... 125 72 54 36.1c 96.98f 100
300425 - 070503 0915..... 127 70 60 36.9c 98.42f 99
300426 - 070426 1130..... 119 70 57 36.3c 97.34f 96
300427 - 070426 1030..... 141 73 67 36.4c 97.52f 99
300428 - 070426 0900..... 130 78 52 36.5c 97.70f 97
300429 - 070419 1230..... 133 79 57 36.3c 98
300430 - 070419 1130..... 141 78 56 37.6c 99
300431 - 070419 0930..... 153 80 53 36.1c 147 100
300432 - 070330 1540..... 136 92 52 99.4 150 98
300433 - 070329 0900..... 141 76 60 36.6c 99
300434 - 070301 1505..... 112 69 86 36.6c 98
300435 - 070130 1300..... 140 83 87 98
300436 - 070105 1040.....
300437 - 061208 1226..... 152 90 76 97.8 147 99%
300438 - 061201 1430..... 123 76 76 97.5
300439 - 061110.......... 136 83 73 97.0 150 98%
300440 - 061020 1534..... 140 79 67 99.8 151 97
300441 - 060929 1452..... 141 78 66 98.3
300442 - 060908 1335..... 139 79 73 98.1
300443 - 060814 1610..... 139 80 59 98.2
300444 - 060808..........
300445 - 060711.......... 172 87 54 97.5 147
300446 - 060623.......... 141 87 71 98.0 147 99%
300447 - 060428.......... 129 73 80 99.4 149 99%
300448 - 060217.......... 153 81 61 98.6 150 99%
300450 - ..
300451 - High blood pressure reflects pressure on patient about effectiveness
300452 - of new treatment and arrangements between UCSF and Kaiser for timely
300453 - care, discussed on 070130, ref SDS 56 Y642, and again on 070301.
300454 - ref SDS 65 Y642
300456 - ..
300457 - Today, Millie's vitals are normal, indicating reduced emotional
300458 - strain, discussed with Brigid on 070315, ref SDS 73 6A7J, and reviewed
300459 - again during the meeting last week with the doctor on 070419,
300460 - ref SDS 87 Y642, citing improvement in patient status beginning a
300461 - month ago on 070329, ref SDS 80 Y642, and continuing today, per
300462 - below. ref SDS 0 Y642
Coordination Plan Communication Collaboration Improve UCSF Schedules
650401 - ..
650402 - Coordination Plan Divided Responsibilities Kaiser UCSF Referral
650403 - Collaboration Primary Care at Kaiser with UCSF Clinical Study Cetuximab
650405 - Follow up ref SDS 90 2S4H, ref SDS 87 RM4G.
650407 - Background on coordination plan to manage divided responsibilities
650408 - between Kaiser and UCSF is reported on 070301. ref SDS 65 RM4G Case
650409 - study on 070130 shows better communication can strengthen care.
650410 - ref SDS 56 4T5N Requirements are listed on 070222. ref SDS 63 KL5G
650411 - On 070418, Millie reported that coordination improved, ref SDS 86
650412 - EQ6I, using email on 070406 for timely, accurate communication.
650413 - ref SDS 84 EQ6I. Progress using explicit links for precision access
650414 - to find critical details was reported on 070419, ref SDS 87 DI8J, and
650415 - UCSF presented feedback on support needed for transitioning to
650416 - Knowledge Management modalities. ref SDS 87 DI9F On 070426 Brigid
650417 - demonstrated skills using the Interent that brings "good management"
650418 - (see POIMS, ref OF 1 1X6G) within reach at UCSF. ref SDS 90 514G
650419 - Coordination of blood tests on 070426 demonstrated that following
650420 - protocols to test for safe treatments prior to getting treatment,
650421 - provides time to make adjustments. ref SDS 90 T15M
650423 - ..
650424 - [On 070610 primary care physician at Kaiser reports right
650425 - communication channels are now open for coordination and
650426 - collaboration with UCSF to treat Millie on referral.
650427 - ref SDS A4 OG7F
650429 - ..
650430 - Coordination took a big step forward on 070510 with UCSF contacting
650431 - Kaiser to schedule the next CT test, which previously was left for the
650432 - patient to coordinate. ref SDS 93 DT8I UCSF reported comprehensive
650433 - care is difficult because coordinating the work to correct mistakes is
650434 - stressful. ref SDS 93 V36R On 070511, Kaiser reported coordination
650435 - breakdown getting blood test reports from UCSF, and so ordered
650436 - additional testing, duplicating UCSF's work. ref SDS 94 T76M
650438 - ..
650439 - At that time, Millie coordinated with Kaiser to correct mistakes in
650440 - the CT test schedule. ref SDS 94 T77M Millie also ordered CA 15-3
650441 - testing to cross-check the lab at UCSF, and provide data for meeting
650442 - with the primary care physician at Kaiser scheduled for 070525.
650443 - ref SDS 94 B64J Millie notified Kaiser on 070514 that UCSF calibrated
650444 - CA 15-3 dropped down to 29 in a test on 070426. She requested results
650445 - of Kaiser's test to cross-check accuracy at the UCSF Lab. ref SDS 95
650446 - IN5P
650448 - ..
650449 - UCSF concern that people avoid coordinating to reduce stress from
650450 - adjusting schedule issues, also, occurs managing scope of CT testing,
650451 - shown on 070510. ref SDS 93 VP4H Communication and coordination with
650452 - Kaiser to perform requirements for the cetuximab study takes extra
650453 - effort to study and present patient history, ref SDS 93 HW5I,
650454 - including risks of compounding preconditions in this case. ref SDS 93
650455 - AL48 Since medical professionals avoid coordination to reduce stress,
650456 - ref SDS 93 TK8H, on 070514 the patient worked with Kaiser to implement
650457 - plans to assess lung and heart disorders with CT testing. ref SDS 95
650458 - IM9O
650460 - ..
650461 - On 070517 the primary care physician advised that planning to assess
650462 - pulmonary embolism and enlarged right ventricle could be implemented,
650463 - but policy considerations prevent comprehensive care. Kaiser's policy
650464 - position to save money by reducing tests on the basis that case
650465 - management will not be guided by test findings, ref SDS 98 OS5G,
650466 - reconciles prior conduct failing to peform required testing during
650467 - 2004, reported on 041007, ref SDS 13 RZ4I, and again this year
650468 - distorting good policy with bad implementation that prevents saving
650469 - lives, time, and money. ref SDS 98 KV3F Doctor Benz noted on 041018
650470 - that patient history in this case requires increased scrutiney.
650471 - ref SDS 98 WX8I
650473 - ..
650474 - Review on 070517 presents questions whether doctors can coordinate
650475 - internal services to manage care by specifying scope of tests based on
650476 - patient history. ref SDS 98 KV3F
650478 - ..
650479 - Coordination is closely related to other subjects...
650481 - 1. Coordination........................... ref SDS 0 ZP3L
650482 - 2. Wicked problems........................ ref SDS 0 VF5M
650483 - 3. CT test scope history.................. ref SDS 0 GH5L
650484 - 4. CT test scope comparison............... ref SDS 0 0136
650485 - 5. Strategy risk management............... ref SDS 0 A67L
650486 - 6. Treatment approval..................... ref SDS 0 L49O
650487 - 7. Side effects assessment................ ref SDS 0 NY6N
650488 - 8. Emotional stress....................... ref SDS 0 Y642
650489 - 9. Pulmonary embolism..................... ref SDS 0 CV5L
650491 - ..
650492 - Review on 070517 showing notification to Kaiser of CA 15-3 29 reported
650493 - at UCSF, and does not appear in Kaiser's medical chart for assessing
650494 - patient progress, ref SDS 96 RH9H, presents communication questions on
650495 - maintaining test data accurately to coordinate external referral for
650496 - comprehensive patient care. ref SDS 96 CG4I
650498 - ..
650499 - The challenge of comprehensive care requires finding time to capture
650500 - an accurate record of patient history, and then finding critical
650501 - details in time to guide the work. Timely, accurate understanding is
650502 - essential to make both internal and external coordination effective.
650503 - This is reflected in UCSF's letter on 070517 describing difficulties
650504 - coordinating lab work for referral patients. ref SDS 98 CV6K When
650505 - people do not have time to understand correlations, implications, and
650506 - nuance bad implementation with snap judgements from cursory first
650507 - impressions turns good policy into poor care.
CA 15-3 37 Blood Tests 070524 Cancer Marker Begins Rising Possible 4
730401 - ..
730402 - CA 15-3 Cancer Marker 37 Shows Possible Progression of Disease
730404 - Follow up ref SDS 90 087J, ref SDS 87 087J.
730406 - Millie had a blood draw at Kaiser on 070511, and another this morning
730407 - in the Infusion Clinic at UCSF. Results of the test at Kaiser were
730408 - received on 070516, and reported to UCSF at that time. ref SDS 96 J55T
730409 - Results of the test today at UCSF were reported a few days later
730410 - 070531, and show suprising increase from 29 to 37, reported in another
730411 - record today. ref SDS A0 A16M
730413 - ..
