CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 27 0000. ref SDS 26 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Millie's vitals seem normal today.
040902 -
040903 - The doctor handed Millie a printed copy of the CT test on 071030, and
040904 - highlighted the report of increased right axillary.  He asked about
040905 - Doctor Rugo's response to this report.
040907 -  ..
040908 - This was reviewed at UCSF on 071213. ref SDS 31 SR5P
040910 -  ..
040911 - The doctor feels that UCSF response is adequate at this time.
040913 -  ..
040914 - Today, examination at Kaiser aligned with findings during examination
040915 - at UCSF yesterday on 080110, which showed treatment with cetuximab
040916 - continues to contain Millie's cancer. ref SDS 33 1J5G
040918 -  ..
040919 - The doctor asked if Millie has followed up on referral to mental
040920 - health for consultations?  The doctor made a referral on 070921,
040921 - ref SDS 17 QY54, to help Millie cope with emotional trauma from
040922 - Kaiser's failure to perform, ref SDS 17 QY9V, which led to notices
040923 - from UCSF that essential treatment would be terminated, reported on
040924 - 071031. ref SDS 23 KM4J
040926 -         ..
040927 -        [On 080226 another IBC patient reports emotional roller
040928 -        coaster living with cancer. ref SDS 40 M36X
040930 -  ..
040931 - Millie advised this has not been done because on 071130 Kaiser
040932 - reported progress paying bills for Millie's treatment on referral at
040933 - UCSF. ref SDS 29 TH8L  Improvement in case management relieved a lot
040934 - of stress handling piles of paper issued by Kaiser and UCSF
040935 - threatening to terminate essential treatment, reported to the doctor
040936 - during the meeting on 071116. ref SDS 27 J65H  The record on 070921
040937 - shows experience from prior referral to Mental Health for stress from
040938 - mounting medical issues along with constant treatment for cancer, was
040939 - not helpful. ref SDS 17 MC5H
040940 -
040941 -     [On 080125 Millie fell and injured right eye and arm. ref SDS 35
040942 -     N65K
040944 -      ..
040945 -     [On 080129 Millie schedules meeting with Mental Health department
040946 -     on 080201. ref SDS 36 RB7F
040948 -      ..
040949 -     [On 080131 nurse at UCSF advises that Millie should be examined at
040950 -     ER whenever there is a significant fall, because Coumadin patients
040951 -     are at risk for internal bleeding. ref SDS 37 546N
040953 -      ..
040954 -     [On 080201 mental health therapyst advised that prior consultation
040955 -     reported on 060428, ref SDS 5 619N, dismissing Millie's need for
040956 -     assistance was improper. ref SDS 38 SG7K
040958 -      ..
040959 -     [On 080204 Millie examined at Minor Injury Clinic at Kaiser in
040960 -     Walnut Creek; no finding of serious injury; no xrays were taken;
040961 -     treatment was heat to speed recovery from bruises. ref SDS 39 546N
040963 -  ..
040964 - We discussed referral for cardio examination to review findings of
040965 - slightly enlarged heart shown in the report for the CT test on 071130
040966 - that was received at UCSF on 071213. ref SDS 31 SR5I  How does this
040967 - new condition relate to prior findings in the CT test at Kaiser on
040968 - 060930 of enlarged right ventricle, reported on 061012. ref SDS 6 7E5L
040970 -  ..
040971 - At this time referral to the heart specialist has been deferred until
040972 - treatable symptoms become manifest, rather than investigate for
040973 - proactive management.
040974 -
040975 -     [On 080305 referral for examination by cardio pulmonary specialist
040976 -     deferred again to consider new findings PE issues and right
040977 -     paratracheal issues. ref SDS 41 HP9T
040978 -
040979 -
040980 -
0410 -

SUBJECTS
Palliative Care Project Expands Team Care for Integrated Oncology Ap

2303 -
230401 -  ..
230402 - Palliative Care Project Expands Team Care for Integrative Oncology
230403 -
230404 - The doctor reported progress today implementing a Palliative Care
230405 - Project at Kaiser.
