CONTACTS 

SUBJECTS
CT Test 080212 Report Evaluate IBC  Pogression Disease 4th Relapse C

0903 -
0903 -    ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 43 0000. ref SDS 42 0000.
090502 -
090503 -
090504 -
090505 -
090506 -
090508 -  ..
0906 -
0907 -
0908 - Progress
0909 -
090901 - CT Test on 080212 Report Received from Kaiser
090902 -
090903 - Follow up ref SDS 40 FP5H, ref SDS 35 0J7N.
090904 -
090905 - Millie received ref DRT 1 0001 a letter from the primary care
090906 - physician at Kaiser transmitting the CT test on 080212. ref SDS 40
090907 - FP5H   Her prior test was on 071210. ref SDS 34 IA5N   The report was
090908 - received during the meeting at UCSF on 071213. ref SDS 35 0J7N
090909 -
090910 -    1.  Subject:  CT Report
090911 -        Received: 2/15/08 5:29 PM
090915 -         ..
090916 -        Here's your CT report:
090918 -         ..
090919 -        Hope you are doing well. ref DRT 1 0001
090924 -  ..
090925 - The primary care physician at Kaiser responds to a copy of the letter
090926 - Millie submitted to UCSF earlier today; a copy was also sent to the
090927 - doctor's assistant, Arlette. ref SDS 43 ID5X  Millie submitted prior
090928 - requests on 080214, ref SDS 42 C45U, which repeated work the day
090929 - before on 080213, ref SDS 41 7G4R, confirming planning in the letter
090930 - to UCSF with copy to Kaiser on 080208, ref SDS 39 OO8V, and discussed
090931 - the day before during a meeting at UCSF on 080207. ref SDS 38 GH5M
090932 -
090933 -            [On 080403 UCSF orders another CT test at Kaiser for
090934 -            Millie. ref SDS 47 669L
090936 -         ..
090937 -        Test History No Evidence Distant Metastasis
090938 -        Distant Metastasis No Evidence 5 Years Imaging Tests
090939 -
090940 -        Follow up ref SDS 35 4C6N, ref SDS 32 FJ4G.
090941 -
090942 -        Type    Date           Received          Source
090943 -         CT     080212 reported on 080215........... ref SDS 0 DA6Q
090944 -         CT     071210 reported on 071213........... ref SDS 35 UG4L
090945 -         CT     070930 reported on 071018........... ref SDS 32 VK8L
090946 -         CT     070723 reported on 070802........... ref SDS 29 IM6M
090947 -         CT     070520 reported on 070524........... ref SDS 28 DA6Q
090948 -         CT     070326 reported on 070329........... ref SDS 27 DA6Q
090949 -         CT     070131 reported on 070202........... ref SDS 26 1Y8G
090950 -         PET/CT 061227 reported on 070102........... ref SDS 24 1Y8G
090951 -         CT     060930 reported on 061012........... ref SDS 22 284J
090952 -         MRI    060708 reported on 060711........... ref SDS 20 PT4K
090953 -         Xray   060623 reported on 060711........... ref SDS 20 WJ6G
090954 -         CT     060505 reported on 060523........... ref SDS 19 E355
090955 -         PET    060414 reported on 060428........... ref SDS 18 WJ6G
090956 -         PET    060120 reported on 060126........... ref SDS 17 WJ6G
090957 -         PET/CT 051005 reported on 051007........... ref SDS 16 WJ6G
090958 -         CT     050530 reported on 050610........... ref SDS 15 G75L
090959 -         CT     050325 reported on 050422........... ref SDS 14 G75L
090960 -         CT     041217 reported on 041230........... ref SDS 13 G75L
090961 -         CT     041103 reported on 041104........... ref SDS 12 WV7H
090962 -         CT     040921 reported on 041005........... ref SDS 10 NL4N
090963 -         CT     040710 reported on 040811........... ref SDS 9 H85S
090964 -         CT     040410 reported on 040416........... ref SDS 7 LK5L
090965 -         CT     040307 reported on 040318........... ref SDS 6 LK5L
090966 -         CT     031031 reported on 031205........... ref SDS 5 IG9K
090967 -         CT     030626 reported on 030710........... ref SDS 4 AL6N
090968 -         CT     030428 reported on 030508........... ref SDS 3 LK5L
090969 -         PET    021218 reported on 030109........... ref SDS 2 LK5L
090970 -         PET    020529 reported on 020603........... ref SDS 1 0001
090972 -         ..