730414 - Test Date Date Received
730415 - 070524......... 37 H U........... 070524, ref SDS A0 A16M
730416 - 070511......... 56 H K........... 070516, ref SDS 96 RH9H
730417 - 070426......... 29 ..U........... 070501, ref SDS 92 EQ6I
730418 - 070329......... 33 H U........... 070406, ref SDS 84 EQ6I
730419 - 070301......... 36 H U........... 070307, ref SDS 66 A16M
730420 - 070215......... 52 H K........... 070307, ref SDS 61 ER5O
730421 - 070208......... 55 H K........... 070307, ref SDS 61 ER5O
730422 - 070201.....cetuximab begins...... 070201, ref SDS 59 G68I
730423 - 070131......... 56 H K........... 070202, ref SDS 60 087J
730424 - 070123......... 52 H K........... 070202, ref SDS 60 087J
730425 - 070118......... 68 H K........... 070123, ref SDS 55 GK5B
730426 - 070104......... 56 H K........... 070110, ref SDS 52 087J
730427 - 061218......... 74 H K........... 061227, ref SDS 46 6P9F
730428 - 061214......... 63 H............. 061227, ref SDS 46 6P9F
730429 - 061201....Pause treatments..... . 061201, ref SDS 42 GJ5M
730430 - 061130......... 67 H............. 061201, ref SDS 42 087J
730431 - 061116......... 66 H............. 061201, ref SDS 42 087J
730432 - 061110......... 56 H............. 061201, ref SDS 42 087J
730433 - 061109......... 61 H............. 061110, ref SDS 41 087J
730434 - 061026......... 57 H............. 061110, ref SDS 41 087J
730435 - 061019......... 56 H............. 061020, ref SDS 39 087J
730436 - 060928......... 51 H............. 060929, ref SDS 36 087J
730437 - 060907......... 68 H............. 060929, ref SDS 36 087J
730438 - 060813......... 73 H............. 060817, ref SDS 33 U24M
730439 - 060809......... 87 H............. 060810, ref SDS 32 2N5J
730440 - 060721..Taxotere capecitabine.... 060721, ref SDS 28 0001
730441 - 060708......... 71 H............. 060711, ref SDS 27 087J
730442 - 060616......... 63 H............. 060623, ref SDS 26 UQ5Q
730443 - 060522......... 59 H............. 060605, ref SDS 25 UQ5Q
730444 - 060501......... 49 H............. 060522, ref SDS 24 MC4F
730445 - 060421......... 44 H............. 060428, ref SDS 22 087J
730446 - 060330......... 40 H............. 060428, ref SDS 22 087J
730447 - 060303......... 36............... 060428, ref SDS 22 087J
730448 - 060210......... 33............... 060217, ref SDS 21 087J
730449 - 060109......... 34............... 060126, ref SDS 20 KV59
730451 - ..
730452 - Note: CA 15-3 test history prior to 2006 listed on 070426.
730453 - ref SDS 90 CY4F
730456 - ..
7307 - Analysis
730801 - CA 15-3 37 Cancer Marker Rising Conflicts Favorable CT and Examination
730803 - Follow up ref SDS 90 GJ5M, ref SDS 87 GJ5M.
730805 - ..
730806 - Patient history applying CA 15-3 cancer marker data is shown in a case
730807 - study on 030710. ref SDS 5 IA7H
730809 - ..
730810 - On 070514 Millie notified Kaiser that on 070426 UCSF reported CA 15-3
730811 - 29 in her case. ref SDS 95 IN5P
730813 - ..
730814 - On 070516 Kaiser reported CA 15-3 increased to 56 in Millie's test on
730815 - 070511, 2 weeks after UCSF reported the lowest level in 6 years of
730816 - systemic treatments. Disparity between cancer marker falling below
730817 - the safe level at UCSF, and rising well above at Kaiser was
730818 - disturbing, reviewed below reporting emotional issues. ref SDS 0 Y642
730820 - ..
730821 - CA 15-3 for the blood test today was not available for review during
730822 - the meeting with the medical team at 0830, since blood was drawn later
730823 - at about 0930 in the Infusion Clinic. At 1020, the Lab submitted test
730824 - results, ref SDS A0 A64L, for assessing safety of Millie getting
730825 - chemotherapy today based on ANC (NEUTS) blood counts, which showed
730826 - rising strength in the immune system. ref SDS A0 P560 UCSF contracts
730827 - with an outside company to perform CA 15-3 calibrations, and this
730828 - usually takes a few days. ref SDS A0 A16M
730830 - ..
730831 - [On 070531 UCSF not concerned results of blood test today show
730832 - CA 15-3 37 rising 30% from the prior report on 070426, because
730833 - CT scans show no metastatic cancer, and IBC inflammation
730834 - appears to be subsiding. ref SDS A2 NQ6K
730836 - ..
730837 - A week later, on 070531 Brigid submitted a letter reporting CA 15-3 37
730838 - for the test today using the Roche Elecsys 2010 ECLIA calibration
730839 - method. ref SDS A0 A16M This increased 30% compared to CA 15-3 29
730840 - reported by UCSF a few weeks ago on 070426. ref SDS 90 087J Rising
730841 - cancer marker aligns with concerns raised by Kaiser's test on 070511,
730842 - showing CA 15-3 56 using a different methodology, and reported by
730843 - Kaiser on 070516. ref SDS 96 RH9H
730845 - [On 070625 CA 15-3 30 improved 30% for blood test on 070621
730846 - aligns with clinical findings of IBC subsiding, indicating
730847 - response to treatment with cetuximab alone. ref SDS A5 PD4N
730849 - ..
730850 - On 070516 Millie asked Kaiser to verify results of the report for the
730851 - test on 070511. ref SDS 96 ZJ9N UCSF was also notified of disparity
730852 - in results for tests 2 weeks apart. ref SDS 96 J55T There is no
730853 - record that Kaiser and UCSF have investigated.
730855 - ..
730856 - On 070517 Nurse's Notes at UCSF report elevated CA 15-3. Nurse
730857 - practitioner ordered retest; but, no test was actually performed to
730858 - check on accuracy of test findings. ref SDS 97 FG5N
730860 - ..
730861 - Disparity between Laboratory test results for CA 15-3 occurs in part
730862 - from differences in calibration methods, noted by Kaiser in a letter
730863 - on 070517, which characterized UCSF and Kaiser modalities as "apples
730864 - and oranges." ref SDS 98 NT3O UCSF commented the same day that rising
730865 - cancer marker remarkably different from UCSF diagnostics reported by
730866 - Kaiser does not require consideration to change treatment, nor verify
730867 - test results, and indicated that accuracy of tests can be improved by
730868 - avoiding cross-checking lab results. ref SDS 98 CV6K,
730870 - ..
730871 - If the test today at UCSF had shown further decline of CA 15-3, or if
730872 - it had remained stable, this might have signalled greater concern to
730873 - investigate accuracy of testing at Kaiser and UCSF. Since Kaiser
730874 - diagnostics track the rise at UCSF this may be grounds to ignore
730875 - disparity in test results at this time.
730877 - ..
730878 - CT testing on 070520 was received today at UCSF and shows no basis for
730879 - rising CA 15-3, since the test finds no evidence of metastatic
730880 - disease. ref SDS 0 TV7N Physical examination today further showed
730881 - continuing improvement with IBC inflammation subsiding at all sites.
730882 - ref SDS 0 M68J On 070517 Brigid cited conflicting evidence of rising
730883 - CA 15-3. ref SDS 98 6E4G
730885 - [On 070531 UCSF not concerned results of blood test today show
730886 - CA 15-3 37 rising 30% from the prior report on 070426, because
730887 - CT scans show no metastatic cancer, and IBC inflammation
730888 - appears to be subsiding. ref SDS A2 NQ6K
Lymphadenopathy Axillary No Findings Left Arm Patient No Complaint S
820401 - ..
820402 - Axillary Left Arm No Lymphadenopathy Lymphedema Prominent
820403 - Lymphadenopathy Axillary Left Arm No Evidence Local Edema
820405 - Follow up ref SDS 90 MW8J, ref SDS 87 MW8J.
820407 - Patient has a long history of IBC on the left breast and associated
820408 - lymphadenopathy symptoms in the left axillary, see case study on
820409 - 040517. ref SDS 11 OW3I
820411 - ..
820412 - Brigid examined the left axilla. Clinical palpation made no findings
820413 - of lumps or other indications of cancer, including swelled lymph nodes
820414 - that might indicate lymphadenopathy that has previously occurred with
820415 - CA 15-3 rising, reported at Kaiser and for the test today at UCSF, per
820416 - above. ref SDS 0 087J The patient made no complaint of lumps or
820417 - discomfort from swelling under the left arm. This aligns with CT test
820418 - on 070520 showing no findings of lymphadenopathy, reported today,
820419 - ref SDS 0 B74K, although, there is no express finding that the analyst
820420 - actually looked at the left and right axillary.
Lymphedema Swelling Persistent Left Arm Upper Intensity Subsides Ras
A10401 - ..
A10402 - Lymphedema Cellulitis Complications Resolved Left Arm Swelling
A10403 - Swelling Left Arm Lymphedema Cellulitis Complications Resolved
A10404 - Left Arm Lymphedema Cellulitis Complications Resolved
A10405 - Cellulitis Lymphedema Complications Resolved Left Arm Swelling
A10407 - Follow up ref SDS 90 4Y93, ref SDS 87 4Y93.
A10409 - Medical history of lymphedema in the left arm is reported in a case
A10410 - study on 070130, ref SDS 56 VX6F, including recent increased swelling
A10411 - and inflammation from mild cellulitis diagnosed by the primary care
A10412 - physician during examination at Kaiser on 070330. ref SDS 83 T87G
A10414 - ..
A10415 - The left arm today has continued swelling from lymphedema. Recent
A10416 - measurement below the elbow was 10.75 inches, showing improvement, but
A10417 - increased above previous norms reported in a study on 060509.
A10418 - ref SDS 23 HO7F
A10420 - ..
A10421 - There wasn't enough time again today for discussing correlations
A10422 - between exercise to strengthen the immune system that resists cancer,
A10423 - and helps dissipate emotional stress, reviewed at UCSF on 070315,
A10424 - ref SDS 73 6A7J, but may compound lymphedema with increased swelling,
A10425 - and complications of Cellulitis, discussed at UCSF on 070222.
A10426 - ref SDS 63 GG4H Lymphedema and Cellulitis in relation to side effects
A10427 - of redness that occur on the cetuximab clinical study were considered
A10428 - on 070419. ref SDS 87 F57K
A10430 - ..
A10431 - Examination today shows no evidence of elevated inflammation on the
A10432 - left arm diagnosed at Kaiser on 070330, ref SDS 83 T87G, and
A10433 - consideration on 070419 in connection with rising IBC, cellulitis,
A10434 - and/or side effects of cetuximab. ref SDS 87 115F Findings today
A10435 - support Millie's letter on 070418 reporting resolution of erratic rash
A10436 - on 070330, ref SDS 86 PZ3P, discussed further below reviewing side
A10437 - effects. ref SDS 0 LS8L
A10439 - ..