230407 -  ..
230408 - The doctor explained the Palliative Care Project integrates a full
230409 - range of comprehensive oncology services, including radiation cancer
230410 - treatment.  The doctor feels this goes beyond current team care
230411 - practice by strengthening communication among practice groups.
230412 - Previously on 040504 the doctor described a vision to expand team care
230413 - practice at Kaiser with integrated oncology services. ref SDS 4 8F5M
230414 -
230415 -     [On 081018 Doctor Stritter's patient advocacy practice seems to
230416 -     complement ideas for Kaiser to implement palliative care project,
230417 -     by adding energy to assist the physician and the patient manage
230418 -     expanding complexities of health care. ref SDS 45 IS6U
230420 -      ..
230421 -     [On 090107 Doctor Stritter attending integrative oncology
230422 -     conference in Florida. ref SDS 46 X35I
230424 -  ..
230425 - The doctor showed his personal website to illustrate application of
230426 - technology for integrated palliative care.  Interactive video explains
230427 - medical procedures to educate patients.  The example today was an
230428 - operation installing a port catheter.  Voice recognition enables
230429 - interactive questions and answers, similar to telephone skill based
230430 - routing tools that have become popular in recent years.
230432 -  ..
230433 - Discussed today limitations of video and voice recognition for working
230434 - intelligently, reviewed on 000304. ref SDS 3 UT9I  Earlier, on 951012
230435 - IBM demonstrated interactive video and voice support for a "smart"
230436 - library, ref SDS 1 8392, promoted for better management. ref SDS 1
230437 - 0658  Review at that time shows good management requires "intelligence
230438 - support," ref SDS 1 0503, explained in NWO. ref OF 13 A56M
230440 -  ..
230441 - The doctor feels better use of resources is needed to meet growing
230442 - demands of an aging population.  This was presented last year on
230443 - 070517 when the doctor explained Kaiser cost containment reading only
230444 - 20% of test data in order for staff to serve more customers with
230445 - current rates of revenue from insurance premiums to pay for qualified
230446 - staff. ref SDS 11 OS5G  Review on 070517 shows that saving time and
230447 - money does not justify reducing test standards for patients that
230448 - require increased test scrutiney, per analysis in the record on
230449 - 070524. ref SDS 12 X24F
230451 -  ..
230452 - We discussed briefly need for doctor patient partnership called out by
230453 - Kaiser's Healthwise Handbook, reviewed on 990625. ref SDS 2 4185
230454 -
230455 -
230456 -
2305 -

SUBJECTS
Default Null Subject Account for Blank Record

2403 -
240401 -  ..
240402 - Communication Coordination Kaiser Improves Millie's Referral Care at UCSF
240403 - Kaiser Payment for Millie's Treatment on Referral to UCSF Approved
240404 -
240405 - The doctor advised that he has agreed to renew authorization for
240406 - Millie's care at UCSF every 3 months.
240408 -  ..
240409 - The doctor mentioned having email communications recently with Doctor
240410 - Rugo at UCSF concerning billings.  This issue was addressed on 071128
240411 - by Paula at Kaiser's MCRC business unit, indicating progress on
240412 - implementing EOC requirements for Kaiser to pay reasonable and
240413 - necessary costs of care at UCSF on referral for clinical trial.
240414 - ref SDS 29 TH8L  Like any bureaucracy it is easy for people in
240415 - isolated groups to lose sight of requirements and yield to pressure
240416 - of tight budgets.
240418 -  ..
240419 - The doctor's report today expanding the referral coordination plan to
240420 - support direct communication between doctors on the medical team is a
240421 - big step toward collaboration to strengthen care.   This reflects the
240422 - doctor's letter on 070610 advising that the right channels for
240423 - communication were open for collaboration with UCSF on Millie's care.
240424 - ref SDS 13 OG7F  Communication between Kaiser and UCSF should be
240425 - submitted to the patient for coordination and alignment to make
240426 - collaboration effective, as shown by notification to Kaiser on 061227.