090973 -    1.  Patient
090981 -         ..
090982 -    2.  CT OF THE CHEST, ABDOMEN AND PELVIS
090987 -         ..
090988 -        Date:  080212 1455
090990 -         ..
090991 -        Performed in:  WCM
090992 -
090996 -
090997 -
090998 -
0910 -

SUBJECTS
CT Test 080212 Report Errors Omissions Comparisons Patient History T

3503 -
350401 -  ..
350402 - Errors Omissions Comparisons Patient History Trend Analysis
350403 - Patient History Comparison PE Cor Pulmonale Esophigitis Enlarged Heart
350404 -
350405 -
350406 - CT test 080425 report continues...
350407 -
350408 -    3.  HISTORY
350409 -
350410 -        72 y/o with h/o metastatic breast cancer.  Currently on
350411 -        clinical trial at UCSF.  Please do in one to two weeks and
350412 -        compare with 12/10/07.
350414 -  ..
350415 - Test report today repeats prior mistakes failing to report patient
350416 - history of pulmonary embolism, and enlarged right ventricle (core
350417 - pulmonale), failing to apply standards applied for Kaiser's CT test on
350418 - 060930, reported on 061012. ref SDS 22 2857  Case study at that time
350419 - on 061012 shows difficulty tracking patient history for comparisons to
350420 - understand progression of medical problems. ref SDS 22 A55J
350422 -  ..
350423 - Test report further fails to cite history of slightly enlarged heart,
350424 - reported in CT test at Kaiser on 071210, received at UCSF on 071213.
350425 - ref SDS 35 SR5I
350427 -  ..
350428 - CT test on 060120 reported findings of likely esophigitis, ref SDS 17
350429 - DH4O, and there has been no follow up, reported on 060428. ref SDS 18
350430 - OX62
350432 -  ..
350433 - Failure to track patient history denies the analyst an agenda to
350434 - investigate changes on issues identified as critical to patient
350435 - health.
350437 -  ..
350438 - CT test 080425 report continues...
350439 -
350440 -    4.  TECHNIQUE: Routine. IV and oral contrast administered. 100 ml
350441 -        of IV Omnipaque 300 were administered.
350442 -
350444 -         ..
350445 -    5.  COMPARISON: Study compared to prior exam of 12/10/07.
350447 -  ..
350448 - Test on 071210 was reviewed at UCSF on 071213. ref SDS 35 SR9I
350450 -  ..
350451 - The report fails to compare with prior reports showing similar
350452 - findings to the test on 071213. ref SDS 35 X65N
350454 -  ..
350455 - Errors and omissions performing test comparisons reported in case
350456 - study on 061012. ref SDS 22 A55J
350458 -  ..
350459 - Case study on medical mistakes reported on 040416. ref SDS 7 GN7J
350461 -         ..
350462 -    6.  FINDINGS
350463 -
350464 -        a.  Patient is s/p left mastectomy and left axillary lymph node
350465 -            dissection.
350466 -
350467 -
350468 -
3505 -

SUBJECTS
Right Axillary Lymph Node Minimally Enlarged CT Test 080212 Findings

6403 -
640401 -  ..
640402 - Making Sense Conflicting Reports and Terminology
640403 - Erroneous Findings Typographical Errors and Omissions
640404 - Right Axillary Lymph Node Minimally Enlarged Erroneous Test Report
640405 -
640406 - Follow up ref SDS 35 SR5P.
640407 -
640408 -        b.  As seen on previous exam, enlarged lymph node is seen in
640409 -            the right axilla.  This node appears minimally enlarged
640410 -            than on the prior exam now measuring 12.7 x 11.3 cm versus
640411 -            11.6 x 11.3 cm on the prior study.
640413 -  ..
640414 - These findings appear conflicting and incorrect compared with prior
640415 - findings in the report received on 071213 for the test on 071210
640416 - which showed...