A10440 - [On 070607 recurrent cellulitis diagnosed during examination at
A10441 - UCSF for treatment of IBC with cetuximab, ref SDS A3 8H3I;
A10442 - condition worsened during treatment in the Infusion Clinic,
A10443 - temperature over 102, ref SDS A3 8J37; UCSF treated Millie with
A10444 - ceftriaxone antibiotics, ref SDS A3 8J9R, cellulitis seemed to
A10445 - subside, and temperature dropped to 101.4, UCSF released Millie
A10446 - to go home, ref SDS A3 8J5C; Kaiser prescribed outpatient
A10447 - ceftriaxone antibiotics for 5 days. ref SDS A3 8L46
IBC Left Arm Examination Stable Subsides Rash Less Intense Conflicts
AG0401 - ..
AG0402 - IBC Left Arm Stable Subsiding Responds Treatment Cetuximab Drug Trial
AG0403 - Left Arm IBC Stable Subsiding Responds Treatment Cetuximab Drug Trial
AG0405 - Follow up ref SDS 90 527G, ref SDS 87 527G.
AG0407 - Examination this moring shows stable to reduced intensity of IBC rash
AG0408 - on the upper left arm.
AG0410 - ..
AG0411 - The area of IBC inflammation on the upper left arm has been stable to
AG0412 - subsiding, i.e., improving by responding to treatment, since the prior
AG0413 - examination at UCSF on 070426. ref SDS 80 527G Observation of IBC
AG0414 - subsiding on the upper left arm aligns with the CT test on 070520 and
AG0415 - received from UCSF this morning, which shows impression of no evidence
AG0416 - for metastatic cancer, per below. ref SDS 0 TV7N
AG0418 - ..
AG0419 - Rising CA 15-3 33 cancer marker reported for the blood test today, per
AG0420 - above, ref SDS 0 087J, seems to conflict with impression of subsiding
AG0421 - IBC rash on the left arm.
AG0423 - ..
AG0424 - Since today starts a new treatment cycle, per above, ref SDS 0 SM6M,
AG0425 - Jackie took photographs for measurable disease.
AG0427 - ..
AG0428 - Brigid took measurements, and indicated the area of rash is about the
AG0429 - same as last month on 070426, ref SDS 90 2E9I, and discussed further
AG0430 - below. ref SDS 0 M652
Right Axillary Lymphadenopathy No Findings Right Arm Patient No Comp
AP0401 - ..
AP0402 - Right Axillary Possible Involvement Red Rash Spreads Right Breast
AP0404 - Follow up ref SDS 90 3D6K, ref SDS 87 3D6K.
AP0406 - Background on patient history testing for lymphadenopathy in the right
AP0407 - axilla is reported in the record on 060929. ref SDS 36 3D6K
AP0409 - ..
AP0410 - Examination of the right axillary yielded the same negative results
AP0411 - finding no evidence of lymphadenopathy, as occurred examining the left
AP0412 - axilla, per above. ref SDS 0 VU6O Also aligns with CT test on 070520,
AP0413 - reviewed during the meeting today, per below. ref SDS 0 B74K
Right Arm Examination Rash Slight Blemishes No Evidence IBC No Findi
AX0401 - ..
AX0402 - IBC Right Arm No IBC Red Rash or Cellulitis
AX0404 - Follow up ref SDS 90 H15M, ref SDS 87 H15M.
AX0406 - Background on slight red dots, rash or blemishes on the right arm is
AX0407 - reported on 070301. ref SDS 65 H15M Examination at that time
AX0408 - concluded the rash is not IBC. Further examination on 070315 reached
AX0409 - the same conclusion, ref SDS 73 FO6H, supported by another review on
AX0410 - 070322. ref SDS 74 LI4M
AX0412 - ..
AX0413 - Examination today yielded no change in analysis that IBC has not
AX0414 - spread to the right arm, and Cellulitis has not occurred in the right
AX0415 - arm. Similarly, there is no evidence of side effects in the right arm
AX0416 - from cetuximab treatment for IBC, reported on 070426. ref SDS 90 H15M
IBC Right Breast Examination Stable Subsides Rash Inflammation Less
B70401 - ..
B70402 - Right Breast IBC Rash Intensity Subsides
B70403 - Rash Right Breast Inflammation Intensity Subsides
B70405 - Follow up ref SDS 90 W58J, ref SDS 87 W58J.
B70407 - ..
B70408 - On 061204 IBC inflammation spread from the left chest area infected
B70409 - with IBC across the sternum and slightly onto the right breast.
B70410 - ref SDS 44 AE5I Since then, IBC has not spread farther. It became
B70411 - more intense through January, and then has continued to subside with
B70412 - treatment.
B70414 - ..
B70415 - Examination of right breast today shows reduced intensity of IBC rash,
B70416 - and there is no spreading of the rash, suggesting favorable response
B70417 - to treatment. This aligns with CT test on 070520 that presents
B70418 - impression of no evidence for metastatic disease, reported below.
B70419 - ref SDS 0 TV7N Rising CA 15-3 33 cancer marker reported for the blood
B70420 - test today, per above, ref SDS 0 087J, may conflict with impression of
B70421 - subsiding IBC on the right breast.
B70423 - ..
B70424 - Today starts a new cycle, so Brigid took measurements; Jackie took
B70425 - photographs, per above, ref SDS 0 2E9I, and discussed further below.
B70426 - ref SDS 0 M652
Rash Chest Right Side Above Breast Below Collar Bone Above Port Cath
BI0401 - ..
BI0402 - Right Chest Rash Not Visible Above Breast and Port Catheter
BI0403 - Rash Above Port Catheter on Right Upper Chest Not Visible Today
BI0405 - Follow up ref SDS 90 583G, ref SDS 87 583G.
BI0407 - Background is reported in the record last week on 070419. ref SDS 87
BI0408 - 583G There has been no further report of inflammation at this
BI0409 - location.
Right Chest Blemish Port Catheter .75" Above Infection .5" Diameter
BW0401 - ..
BW0402 - Port Catheter Infection Blemish Right Chest Blood Culture Investigate
BW0404 - Follow up ref SDS 90 IL3L, ref SDS 87 S640.
BW0406 - Today the entry to the port catheter shows very mild inflammation, if
BW0407 - any, more of a skin blemish. Last week on 070517 Nurse's Notes report
BW0408 - this location is red and tender again, ref SDS 97 UD4K, but today the
BW0409 - site seems normal, indicating resolution of issue observed by Doctor
BW0410 - Rugo on 070419. ref SDS 87 S640
BW0412 - ..
BW0413 - The previous blemish above the port catheter observed on 070419,
BW0414 - ref SDS 87 Q564, now presents no visible impression.
Left Supraclavicular Examination Palpation Neck Lymphadenopathy No F
C50401 - ..
C50402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
C50403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
C50404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
C50406 - Follow up ref SDS 90 8R6M, ref SDS 87 8R6M.
C50408 - During examination on 070130, Doctor Rugo asked about history of
C50409 - radiation to the neck, and sequence of finding recurrence from Doctor
C50410 - Laio's biopsy reported on 040309. ref SDS 8 0001 Background of image
C50411 - testing, and consideration for radiation treatment of left
C50412 - supraclavicular is reported on 060623. ref SDS 26 8R6M
C50414 - ..
C50415 - Like the left and right axillary locations, examination today for
C50416 - cancer in left supraclavicular region found no evidence of lumps or
C50417 - other indications of lymphadenopathy, as reported above, ref SDS 0
C50418 - VU6O, and citing conflict with rising CA 15-3, reported at Kaiser and
C50419 - for the test today at UCSF, also, per above. ref SDS 0 087J CT test
C50420 - on 070520 shows no findings of lymphadenopathy, reported during
C50421 - examination today, per below. ref SDS 0 B74K There is no express
C50422 - finding in the CT test report that the analyst actually looked at the
C50423 - left and right supraclavicular.
C50425 - ..
C50426 - Patient history of cancer recurrence discovered from lymphadenopathy
C50427 - in the left supraclavicular, reported on 040227. ref SDS 7 886G
C50428 - Rising cancer marker reported today at UCSF confirming Kaiser's report
C50429 - on 070516 requires careful examination of this area.
IBC Left Breast Examination Stable No New Sites Rash Intensity Susid
CN0401 - ..
CN0402 - 2 Scenarios IBC Subsides Conflicts CA 15-3 37 Cancer Marker Rises 30%
CN0403 - IBC Rash Left Breast Stomach and Back Seems to Be Subsiding
CN0404 - Examination IBC Rash Subsiding Responding to Treatment Cetuximab
CN0405 - Cetuximab Effective Treatment IBC Subsiding Left Breast Stomach Back
CN0407 - Follow up ref SDS 90 025H, ref SDS 87 025H.
CN0409 - Background of IBC 3rd relapse on left breast beginning on 060623, and
CN0410 - treatment with Taxotere and capecitabine ending on 061201, with
CN0411 - subsequent progression of disease spreading to other areas is reported
CN0412 - on 070301. ref SDS 65 025H
CN0414 - ..
CN0415 - Case study on 070130 shows erratic changes in severity/intensity of
CN0416 - IBC rash on left chest area, with referral to UCSF. ref SDS 56 5N6L
CN0418 - ..
CN0419 - All case studies for Millie's patient history are listed on 061018.
CN0420 - ref SDS 38 0001
CN0422 - ..
CN0423 - Cetuximab treatment started at UCSF on 070201. ref SDS 59 G68I
CN0425 - ..
CN0426 - Strategy for treating progression of disease was reviewed on 070301.
CN0427 - ref SDS 65 1T4O Rising CA 15-3 reported by Kaiser and shown in the
CN0428 - blood test today, per above, ref SDS 0 087J, elevates strategy in
CN0429 - treatment considerations.
CN0431 - ..