240427 - ref SDS 7 KO3P
240428 -
240429 -        [On 080305 the doctor reported new procedures at UCSF beginning
240430 -        080304 have suddenly prevented communication, which formerly
240431 -        was fast and easy for transmitting the record in time to be
240432 -        effective.
240434 -         ..
240435 -        [On 080306 UCSF reported reliance on Kaiser for backup
240436 -        examination to support diagnosis and treatment planning.
240437 -        ref SDS 42 JT3L
240439 -         ..
240440 -        [On 080307 notified primary care physician at Kaiser that UCSF
240441 -        draws support backup examinations and reviews. ref SDS 43 HT3U
240443 -         ..
240444 -        [On 080312 primary care physician at Kaiser concurrs Kaiser and
240445 -        UCSF functioning as a team for Millie's treatment on referral
240446 -        deserves support. ref SDS 44 HT3U
240447 -
240448 -
240449 -
2405 -

SUBJECTS
Default Null Subject Account for Blank Record

2503 -
250401 -  ..
250402 - Medical Chart Reports Examination Diagnosis Prescription Prognosis
250403 -
250404 - Follow up ref SDS 27 YT5N, ref SDS 17 YT5N.
250405 -
250406 - Received the doctor's report in the medical chart for the meeting
250407 - today...
250409 -         ..
250410 -    1.  Received:
250411 -        01/18/08 11:56 PM
250413 -         ..
250414 -    2.  This is a 71 year old woman with a history of inflammatory
250415 -        cancer of left breast who was initially diagnosed 03/04/02.
250416 -        She had recurrent disease noted initially in the cervical LN's
250417 -        03/03/04. She has been treated on several salvage regimes. On
250418 -        E2100 Study with Avastin, she had a PE noted on CT 11/03/2004.
250419 -        She was placed on anticoagulation therapy for one year. Then,
250420 -        because of progression of disease, the patient was started on
250421 -        Taxotere and Xeloda 4/15/05. She had a total of 8 cycles
250422 -        ending 9/16/05. She had a palliative left mastectomy performed
250423 -        10/21/05. Then her left chest lesions began expanding again.
250424 -        The patient started Taxotere and Xeloda again 07/21/06 for 7
250425 -        cycles. She was started on a Clinical Trial 02/01/07 at UCSF
250426 -        and was randomized to the Erbitux only (no Carbo) Arm. Patient
250427 -        is her for follow up.
250429 -         ..
250430 -        Seems like there is a slow increase in desease progression
250431 -        based on gradually increasing CA 15-3 and changes in CT scan.
250433 -  ..
250434 - Spelling problem change "desease" to "disease."
250436 -  ..
250437 - "Slow increase" in disease seems to align with "increased erythema on
250438 - lower left chest wall" reported in findings from examination.
250439 - ref SDS 0 1Z6O
250441 -  ..
250442 - Citing slow rising cancer marker CA 15-3 correlates with conclusion of
250443 - slowly progressing disease; however, "changes in CT scan" should be
250444 - amplified to cite date of test on 071210, and specific findings of 11
250445 - x 11 mm node in right axillary, reviewed at UCSF on 071213.
250446 - ref SDS 31 SR5P
250448 -  ..
250449 - Medical Chart continues...
250450 -
250451 -    3.  Current Medications
250452 -
250453 -        TIMOLOL MALEATE 0.5% EYE DR
250454 -        WARFARIN 4MG TABLETS
250455 -        ACYCLOVIR 800MG TABLETS
250456 -        LORAZEPAM 1 MG TABLETS
250457 -        ERBITUX
250459 -         ..
250460 -    4.  Physical Examination
250461 -
250462 -        Performance Status: 0
250463 -        Lymph nodes: negative palpation
250464 -        Chest wall: increasing erythema on lower left chest wall
250465 -        Ext: LUE edema with patch of erythema involving upper arm; LUE
250466 -        measured at 31 cm
250468 -  ..