640417 -
640418 -                There is an 11 x 11 mm right axillary lymph node, which
640419 -                previously measured 8 x 7 mm. ref SDS 35 SR5P
640421 -  ..
640422 - Thus the current report of 12.7 x 11.3 cm is 10 times greater than
640423 - prior report of 11 x 11 mm. ref SDS 35 SR5P  Assuming the analyst
640424 - directly compared the images, then finding in the current report of
640425 - "minimally enlarged" could mean the prior report of mm was incorrect,
640426 - or the current report of cm is incorrect.  If both reports are
640427 - correct, then "minimally enlarged" is grossly incorrect.
640428 -
640429 -                [On 080219 doctor describes CT test results for the
640430 -                test on 080212 shown here do not signal rapid
640431 -                progression of disease that requires immediate increase
640432 -                in treatment by adding carboplatin to cetuximab.
640433 -                ref SDS 45 I33K
640435 -  ..
640436 - Since lymph nodes on the order of 12.7 x 11.3 cm would be about a 5
640437 - inch lump, that the patient would notice, and the doctor would
640438 - recognize in examination with palpation.  Since neither the patient
640439 - nor the doctor have noticed a lump, it seeems likely the report today
640440 - is incorrect, and should say 12.7 x 11.3 mm.  This interpretation most
640441 - closely aligns with findings of "minimally enlarged."
640443 -  ..
640444 - This record suggests the report on 080212 has typographical or
640445 - possibly dictation and/or language barriar errors showing "cm" units
640446 - of measure that are actually "mm."
640448 -  ..
640449 - Recommend consideration of training and standards for using mm units
640450 - of measure below 2 cm, and then using cm from 2 cm and above.  This
640451 - would help reduce errors, ambiguity, and doubt about errors.
640452 -
640453 -        [On 080428 next CT test used consistent units of measure.
640454 -        ref SDS 48 CB8N
640456 -  ..
640457 - Problems with image test reporting were previously reviewed on 040416,
640458 - and reflect continuing quality issues. ref SDS 7 PTSX
640459 -
640461 -  ..
640462 - Axilla Right 3 Nodes Progression IBC Disease Conflicts Examination
640463 - Right Axilla 3 Nodes Progression IBC Disease Conflicts Examination
640464 - 3 Nodes Progression IBC Disease Right Axilla Conflicts Examination
640465 -
640466 - Even so, 12.7 x 11.3 mm is a .5 inch lump, and two others make a total
640467 - of 3 nodes in the right axilla reported on 071213 for the CT test on
640468 - 071210. ref SDS 0 EO8F
640470 -  ..
640471 - That condition should be evident by palpatation examination, and
640472 - should be recognized by the patient, particularly a patient sensitive
640473 - to swelling under the arm (i.e., the axilla).  For example, the
640474 - patient complained about lumps under the left arm on 040416, and the
640475 - CT test reported 18 mm (1.8 cm) nodes. ref SDS 7 EH47  Earlier on
640476 - 030710 the patient complained of discomfort under the left arm and the
640477 - doctor palpated a mass (characterized at that time as scar tissue from
640478 - surgery 15 months earlier); the CT test on 030626 reported findings of
640479 - nodes of 1.5 cm. ref SDS 4 XX4G  On 030508 Millie had reported feeling
640480 - a lump under the left arm, and the doctor concurred; the CT test
640481 - reported 2 nodes of less than 1 cm. ref SDS 3 7C84
640483 -  ..
640484 - At this time, neither the patient nor the doctor have recognized a
640485 - lump in the right axillary.
640487 -  ..
640488 - This record raises questions about credibility and quality of image
640489 - testing.
640491 -  ..
640492 - Recommend scans be double read, and differences reconciled on 10% of
640493 - scans.  UCSF can request the scan films from Kaiser and perform
640494 - independent analysis.  Doctor Guardino at Stanford did this for a 2nd
640495 - opinon on 041019. ref SDS 11 ER8O
640496 -
640498 -  ..
640499 - 300% Increase Lymphadenopathy Signals Progression IBC Disease
640500 - Right Axillary 3 Nodes Found Increase 300% Compared Prior Test
640501 -
640502 - CT Test 080212 Findings continue...