CN0432 - Examination today shows intensity of IBC rash continues to subside or
CN0433 - remains stable, and there is no evident expansion of IBC rash areas,
CN0434 - and further there are no new IBC rash sites, as listed on 070301.
CN0435 - ref SDS 65 4140 The current condition today is...
CN0437 - left breast chest................. 060623, ref SDS 26 025H
CN0438 - right breast...................... 061204, ref SDS 44 AE5I
CN0439 - stomach........................... 070130, ref SDS 56 M68J
CN0440 - back.............................. 070130, ref SDS 56 M68J
CN0441 - left arm.......................... 070202, ref SDS 60 6Q5N
CN0443 - ..
CN0444 - Doctor Rugo carefully examined the stomach and back for signs of rash
CN0445 - previously diagnosed on 070130 ref SDS 56 M68J, and noted these rash
CN0446 - areas have nearly disappeared after 4 cycles of treatment with
CN0447 - cetuximab.
CN0449 - [On 070531 UCSF not concerned results of blood test today show
CN0450 - CA 15-3 37 rising 30% from the prior report on 070426, because
CN0451 - CT scans show no metastatic cancer, and IBC inflammation
CN0452 - appears to be subsiding. ref SDS A2 NQ6K
CN0454 - ..
CN0455 - CT test on 070520, and reported by UCSF today, shows no evidence of
CN0456 - metastatic disease progressing, ref SDS 0 TV7N; typically, IBC does
CN0457 - not register well with CT testing, unless analysts look for thickened
CN0458 - skin, illustrated by the record on 030710, ref SDS 5 VM7I, and which
CN0459 - aligned with prior PET test on 021218, reporting uptakes in upper left
CN0460 - chest wall, received from Kaiser on 030109. ref SDS 3 L66M Like the
CN0461 - left and right axillary, reported above, ref SDS 0 VU6O, and, also,
CN0462 - the right breast area, ref SDS 0 613F, examination of the left breast
CN0463 - today finding no evidence of IBC progression appears conflicting with
CN0464 - rising CA 15-3. Patient history shows there is typically a lag
CN0465 - between changes in the cancer marker and observing increased IBC,
CN0466 - ref SDS 0 087J, which suggests requirements for increased scrutiny
CN0467 - with testing and examination for signals to strengthen treatment,
CN0468 - planned under strategy. ref SDS 0 K36G
Prognosis Stable Subsiding IBC Rash Conflicts Rising CA 15-3 37 Canc
CV0401 - ..
CV0402 - Prognosis Good IBC Stable Cetuximab Clinical Study
CV0403 - Stable Low Intensity IBC Rash Very Good Response to Treatment
CV0404 - Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
CV0406 - Follow up ref SDS 90 M645, ref SDS 87 M645.
CV0408 - ..
CV0409 - Subsiding IBC and no new disease sites, ref SDS 0 M68J, together with
CV0410 - favorable CT test reported today, ref SDS 0 TV7N, indicate treatment
CV0411 - with cetuximab alone seems effective at this time, as discussed with
CV0412 - Doctor Rugo on 070130. ref SDS 56 M645 This aligns with Brigid's
CV0413 - report on 070510 that success treating Millie's cancer is remarkable
CV0414 - and unexpected because other patients have had progression of disease
CV0415 - that required adding carboplatin after only a few weeks of treatment
CV0416 - with cetuximab alone. ref SDS 93 6A9H
CV0418 - ..
CV0419 - Rising cancer marker at Kaiser and from testing today at UCSF,
CV0420 - reviewed above, ref SDS 0 GJ5M, indicates possible progression of
CV0421 - disease, which may lead to adding carboplatin called out in the
CV0422 - clinical study protocol, received from UCSF on 070116. ref SDS 53 NL7I
CV0423 - Brigid's letter on 070517 advised that UCSF does not propose changing
CV0424 - treatment based on rising CA 15-3 reported by Kaiser. ref SDS 98 6E4G
CV0425 - This aligns with examination today showing IBC continues to subside,
CV0426 - ref SDS 0 M68J, and with CT test showing not evidence of metastatic
CV0427 - cancer, per below. ref SDS 0 TV7N
CV0429 - [On 070525 primary care physician at Kaiser concurs with UCSF
CV0430 - prognosis and recommends continuing with cetuximab alone.
CV0431 - ref SDS A1 M645
Wicked Problems Complex Compound Issues Policy Conflicts Medical Tes
DT0401 - ..
DT0402 - Wicked Problems Good Management Looks Like Unnecessary Overkill
DT0403 - Communication Coordination Failure Perform Complex Wicked Problems
DT0404 - Comparison Evaluate Progression Lung Heart Disorders Side Effects
DT0405 - Unnecessary Overkill Evaluate Progression Disease Comparison CT Tests
DT0407 - Follow up ref SDS 90 VF5M, ref SDS 87 VF5M.
DT0409 - ..
DT0410 - Wicked problems were reviewed on 070426, ref SDS 90 VF5M, citing
DT0411 - research on 060722 showing complexities of health care cause people to
DT0412 - get confused, mistake, and ignore symptoms of life threatening disease
DT0413 - as expected and benign side effects that patients must tolerate for
DT0414 - cancer treatments. ref SDS 29 346F Difficult problems require
DT0415 - increased scrutiney to recognize correlations, implications and nuance
DT0416 - in time to be effective, especially in Millie's case of personal and
DT0417 - family history that signals high susceptibility, shown by case study
DT0418 - on 060722, ref SDS 29 6G6O, and where treatment has documented risks
DT0419 - of patient preconditions, in this case for lung and heart disorders,
DT0420 - discussed below, ref SDS 0 CV5L, citing the record on 070116.
DT0421 - ref SDS 53 I75I
DT0423 - ..
DT0424 - Scope of CT testing for increased scrutiney of side effects from
DT0425 - cetuximab to evaluate progression of disease for preconditions of
DT0426 - blood clots in the lungs, pulmonary embolism, and enlarged right
DT0427 - ventricle, Cor Pulmonale was discussed with the medical team at UCSF
DT0428 - on 070510 to order CT testing at 1 mm scans rather than 5 mm, which
DT0429 - reduces scrutiney to only 20% of the data. ref SDS 93 VP4H At that
DT0430 - time, UCSF proposed reduced scrutiney at 5 mm intervals, ref SDS 93
DT0431 - XS9L, which conflicts with Millie's patient history identifying lung
DT0432 - and heart disorders with only elevated review using thin slice spiral
DT0433 - CT testing at 1 mm intervals. ref SDS 93 HW5I UCSF explained
DT0434 - increased risks examining only 20% of test data has been effective for
DT0435 - other patients, ref SDS 93 KD5I, and avoids inconvenience of stressful
DT0436 - coordination with Kaiser from team care practice on referral.
DT0437 - ref SDS 93 TK8H Desire to avoid stressful communication coordinating
DT0438 - the work is shown by difficulty arranging referral listed in the case
DT0439 - study on 070130, ref SDS 57 2X6L, difficulty obtaining results of
DT0440 - cancer marker tests shown in a follow up case study on 070307,
DT0441 - ref SDS 70 Q65K, and further difficulty scheduling tests, presented in
DT0442 - another case study on 070307. ref SDS 70 G56L
DT0444 - ..
DT0445 - On 070517 Kaiser notified Millie not to worry about reviewing only 20%
DT0446 - of test data, since this saves Kaiser time and money to treat other
DT0447 - patients. ref SDS 98 OS5G Review on 070517 shows that saving time and
DT0448 - money does not justify reducing test standards for patients that
DT0449 - require increased test scrutiney, per below. ref SDS 0 X24F
DT0451 - ..
DT0452 - Patient history reviewed at that time on 070517 does not support
DT0453 - assurances not to worry in the absence of affirmative test data.
DT0454 - ref SDS 98 KV9G Case study on 061012 shows the Imaging Department at
DT0455 - Kaiser in Walunt Creek CA has consistently ignored doctor's orders to
DT0456 - perform thin slice spiral CT testing, has failed to present patient
DT0457 - history of lung and heart disorders, and failed to compare prior test
DT0458 - findings for evaluating progression of pulmonary embolism and enlarged
DT0459 - right ventricle, ref SDS 37 A55J, which currently presents increased
DT0460 - risk from treatment with cetuximab, discussed by the doctors during
DT0461 - referral arrangements on 061230, ref SDS 48 PN6R, cited in Consent
DT0462 - doucments for the clinical study received on 070116,
DT0464 - ..
DT0465 - This record suggests that team care, referral, collaboration,
DT0466 - communication and coordinating case management present "wicked
DT0467 - problems" for health care that compound inherent difficulties of
DT0468 - complex medical practice. On 070517 UCSF confirmed that referral care
DT0469 - presents difficulties for case management, citing conflicting results
DT0470 - from Laboratories. At that time, UCSF proposed solving this problem
DT0471 - by avoiding cross-checking test data to verify accuracy. ref SDS 98
DT0472 - 466H
DT0474 - ..
DT0475 - Wicked problems evaluating progression of lung and heart disorders
DT0476 - occur tracking case management in the following subjects....
DT0478 - 1. Coordination........................... ref SDS 0 ZP3L
DT0479 - 2. Wicked problems........................ ref SDS 0 VF5M
DT0480 - 3. CT test scope history.................. ref SDS 0 GH5L
DT0481 - 4. CT test scope comparison............... ref SDS 0 0136
DT0482 - 5. Emotional stress....................... ref SDS 0 Y642
DT0483 - 6. Strategy risk management............... ref SDS 0 A67L
DT0484 - 7. Treatment approval..................... ref SDS 0 L49O
DT0485 - 8. Side effects assessment................ ref SDS 0 NY6N
DT0486 - 9. Pulmonary embolism..................... ref SDS 0 CV5L
Measurable Disease IBC CA 15-3 37 Test 070524 Cancer Marker Rises Co
E80401 - ..