250469 - Finding "increasing erythema on lower left chest wall" is marked
250470 - change from examination on 071116 that reported "decreased erythema."
250471 - ref SDS 27 U55R  Seems to align with narrative report of slow
250472 - progression of disease, per above. ref SDS 0 DR4L  Seems conflicting
250473 - with report of "stable rash" in treatment plan, per below, ref SDS 0
250474 - WA5G, although "rash" may pertain to other than IBC rash.
250476 -  ..
250477 - Medical Chart continues...
250478 -
250479 -        Lab:
250480 -        CA 15-3
250482 -         ..
250483 -        75 H
250484 -        74 H
250485 -        56 H
250486 -        52 H
250487 -        55 H
250488 -        56 H
250489 -        52 H
250490 -        68 H
250491 -        56 H
250492 -        74 H
250494 -  ..
250495 - Lab report listed in the chart today, repeats results from the meeting
250496 - 2 months ago on 071116, ref SDS 27 U574, for blood tests at Kaiser, on
250497 - 071017, and received from Kaiser on 071023. ref SDS 19 UW5J  Tests at
250498 - Kaiser use different calibration methods from tests performed at UCSF,
250499 - and so direct correlations can be misleading.
250501 -  ..
250502 - Millie has had two additional blood tests since 071116.  Labs for test
250503 - at UCSF on 080110 showed CA 15-3 was 51, ref SDS 34 A16M, up 3 points
250504 - from the prior test at UCSF on 071213. ref SDS 32 A16M
250506 -  ..
250507 - Medical Chart continues...
250508 -
250509 -    5.  Imaging
250510 -
250511 -        12/10/07 CT THORAX, ABDOMEN, PELVIS W CONTRAST - increased
250512 -        right axillary LN
250514 -  ..
250515 - Why no mention of enlarged heart shown in test reviewed at UCSF on
250516 - 071213? ref SDS 31 SR5I
250518 -  ..
250519 - Medical Chart continues...
250520 -
250521 -        09/30/07 CT ABDOMEN, PELVIS, THORAX W CONTRAST
250522 -        05/20/07 CT THORAX, ABDOMEN, PELVIS W CONTRAST - no change
250523 -        12/27/06 BASE SKULL TO MIDTHIGH PET/CT
250524 -        10/16/06 HAND, TWO VIEWS
250525 -        10/13/06 MAMMOGRAPHY UNILATERAL
250526 -        07/08/06 MRI BRAIN WO/W CONTRAST(STD)- negative
250528 -         ..
250529 -    6.  Impression
250530 -
250531 -        1.  Metastatic breast cancer (IBC)lung, lymph node and chest
250532 -            wall
250533 -        2.  Right axillary LN increase
250534 -        3.  Hx of PE on Warfarin INR 2-3
250535 -        4.  Rash stable
250537 -  ..
250538 - How does "rash stable" correlate with physical examination finding
250539 - "Chest w*ll: increasing erythema on lower left chest wall," per above?
250540 - ref SDS 0 1Z6O
250542 -  ..
250543 - Millie has numerous types of "rash" so context helps clarify what
250544 - might be stable., e.g., IBC rash on upper left arm, on left chest,
250545 - left stomach, right breast, upper left chest; rash on face side
250546 - effect of cetuxmiabe treatment for IBC; rash on upper right arm that
250547 - has not been diagnosed because it seems to come and go.
250549 -         ..
250550 -    7.  Plan
250551 -
250552 -        1.  Continue Clinical Trial on Erbitux
250553 -        2.  UCSF to add Carbo if she progresses
250554 -        3.  Mental Health referral
250555 -        4.  Continue Ativan for panic attacks
250556 -        5.  Repeat CT scan in March
250557 -        6.  Outside Authorization for UCSF Clinical Trial to be
250558 -            submitted every 3 months
250559 -        7.  RTC 8 weeks
250560 -
250561 -
250562 -
250563 -
250564 -
250565 -
250566 -
2506 -