640503 -
640504 -        c.  Slightly superior to this node there appears to be a second
640505 -            enlarged node measuring approximately 1.9 x 0.9 cm.  This
640506 -            was present on the prior exam and is unchanged.  In the
640507 -            inferior right axilla (image 16) there is a 1 cm lymph node
640508 -            which appears larger than on the prior exam.
640510 -  ..
640511 - This part of the report finds two (2) new nodes that were not reported
640512 - in the prior test on 071210, received on 071213. ref SDS 35 SR5P
640513 - Finding three (3) nodes increases prior findings of only 1 node by
640514 - 300%, and so seems significant apart from issue of size.
640516 -  ..
640517 - Accordingly, saying these nodes were "present on the prior exam"
640518 - conflicts with the report for the test on 071210.  The review on
640519 - 071213 reports only a single enlarged lymph node.  This seems to be a
640520 - 300% mistake. ref SDS 35 SR5P
640522 -  ..
640523 - It is unclear if the same error is repeated for this part using "cm"
640524 - in place of "mm." ref SDS 0 H64H
640526 -  ..
640527 - Is the size really 1,9 cm, which is .75 iches, this would be one of
640528 - the largest nodes ever reported during 6 years of testing.  Nodes of
640529 - this size seem like they would be recognized???
640530 -
640531 -
640532 -
640533 -
640535 -  ..
640536 - Pretracheal Paratracheal Evidently Same Region
640537 - Paratracheal Adenopathy Unchanged Prior Study 3 Nodes Identified
640538 -
640539 - CT Test 080212 Findings continue...
640540 -
640541 -        d.  As seen previously, right paratracheal adenopathy is noted.
640542 -            On current exam this appears to represent two separate
640543 -            nodes each measuring approximately 6 mm in diameter.  The
640544 -            appearance is unchanged from the prior study.  A less than
640545 -            1 cm prevascular lymph node is also seen.  No significant
640546 -            hilar adenopathy is identified.
640548 -  ..
640549 - Findings in the report today may increase from 1 node to 3, a 300%
640550 - increase in the paratracheal region from the prior test on 071210,
640551 - reviewed on 071213. ref SDS 35 8L4J
640552 -
640553 -                [On 080428 report for CT test o 080425 describes small
640554 -                right paratracheal and prevascular lymph nodes are
640555 -                similar in appearance to the report today. ref SDS 48
640556 -                MR5M
640558 -  ..
640559 - Terminology of "right paratracheal" differs today from the last report
640560 - that described "pretracheal." ref SDS 35 SR5P  This may resolve
640561 - ambiguity about correlations with much earlier tests reviewed in the
640562 - record on 071213, ref SDS 35 YK6J, since right paratracheal reported
640563 - today aligns with terminology for the test 20 months ago on 060523.
640564 - ref SDS 19 4O8P
640566 -  ..
640567 - Findings today of 6 mm nodes and less than 1 cm node, ref SDS 0 RV70,
640568 - also fits the description of findings 20 months ago on 060505 of "less
640569 - than 1 cm nodes" (plural), reported on 060523. ref SDS 19 4O8P
640571 -  ..
640572 - Correlations with earlier findings of likely esophagitis, reviewed on
640573 - 060523 remain unresolved. ref SDS 19 PA5G
640574 -
640576 -  ..
640577 - Pulmonary Embolism Findings CT Test 080212 Similar 060930
640578 - Lung New Increased Densities Right Side No Findings on Left Side
640579 -
640580 - Follow up ref SDS 35 SR5I.
640581 -
640582 - CT Test 080212 Findings continue...
640583 -
640584 -        e.  Stable scarring is noted laterally in the left lung apex.
640585 -            New ill defined areas of increased density are seen in the
640586 -            right middle lobe along the fissure.  This may merely be
640587 -            volume averaging with the fissure, but developing
640588 -            infiltrate within the lung cannot entirely be excluded.
640589 -            Patchy ill defined areas of increased density are seen in
640590 -            the right lower lobe, unchanged from previous exam.  No
640591 -            pleural effusions are noted.
640593 -  ..
640594 - Pulmonary embolism was found in a CT test on 060930, reviewed on
640595 - 061012.  Findings in the current test seems similar to language in the
640596 - prior report....