E80402 - Measurable Disease IBC No New Sites No Expansion Intensity Declines
E80403 - Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
E80404 - Measurable Disease IBC Observed with Tape Measure Photograph Pictures
E80405 - CA 15-3 Diagnostic Measurable Disease IBC Not Measured by Image Testing
E80407 - Follow up ref SDS 90 M652, ref SDS 87 M652.
E80409 - Background on measurable disease for IBC using cancer biomarker CA
E80410 - 15-3 and photographic records showing spread of cancer is reported in
E80411 - a case study on 070101. ref SDS 49 4Q6K
E80413 - ..
E80414 - CA 15-3 37 at UCSF and 56 at Kaiser present sudden reversal of prior
E80415 - favorable trends, ref SDS 0 087J, with implications of possible
E80416 - progression of disease. see "prognosis." ref SDS 0 M645
E80418 - ..
E80419 - CT testing on 070520 finds no evidence of metastatic disease, shown in
E80420 - the report received today, per below. ref SDS 0 TV7N This aligns with
E80421 - examination that observes no progression of IBC rash. ref SDS 0 M68J
E80423 - ..
E80424 - Jackie and Brigid used procedures reported on 070329, ref SDS 80 EX8O,
E80425 - to take pictures today for the clinical study protocol that show
E80426 - measurable disease of IBC has not expanded, and that intensity of rash
E80427 - sites has subsided, since evaluation of the previous cycle on 070426,
E80428 - also, reported above. ref SDS 0 M68J
Lung Cancer No Discussion Metastatic Disease Nodes Doctor's Progress
EK0401 - ..
EK0402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
EK0403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
EK0405 - Follow up ref SDS 90 G25K, ref SDS 87 G25K.
EK0407 - Background is reported on 070130 in the record meeting with Doctor
EK0408 - Rugo at UCSF. ref SDS 56 G25K Findings of no "interstitial disease"
EK0409 - in the most recent CT test on 070520, shown below, ref SDS 0 SP3F, do
EK0410 - not support concern about lung cancer shown in Kaiser's Medical Chart
EK0411 - on 061208, ref SDS 45 G25K, and further indicates this side effect of
EK0412 - cetuximab treatment has not occurred in Millie's case so far, reported
EK0413 - previously on 070329. ref SDS 80 123I Interstitial lung disease was
EK0414 - listed in the clincial study Consent documents received from UCSF on
EK0415 - 070116. ref SDS 53 0256
EK0417 - ..
EK0418 - There was no discussion of this issue today, so that attention could
EK0419 - focus on assessing Millie's response to treatment for IBC, with
EK0420 - analysis of rising CA 15-3 cancer marker, per above. ref SDS 0 GJ5M
CT Test Distant Metastasis No Findings Lymphadenopathy Cancer CT Sca
EQ0401 - ..
EQ0402 - CT Test 070520 No Findings Metastatic Disease
EQ0404 - Follow up ref SDS 80 EY5O, ref SDS 65 EY5O.
EQ0406 - Report on results for the CT test on 070520, as scheduled on 070516,
EQ0407 - ref SDS 96 EF9M, was received today during the meeting. Impressions
EQ0408 - of no metastatic disease, ref SDS 0 TV7N, align with patient history
EQ0409 - showing no evidence of regional nor distant metastasis, reported
EQ0410 - previously on 070329 for the test on 070326. ref SDS 80 EY5O
EQ0412 - [On 070802 received next CT test. ref SDS A6 O85M
EQ0414 - ..
EQ0415 - Test History No Evidence Distant Metastasis
EQ0416 - Distant Metastasis No Evidence 5 Years Imaging Tests
EQ0418 - Follow up ref SDS 80 DA8O, ref SDS 60 GB8J.
EQ0420 - Type Date Received Source
EQ0421 - CT 070520 reported on 070524........... ref SDS 0 DA6Q
EQ0422 - CT 070326 reported on 070329........... ref SDS 80 DA6Q
EQ0423 - CT 070131 reported on 070202........... ref SDS 60 1Y8G
EQ0424 - PET/CT 061227 reported on 070102........... ref SDS 50 1Y8G
EQ0425 - CT 060930 reported on 061012........... ref SDS 37 284J
EQ0426 - MRI 060708 reported on 060711........... ref SDS 27 PT4K
EQ0427 - Xray 060623 reported on 060711........... ref SDS 27 WJ6G
EQ0428 - CT 060505 reported on 060523........... ref SDS 24 E355
EQ0429 - PET 060414 reported on 060428........... ref SDS 22 WJ6G
EQ0430 - PET 060120 reported on 060126........... ref SDS 20 WJ6G
EQ0431 - PET/CT 051005 reported on 051007........... ref SDS 19 WJ6G
EQ0432 - CT 050530 reported on 050610........... ref SDS 18 G75L
EQ0433 - CT 050325 reported on 050422........... ref SDS 17 G75L
EQ0434 - CT 041217 reported on 041230........... ref SDS 16 G75L
EQ0435 - CT 041103 reported on 041104........... ref SDS 15 WV7H
EQ0436 - CT 040921 reported on 041005........... ref SDS 13 NL4N
EQ0437 - CT 040710 reported on 040811........... ref SDS 12 H85S
EQ0438 - CT 040410 reported on 040416........... ref SDS 10 LK5L
EQ0439 - CT 040307 reported on 040318........... ref SDS 9 LK5L
EQ0440 - CT 031031 reported on 031205........... ref SDS 6 IG9K
EQ0441 - CT 030626 reported on 030710........... ref SDS 5 AL6N
EQ0442 - CT 030428 reported on 030508........... ref SDS 4 LK5L
EQ0443 - PET 021218 reported on 030109........... ref SDS 3 LK5L
EQ0444 - PET 020529 reported on 020603........... ref SDS 2 0001
EQ0447 - ..
EQ0448 - Patient Personal Physician 71/F Radiology Report
EQ0452 - ..
EQ0453 - CT Scan Chest, Abdomen and Pelvis with Contrast (Digital)
EQ0456 - ..
EQ0457 - Ordered on 05/20/2007 15:13 at WCR OUTPATIENT
EQ0460 - ..
EQ0461 - CT CHEST, ABDOMEN, PELVIS
CT Test 070520 History Identifies Breast Cancer Mistakes Testing Fai
F50401 - ..
F50402 - History Missing Context Pulmonary Embolism Enlarged Right Ventricle
F50404 - Follow up ref SDS 80 GH5L. ref SDS 60 0Z6O.
F50406 - ..
F50407 - HISTORY
F50409 - Metastatic breast cancer
F50411 - ..
F50412 - This report repeats past practice omitting context of patient history
F50413 - on pulmonary embolism and Cor Pulmonale heart disorder enlarged right
F50414 - ventricle. Millie's patient history of lung and heart disorders was
F50415 - diagnosed by Kaiser in a report on a CT test performed on 060930, and
F50416 - received from Kaiser on 061012. ref SDS 37 294Q Kaiser CT tests on
F50417 - 070131, and reviewed on 070202, ref SDS 60 0Z6O, and again on 070326,
F50418 - reviewed on 070329 all present the same mistake of listing only cancer
F50419 - and omitting lung and heart disorders. ref SDS 80 GH5L
F50421 - ..
F50422 - Background on managing context to interpret testing is also presented
F50423 - on 070202. ref SDS 60 4I3N
F50425 - ..
F50426 - CT test report continues...
F50428 - Methods
F50430 - Scans were done through the chest, abdomen and pelvis in
F50431 - the axial projection.
F50433 - ..
F50434 - IV contrast: Yes
F50435 - Oral contrast: Yes
F50436 - Reformations: No
F50438 - ..
F50439 - This is the same explanation for the test at Kaiser on 070326, and
F50440 - reported on 070329. ref SDS 80 GR4G
CT Test 070520 Comparison Failed Perform Context Management Missing
FN0401 - ..
FN0402 - Comparison: 070326 070131 061230 060930 Omitted Chronic Mistakes
FN0404 - Follow up ref SDS 80 0136, ref SDS 60 0136.
FN0406 - Comparison [omitted]
FN0408 - ..
FN0409 - Failure to track patient history of lung and heart disorders, per
FN0410 - above, ref SDS 0 GH5L, aligns with failure to perform analysis for the
FN0411 - CT test on 070520 to assess progression of lung and heart disease by
FN0412 - performing comparison with the CT test on 060930 that diagnosed
FN0413 - pulmonary embolism, and enlarged right ventricle, reported on 061012,
FN0414 - ref SDS 37 294Q, presents a recurrent problem shown in case study at
FN0415 - that time on 061012. ref SDS 37 A55J
FN0417 - ..
FN0418 - Requirements to distinguish lung and heart preconditions with symptoms
FN0419 - of fatigue, weakness, and shortness of breath, cited in patient
FN0420 - history, per above, ref SDS 0 GH5L, were reviewed on 061230 by Kaiser
FN0421 - and UCSF considering treatment with cetuximab. ref SDS 48 PN6R
FN0422 - Clinical study Consent documents received on 070116 list lung and
FN0423 - heart disorders as side effects to monitor safety of patients.
FN0424 - ref SDS 53 I75I Since fatigue, tiredness and weakness are, also, side
FN0425 - effects of cetuximab treatments, also, listed in the Consent documents
FN0426 - reviewed on 070116, ref SDS 53 O64M, this context of common symptoms
FN0427 - presents a "wicked problem" distinguishing side effects that must be
FN0428 - ignored to benefit from cancer treatments, from avoiding progression
FN0429 - of lung and heart disease in time to be effective avoiding death.
FN0430 - Complex, difficult problems that risk death require increased
FN0431 - scrutiney, discussed above. ref SDS 0 VF5M On 070130 Doctor Rugo
FN0432 - planned regular CT testing for increased scrutiney. ref SDS 56 456H
FN0434 - ..
FN0435 - Evaluating progression of lung and heart disease requires comparison
FN0436 - to make sense of findings based on context of patient history, and was
FN0437 - considered in the record on 070329, reviewing the report for the CT
FN0438 - test on 070326 that failed to perform comparisons. ref SDS 80 NO9O
FN0439 - Comparison of the test on 070520 with prior findings on 060930 was
FN0440 - planned on 070419, ref SDS 87 4M5K, to correct errors in testing on
FN0441 - 070131, which Kaiser planned to rememdy on 070202, ref SDS 60 T85F,
FN0442 - and again in the test on 070326, which Kaiser planned to correct on
FN0443 - 070330. ref SDS 83 0136
FN0445 - ..
FN0446 - On 070517 Kaiser disclosed a new policy saving time and money to care
FN0447 - for more patients by examining only 20% of test data scanned at 1 mm
FN0448 - intervals, and to avoid comparisons for assessing progression of
FN0449 - disease. ref SDS 98 OS5G Review shows that failure to apply policy in
FN0450 - the context of patient history fails to meet requirements for
FN0451 - effective care. ref SDS 98 WX8I
FN0453 - ..
FN0454 - Failure to evaluate progression of lung and heart disorders affects
FN0455 - case management in the following subjects....
FN0457 - 1. Coordination.............................. ref SDS 0 ZP3L
FN0458 - 2. Wicked problems........................... ref SDS 0 VF5M
FN0459 - 3. CT test scope history..................... ref SDS 0 GH5L
FN0460 - 4. CT test scope comparison.................. ref SDS 0 0136
FN0461 - 5. Emotional stress.......................... ref SDS 0 Y642
FN0462 - 6. Strategy risk management.................. ref SDS 0 A67L
FN0463 - 7. Treatment approval........................ ref SDS 0 L49O
FN0464 - 8. Side effects assessment................... ref SDS 0 NY6N
FN0465 - 9. Pulmonary embolism........................ ref SDS 0 CV5L
FN0466 - 10. Cor pulmonale enlarged right.ventricle.... ref SDS 0 VJ4J
CT Test 070520 Findings No Cancer Lymphadenopathy No Evidence Metast
FX0401 - ..
FX0402 - CT Scan Failed to Test for Pulmonary Embolism Cor Pulmonale
FX0403 - Cancer No Findings Lymphadenopathy No Evidence Metastatic Disease
FX0405 - Follow up ref SDS 80 B74K ref SDS 60 013T.
FX0407 - Findings...
FX0408 - ..
FX0409 - Chest CT
FX0411 - Mediastinum: No abnormally enlarged lymph nodes.
FX0413 - Heart: Normal
FX0415 - Hila: No abnormally enlarged lymph nodes
FX0417 - ..
FX0418 - Lungs: The previously described 4 very small 2-3mm
FX0419 - nodules are all stable. No new lung nodules identified.
FX0420 - no interstitial disease. Scarring in the left apex is
FX0421 - stable; likely post radiation fibrosis.
FX0423 - [On 071018 CT test on 070930 reports some
FX0424 - interstitial prominence and ground-glass opacity
FX0425 - within the right lower lobe medially, is slightly
FX0426 - increased, seems conflicting with the CT test on
FX0427 - 070723 reviewed on 070802 that makes no finding of
FX0428 - interstitial disease, ref SDS A6 OX4O, and which was
FX0429 - expressly found not to exist in the test on 070520,
FX0430 - reviewed today. ref SDS 0 SP3F
FX0432 - ..
FX0433 - Pleura: Normal
FX0435 - ..
FX0436 - Effusions: None
FX0438 - ..
FX0439 - Bony thorax and soft tissues: S/P left mastectomy.
FX0440 - Portacath remains in right anterior chest wall entering
FX0441 - rt subclavian vein.
FX0443 - ..
FX0444 - No change in the fat stranding in the left axilla.
FX0446 - ..
FX0447 - ABDOMEN CT:
FX0449 - Liver: Normal size. Cyst in the dome unchanged.
FX0451 - Gallbladder and bile ducts: Normal
FX0453 - Spleen: Stable. Calcified granuloma and calcified
FX0454 - splenic artery aneurysm are stable.
FX0456 - ..
FX0457 - Pancreas: Normal
FX0458 - Right Kidney: Normal
FX0459 - Left Kidney: Normal
FX0460 - Adrenal glands: Normal
FX0461 - Aorta: Normal
FX0462 - Adenopathy: No abnormally enlarged lymph nodes.
FX0463 - Ascites: None
FX0465 - ..
FX0466 - Bowel and Mesentery: Normal. Diverticuli in the sigmoid
FX0467 - colon.
FX0469 - ..
FX0470 - Pelvis CT:
FX0472 - s/p hysterectomy. Left ovarian tissue appears to be
FX0473 - present. The right ovary is not seen.
FX0475 - ..
FX0476 - Regional skeleton: No metastatic lesions seen. There
FX0477 - are degenerative changes.
FX0479 - ..
FX0480 - IMPRESSION
FX0482 - No change. No evidence for metastatic disease.
FX0489 - ..
FX0490 - [On 070531 UCSF not concerned results of blood test today
FX0491 - show CA 15-3 37 rising 30% from the prior report on 070426,
FX0492 - because CT scans show no metastatic cancer, and IBC
FX0493 - inflammation appears to be subsiding. ref SDS A2 NQ6K
FX0495 - ..
FX0496 - Research indicates that Susan graduated from the Lucas Center at
FX0497 - Stanford University in 2002, shown at...
FX0499 - http://rsl.stanford.edu/lucas/report/lucas_report-2002.pdf
FX0501 - ..
FX0502 - Gary H. Glover is the Director, Radiological Sciences Laboratory at
FX0503 - Stanford.
FX0505 - http://rsl.stanford.edu/glover/
FX0507 - email@example.com
FX0509 - ..
FX0510 - 650-723-7577
Emotional Trauma Stress Moderate Pulse Normal Cancer Subsides Reliev
GA0401 - ..
GA0402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
GA0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
GA0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
GA0406 - Follow up ref SDS 90 Y642, ref SDS 87 Y642.
GA0408 - Medical issues create an emotional roller coaster explained on 070105,
GA0409 - ref SDS 51 Y642, and reviewed on 070301. ref SDS 65 Y642 Stress and
GA0410 - trauma are compounded with rising complexity of case history, listed
GA0411 - above. ref SDS 87 LU3J
GA0413 - ..
GA0414 - Improved prognosis, ref SDS 0 M645, and better coordination,
GA0415 - ref SDS 0 ZO6F, relieve stress reflected in Millie's vitals that
GA0416 - remain calm today, e.g., pulse below 60, ref SDS 0 KB5L, and reported
GA0417 - in patient history for treatment after examination. ref SDS A0 AW4L
GA0419 - [On 070607 sudden attack of Lymphedema and Cellulitis that
GA0420 - require emergency care cause emotional stress to accelerate
GA0421 - like a roller coaster. ref SDS A3 6A7J
GA0423 - ..
GA0424 - Sudden rise of the cancer marker reported at Kaiser on 070516, and
GA0425 - confirmed by UCSF today, per above, increase worry and doubt that
GA0426 - create emotional disturbance, noted above. ref SDS 0 VH68 Kaiser
GA0427 - reporting on 070516 that substantial rise of cancer marker is
GA0428 - "stable," ref SDS 96 QN6M, casts further doubt about communication
GA0429 - channels essential for collaborating on referral care. ref SDS 96 CG4I
GA0431 - ..
GA0432 - Communication breakdowns between UCSF and Kaiser failing to
GA0433 - coordinate, verify, and reconcile lab results, ref SDS 0 4L6N, create
GA0434 - doubt about reliance on test reports that increase stress.
GA0436 - [On 070610 Kaiser reported the right channels for communication
GA0437 - are now open with UCSF for coordinating referral work.
GA0438 - ref SDS A4 OG7F
GA0440 - ..
GA0441 - Coordination difficulties between Oncology and the Imaging Department
GA0442 - at Kaiser, and referral issues with UCSF, noted above, on evaluating
GA0443 - progression of of lung and heart disease, ref SDS 0 ZP4N, during
GA0444 - treatment on the cetuximab clinical study add stress when doctors are
GA0445 - prevented from performing case management based on patient history,
GA0446 - with implications for diagnosis, and treatment. ref SDS 0 L49O As a
GA0447 - result, emotional stress occurs tracking case management in the
GA0448 - following subjects....
GA0450 - 1. Coordination........................... ref SDS 0 ZP3L
GA0451 - 2. Wicked problems........................ ref SDS 0 VF5M
GA0452 - 3. CT test scope history.................. ref SDS 0 GH5L
GA0453 - 4. CT test scope comparison............... ref SDS 0 0136
GA0454 - 5. Emotional stress....................... ref SDS 0 Y642
GA0455 - 6. Strategy risk management............... ref SDS 0 A67L
GA0456 - 7. Treatment approval..................... ref SDS 0 L49O
GA0457 - 8. Side effects assessment................ ref SDS 0 NY6N
GA0458 - 9. Pulmonary embolism..................... ref SDS 0 CV5L
Strategy Continue Planning on 070419 Distinguish IBC Progression fro
GR0401 - ..
GR0402 - Planning Case Management from Patient Profile Work Up
GR0403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
GR0404 - Strategy Cetuximab Continued with Low ANC Expanding IBC Disease
GR0406 - Follow up ref SDS 90 K36G, ref SDS 87 K36G.
GR0408 - Background is reported on 070301. ref SDS 65 K36G
GR0410 - ..
GR0411 - Sudden increase of CA 15-3 cancer marker reported by UCSF and Kaiser,
GR0412 - noted above, ref SDS 0 087J, increase attention on strategy for the
GR0413 - treatment plan. On 070517 UCSF advised in a letter that Kaiser's
GR0414 - report of rising CA 15-3 does not require considerations for changing
GR0415 - treatments. ref SDS 98 6E4G
GR0417 - ..
GR0418 - Current strategy and planning to add carboplatin with progression of
GR0419 - disease is listed in the record on 070419, ref SDS 87 883I, including
GR0420 - coordination issues, ref SDS 87 RM4G, supplemented by further review
GR0421 - today, per above. ref SDS 0 ZO6F
GR0423 - ..
GR0424 - UCSF Strategy of increased scrutiney to avoid "wicked problems"
GR0425 - distinguishing lung and heart disorders caused by cetuximab treatments
GR0426 - that otherwise relieve IBC disease from side effects of chemotherapy
GR0427 - that must be tolerated and ignored to treat cancer, by using CT
GR0428 - testing for progression of pulmonary embolism and enlarged right
GR0429 - ventricle, per above, ref SDS 0 X24F, was prevented by Kaiser's new
GR0430 - strategy to save time and money for treating other patients with a
GR0431 - policy of reduced scrutiney to review only 20% of test data, and not
GR0432 - performing comparisons to assess progression of lung and heart
GR0433 - disorders. discussed above, ref SDS 0 AL6J, and considering approval
GR0434 - for continuing cetuximab treatments. ref SDS 0 L49O
GR0436 - ..
GR0437 - Failure to evaluate progression of lung and heart disorders affects
GR0438 - case management in the following subjects....
GR0440 - 1. Coordination........................... ref SDS 0 ZP3L
GR0441 - 2. Wicked problems........................ ref SDS 0 VF5M
GR0442 - 3. CT test scope history.................. ref SDS 0 GH5L
GR0443 - 4. CT test scope comparison............... ref SDS 0 0136
GR0444 - 5. Emotional stress....................... ref SDS 0 Y642
GR0445 - 6. Strategy risk management............... ref SDS 0 A67L
GR0446 - 7. Treatment approval..................... ref SDS 0 L49O
GR0447 - 8. Side effects assessment................ ref SDS 0 NY6N
GR0448 - 9. Pulmonary embolism..................... ref SDS 0 CV5L
Treatment IBC 12th Cycle 3rd Relapse 5th Cycle 1st Treatment Chemoth
GX0401 - ..
GX0402 - Treatment IBC 3rd Relapse Start 5th Cycle Cetuximab Clinical Study
GX0403 - Cetuximab 5th Cycle Treatment IBC 3rd Relapse Clinical Study UCSF
GX0405 - Follow up ref SDS 90 7X6N, ref SDS 87 PF3O.
GX0407 - Patient history of cetuximab treatments in the Infusion Clinic is
GX0408 - listed in the record for today. ref SDS A0 7T3H
GX0410 - ..
GX0411 - Examination today showing treatment has been effective supports
GX0412 - approval for Millie to start the 5th cycle of treatment with cetuximab
GX0413 - alone, in accordance with strategy reviewed on 070329, ref SDS 80
GX0414 - 1R9H, considered again by Doctor Rugo on 070419. ref SDS 87 883I, and
GX0415 - reviewed today, per above. ref SDS 0 K36G UCSF advised that rising CA
GX0416 - 15-3, which can signal progression of cancer, does not justify
GX0417 - changing treatment at this time, per review above. ref SDS 0 4L6N
GX0419 - [On 070625 CA 15-3 30 improved 30% for blood test on 070621 aligns
GX0420 - with clinical findings of IBC subsiding, indicating response to
GX0421 - treatment with cetuximab alone. ref SDS A5 PD4N
GX0423 - ..
GX0424 - Strategy for managing risks of cetuximab compounding lung and heart
GX0425 - disorders, per above, ref SDS 0 A67L, was also reviewed on 070419.
GX0426 - ref SDS 87 RQ7K On 070510 discussed coordinating with Kaiser on
GX0427 - evaluating preconditions of pulmonary embolism and enlarged right
GX0428 - ventricle using thin slice spiral technology because patient history
GX0429 - shows this method has been effective in Millie's case. UCSF noted
GX0430 - that six (6) other patients in the clinical study are tested without
GX0431 - thin slice spiral CT test technology. ref SDS 93 VP4H Previously, on
GX0432 - 041018 Doctor Benz noted that Kaiser should investigate growing
GX0433 - symptoms of pulmonary embolism, which many CT tests without thin slice
GX0434 - spiral technology failed to diagnose. ref SDS 14 LX42 Kaiser
GX0435 - investigated with thin slice spiral CT testing, and on 041104
GX0436 - diagnosed Millie's condition of pulmonary embolism, which resulted in
GX0437 - major change to her treatment, ref SDS 15 RZ4I, similar to
GX0438 - considerations today.
GX0440 - ..
GX0441 - On 070514 Millie coordinated with Kaiser to implement plans for follow
GX0442 - up testing to assess risks of cetuximab treatments on compounding
GX0443 - preconditions of lung and heart disorders. ref SDS 95 IN4V Without
GX0444 - support from UCSF, Kaiser reported on 070517 that all CT scans at
GX0445 - Kaiser (presumably Walnut Creek facility) use thin slice spiral
GX0446 - technology, but that unless the doctor orders a full review, only 20%
GX0447 - of the scans are examined. The doctor presented Kaiser's policy
GX0448 - position that examining 20% of the data saves Kaiser a lot of time and
GX0449 - money that can be used to help other patients. The doctor also noted
GX0450 - that even if Kaiser found advancing lung and heart disease with
GX0451 - cetuximab, this would not affect case management, ref SDS 98 D66M,
GX0452 - contrary to practice on 041104, when Kaiser immediately ended
GX0453 - treatment that was associated with blood clots in the lungs.
GX0455 - ..
GX0456 - Treatment was approved this morning for Millie to begin the 5th cycle
GX0457 - on the cetuximab clinical study. Approval was based on tests today
GX0458 - showing NEUTS blood counts increased to 1.84, which is a safe level
GX0459 - for treatment using UCSF criteria, ref SDS A0 P560, and in accordance
GX0460 - with Nurse's Notes for treatment on 070426 citing standard practice to
GX0461 - test blood counts for safe treatment in advance of giving treatment.
GX0462 - ref SDS 91 ME4H Approval was further based on CT testing at Kaiser on
GX0463 - 070520 finding no metastatic disease, indicating cetuxumab treatment
GX0464 - has been effective for Millie, reported above. ref SDS 0 TV7N
GX0465 - Kaiser's report for the CT test on 070520 further presents no findings
GX0466 - on lung and heart disorders. ref SDS 0 B74K Kaiser's standards for
GX0467 - review on 070517 treat silence as finding stability. ref SDS 98 OS5G
GX0468 - UCSF standards on 070510 seem to present silence from reviewing 20% of
GX0469 - the data adequate for evaluating risks, ref SDS 93 KD5I, which have
GX0470 - never been effective diagnosing lung and heart disorders in Millie's
GX0471 - case, reviewed on 070517, ref SDS 98 WX91, citing prior discussion on
GX0472 - 070510. ref SDS 93 HW5I
GX0474 - ..
GX0475 - Failure to evaluate progression of lung and heart disorders affects
GX0476 - case management in the following subjects....
GX0478 - 1. Coordination........................... ref SDS 0 ZP3L
GX0479 - 2. Wicked problems........................ ref SDS 0 VF5M
GX0480 - 3. CT test scope history.................. ref SDS 0 GH5L
GX0481 - 4. CT test scope comparison............... ref SDS 0 0136
GX0482 - 5. Emotional stress....................... ref SDS 0 Y642
GX0483 - 6. Strategy risk management............... ref SDS 0 A67L
GX0484 - 7. Treatment approval..................... ref SDS 0 L49O
GX0485 - 8. Side effects assessment................ ref SDS 0 NY6N
GX0486 - 9. Pulmonary embolism..................... ref SDS 0 CV5L
Side Effects Cetuximab Acne-like Rash Face Dry Skin Face Chest Arms
HB0401 - ..
HB0402 - Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
HB0403 - Energy Strength Rising Minimal Side Effects Cetuximab Treatment
HB0404 - Facial Skin Dryness New Side Effect Cetuximab Curel Lotion Prescribed
HB0405 - Curel Lotion Prescribed Facial Skin Dryness New Side Effect Cetuximab
HB0407 - Follow up ref SDS 90 TQ6L, ref SDS 87 TQ6L.
HB0409 - Side effects of cetuximab treatment are listed in the record receiving
HB0410 - treatment today in the Infusion Clinic, ref SDS A0 QU8K, and were
HB0411 - presented in the Clinical Study Consent form received from UCSF on
HB0412 - 070116. ref SDS 53 O64M
HB0414 - ..
HB0415 - Doctor Rugo observed continuing minimal acne-like rash on the face,
HB0416 - noted previously during examination on 070419, ref SDS 87 847H, and
HB0417 - earlier by the primary care physician at Kaiser on 070330. ref SDS 83
HB0418 - N49K Details are shown in the record on treatment in the Infusion
HB0419 - Clinic later today. ref SDS A0 QU8K
HB0421 - ..
HB0422 - Erratic changes in intensity of IBC rash on upper left arm, and other
HB0423 - sites, as well as concern about Cellulitis and side effects of
HB0424 - cetuximab treatments have subsided, since starting the previous cycle
HB0425 - on 070426, as discussed above, ref SDS 0 4Y93, and reviewed further in
HB0426 - the record today for treatment in the Infusion Clinic, ref SDS A0 SU6L
HB0428 - ..
HB0429 - Causes of changes in rash intensity were listed on 070426. ref SDS 91
HB0430 - 8B8Y
HB0432 - ..
HB0433 - Millie continues to feel good, reported on 070419. ref SDS 87 8477
HB0435 - ..
HB0436 - Fatigue shown by sleeping for several hours after getting home was
HB0437 - first reported on 070419, ref SDS 87 H59I, and continued today.
HB0438 - ref SDS A0 BB7G
HB0440 - ..
HB0441 - Strategy to use CT tests, was presented by Doctor Rugo during the
HB0442 - meeting at UCSF on 070130, ref SDS 56 JG5K, for managing side effects
HB0443 - of cetuximab that cause complications of lung and heart disorcers,
HB0444 - blood clots in the lungs, pulmonary embolism, enlarged right
HB0445 - ventricle, Cor Pulmonale, etc., listed in the Consent document for
HB0446 - getting treatment in the Cetuximab Clinical Study, reviewed on 070116.
HB0447 - ref SDS 53 I75I CT testing helps avoid wicked problems of cetuximab
HB0448 - side effects masking symptoms when life threatening progression of
HB0449 - disease occurs, per above, ref SDS 0 A67L, and discussed further
HB0450 - below. ref SDS 0 XR9N Complex, "wicked" problems that required
HB0451 - increased scrutiney are reviewed above. ref SDS 0 VF5M
HB0453 - ..
HB0454 - Failure to evaluate progression of lung and heart disorders from side
HB0455 - effects of treatment with cetuximab affects case management in the
HB0456 - following subjects....
HB0458 - 1. Coordination........................... ref SDS 0 ZP3L
HB0459 - 2. Wicked problems........................ ref SDS 0 VF5M
HB0460 - 3. CT test scope history.................. ref SDS 0 GH5L
HB0461 - 4. CT test scope comparison............... ref SDS 0 0136
HB0462 - 5. Emotional stress....................... ref SDS 0 Y642
HB0463 - 6. Strategy risk management............... ref SDS 0 A67L
HB0464 - 7. Treatment approval..................... ref SDS 0 L49O
HB0465 - 8. Side effects assessment................ ref SDS 0 NY6N
HB0466 - 9. Pulmonary embolism..................... ref SDS 0 CV5L
Cetuximab Clinical Study UCSF Drug Trial Clinical Examination IBC Su
HL0401 - ..
HL0402 - Cetuximab UCSF Clinical Study Treatment Begins 070201
HL0403 - UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
HL0404 - Drug Trials UCSF Has Other Clinical Study Treatments May Help Millie
HL0406 - Follow up ref SDS 90 ZJ9N, ref SDS 87 ZJ9N.
HL0408 - UCSF advised today that treatment with cetuximab alone on the clinical
HL0409 - study continues to be effective, shown by CT test on 070520 finding no
HL0410 - evidence of metastatic disease, and reported today, per above,
HL0411 - ref SDS 0 TV7N, and which aligns with clincial examination today,
HL0412 - also, shown above. ref SDS 0 M68J
HL0414 - ..
HL0415 - Sudden 30% rise of CA 15-3 37 cancer biomarker, per above, ref SDS 0
HL0416 - 087J, was explained by UCSF as conflicting with CT testing, which does
HL0417 - not typically register findings of IBC, reviewed above, ref SDS 0
HL0418 - EZ4G, and by observations that seem to show continued response to
HL0419 - treatment.
HL0421 - ..
HL0422 - Strategy to add carboplatin, and transition to an Avastin trial, as
HL0423 - needed, was most recently reviewed on 070419. ref SDS 87 838N On
HL0424 - 070517 UCSF advised that changing treatment is not needed at this
HL0425 - time, ref SDS 98 6E4G, and was affirmed during the meeting today, per
HL0426 - above. ref SDS 0 X68L
HL0428 - ..
HL0429 - Strategy to use CT tests for monitoring progression of lung and heart
HL0430 - disorders from side effects of treatment with cetuximab is discussed
HL0431 - above, ref SDS 0 NY6N, citing coordination issues with referral work
HL0432 - on the scope of CT tests, ref SDS 0 ZP3L, for increased scrutiney of
HL0433 - pulmonary embolism and enlarged right ventricle, discussed below.
HL0434 - ref SDS 0 XR9N
Schedule Treatment Cetuximab 070524 Weekly Through 070802 Clinical S
HX0401 - ..
HX0402 - Schedule Treatment Start Cetuximab Carboplatin 070201
HX0404 - Follow up ref SDS 90 N96O, ref SDS 87 N96O.
HX0406 - ..
HX0407 - On 070510 Nola in the Infusion Clinic scheduled Millie for weekly
HX0408 - treatments through August 2nd. ref SDS 93 QK6L
HX0410 - ..
HX0411 - Meetings and treatments continue on Thursdays, so the next meeting at
HX0412 - UCSF with the medical team will be on 070607 prior to getting the 3rd
HX0413 - treatment of cycle #5, and then Millie will meet with the medical team
HX0414 - on 070621, to start the 6th cycle, as shown on 070510. ref SDS 73 NM4M
Pulmonary Embolism Blood Clots Lung Disorder Enlarged Right Ventricl
IB0401 - ..
IB0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
IB0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
IB0404 - Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
IB0406 - Follow up ref SDS 90 CV5L, ref SDS 87 CV5L.
IB0408 - Background on pulmonary embolism and correlation with IBC treatment
IB0409 - with cetuximab that has documented side effects of blood clots in the
IB0410 - lungs, and heart disorders noted in Consent materials received on
IB0411 - 060116, ref SDS 53 I75I, is reported in the record meeting with the
IB0412 - medical team at UCSF on 070130, ref SDS 56 CV5L, citing requirements
IB0413 - to increase scrutiney for progression of lung and heart preconditions
IB0414 - diagnosed at Kaiser by CT testing on 060930, reported on 061012. The
IB0415 - need for increased scrutiney to check for progression of lung and
IB0416 - heart disorders was updated on 070329 when the CT test on 070326
IB0417 - failed to report findings and comparisons to assess progression of
IB0418 - pulmonary embolism, and enlarged right ventricle, ref SDS 80 LZ6H,
IB0419 - noted as well the next day at Kaiser on 070330. ref SDS 83 NU55
IB0421 - ..
IB0422 - As shown above, the recent CT test at Kaiser on 070520 failed again to
IB0423 - compare findings for evaluating progression of lung and heart
IB0424 - disorders needed to evaluate compounding effects of treatment with
IB0425 - cetuximab, noted above. ref SDS 0 0136
IB0427 - ..
IB0428 - Requirements for increased scrutiney of "wicked," complex problems to
IB0429 - avoid mistaking side effects of cetuximab and failing to treat
IB0430 - complications from blood clots in the lungs, pulmonary embolism, and
IB0431 - enlarged right ventricle are discussed above. ref SDS 0 NZ4F Failure
IB0432 - to evaluate progression of lung and heart disorders from side effects
IB0433 - of treatment with cetuximab affects case management in the following
IB0434 - subjects....
IB0436 - 1. Coordination........................... ref SDS 0 ZP3L
IB0437 - 2. Wicked problems........................ ref SDS 0 VF5M
IB0438 - 3. CT test scope history.................. ref SDS 0 GH5L
IB0439 - 4. CT test scope comparison............... ref SDS 0 0136
IB0440 - 5. Emotional stress....................... ref SDS 0 Y642
IB0441 - 6. Strategy risk management............... ref SDS 0 A67L
IB0442 - 7. Treatment approval..................... ref SDS 0 L49O
IB0443 - 8. Side effects assessment................ ref SDS 0 NY6N
IB0444 - 9. Pulmonary embolism..................... ref SDS 0 CV5L
IB0447 - ..
IB0448 - INR 2.2 Blood Test Patient Stable for Coumadin Treatments Pulmonary Emboli
IB0450 - Follow up ref SDS 90 FE9I, ref SDS 87 FE9I.
IB0452 - On 070330 Millie's letter to Kaiser notified Gloria of INR stable
IB0453 - blood tests for past 2 months; continuing current Coumadin regimen.
IB0454 - ref SDS 82 ZH4H
IB0456 - ..
IB0457 - The blood test this morning in the Infusion Clinic shows INR 2.2 and
IB0458 - PT 25.5, and remains stable with the current treatment. ref SDS A0
IB0459 - SE6N
Examination Stethoscope No Findings Enlarged Right Ventricle Heart S
IK0401 - ..
IK0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
IK0404 - Follow up ref SDS 90 Q35O, ref SDS 87 Q35O.
IK0406 - Examination with a stethoscope today included multiple locations on
IK0407 - Millie's back and chest. There were no findings of cardio pulmonary
IK0408 - issues from clinical examination.
IK0410 - ..
IK0411 - After meeting with the medical team in the Breast Care Center, Millie
IK0412 - was treated in the Infusion Clinic. Vitals were taken three times.
IK0413 - The first test at 0945 reported Sa02 98%. ref SDS A0 AW4L
Enlarged Right Ventricle Heart Disorder Cor Pulmonale Related Pulmon
IV0401 - ..
IV0402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
IV0403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
IV0404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
IV0406 - Follow up ref SDS 90 VJ4J, ref SDS 87 VJ4J.
IV0408 - Background on heart disorder Cor Pulmonale from enlarged right
IV0409 - ventricle, and plans for CT testing is reported on 070130. ref SDS 56
IV0410 - VJ4J Considerations on ordering the thin slice spiral CT test to
IV0411 - evaluate enlarged right ventricle, along with pulmonary embolism and
IV0412 - measureable metastatic disease for the cetuximab clinical study, were
IV0413 - reported on 070419, ref SDS 87 CV5L, as further noted above.
IV0414 - ref SDS 0 CV5L
Dizziness Mild Recurrent from 060812 10 Seconds Getting Out of Bed S
JB0401 - ..
JB0402 - Dizziness Mild Symptoms Recur
JB0404 - Follow up ref SDS 31 PT4K. ref SDS 27 PT4K.
JB0406 - Millie reported today that mild dizziness occurring for 10 seconds or
JB0407 - so getting out of bed in the morning has returned the past few weeks.
JB0409 - ..
JB0410 - Mild dizziness getting up in the morning originally occurred on
JB0411 - 060217, and was carefully reviewed at that time. ref SDS 21 PT4K
JB0412 - Subsequently, on 061012 review of the CT test on 060930 showed
JB0413 - diagnosis of enlarged right ventricle. ref SDS 37 7E5L Research
JB0414 - indicates that dizziness may be a symptom of this heart disorder.
JB0415 - ref SDS 37 IR46
JB0417 - [...in another record, after examination dizziness issue tested
JB0418 - in the Infusion Clinic by taking vitals standing and showed
JB0419 - disparity with diagnostics sitting, but not enough to suggest
JB0420 - significant problem. ref SDS A0 Y14O
JB0422 - ..
JB0423 - [On 070525 dizziness was presented to primary care physician at
JB0424 - Kaiser. ref SDS A1 PT4K