640597 -
640598 -                Exam was technically adequate to determine presence of
640599 -                a pulmonary embolism.  There are filling defects within
640600 -                the subsegemental branches of the right lower lobe
640601 -                pulmonary arteries. ref SDS 22 294Q
640603 -  ..
640604 - What are implications of "new increased densities..." and "infiltrate
640605 - within the lung" in relation to ongoing treatment for pulmonary
640606 - embolism, and/or medical problems?  The test on 071210 reviewed on
640607 - 071213 described...
640608 -
640609 -                ...some stable interstial/fibrotic change within the
640610 -                left lung apex.  There is a stable ill defined 4 mm
640611 -                nodular density within the left lung base.  There is
640612 -                also a stable 3 mm ill defined nodular density within
640613 -                the left lung base on image #51. ref SDS 35 SR59
640615 -  ..
640616 - Stable nodules in the lungs were cited by the primary care physician
640617 - at Kaiser in a letter on 070117 to explain the medical chart reporting
640618 - lung cancer. ref SDS 25 TS8G  The report today for the test on 080212
640619 - does not mention lung cancer, nor fibrotic change reported for in the
640620 - test on 071210.  Nodular densities described for the test on 071210
640621 - are all located on the left side.  Increased densities reported for
640622 - the test on 080212 were all found on the right side, and there is no
640623 - mention of anything on the left side.  Does this mean findings on the
640624 - left side are all resolved?
640626 -  ..
640627 - Should the patient change conduct to reduce risks?
640628 -
640629 -            [On 080226 letter to Kaiser with copy to UCSF requests
640630 -            comment from medical team, including notice to coagulation
640631 -            control case management. ref SDS 46 S14Y
640632 -
640633 -            [On 080428 the medical team has not commented; report for
640634 -            follow up CT test on 080425 reviewed on 080428 shows
640635 -            findings of "increased opacity also noted in the right
640636 -            lower lobe." ref SDS 48 644L
640638 -             ..
640639 -            [On 080507 Millie reports spike in heart beat (pulse)
640640 -            while laying down in bed; cases study shows occassional
640641 -            spike in pulse reported by heart monitor during
640642 -            exercise, evaluated previously as defective equipment.
640643 -            ref SDS 49 CK4K
640645 -  ..
640646 - CT Test 080212 Findings continue...
640647 -
640648 -        f.  Stable cyst measuring 2.0 x 1.7 cm is seen at the hepatic
640649 -            dome.  The liver otherwise appears unremarkable.  No focal
640650 -            masses or biliary ductal dilatation is noted.
640651 -
640653 -  ..
640654 - Splenic Artery Aneurysms Calcified Lymph Nodes Prior Infection
640655 -
640656 -
640657 -        g.  Coarse calcifications are again seen in the spleen
640658 -            consistent with prior granulomatous infection.  Large
640659 -            coarse calcifications are seen near the splenic hilum.
640660 -            These have been unchanged from multiple prior exams and are
640661 -            most consistent with calcified splenic artery aneurysms.
640662 -            They could, however, represent densely calcified lymph
640663 -            nodes, possibly from prior infection.
640665 -  ..
640666 - Artery aneurysms and infection in the spleen does not sound positive
640667 - but has been reported for a long time, and no one has said anything;
640668 - no evident affect on health and life.
640670 -  ..
640671 - CT Test 080212 Findings continue...
640672 -
640673 -        h.  The pancreas, adrenals, and gallbladder appear
640674 -            unremarkable.
640676 -             ..
640677 -        i.  The kidneys appear normal in size and shape.  Several less
640678 -            than 1 cm hypodensities are again seen in both kidneys,
640679 -            unchanged from previous exam.  These are too small to
640680 -            completely characterize with CT but likely represent cysts.
640682 -             ..
640683 -        j.  The small bowel and colon appear unremarkable.
640685 -             ..
640686 -        k.  No significant adenopathy is seen within the abdomen or
640687 -            pelvis.  No free fluid or focal fluid collections are
640688 -            noted.  Bone windows show degenerative changes.  No lytic
640689 -            or blastic lesions are appreciated.
640691 -  ..
640692 - CT Test 080212 report concludes...
640693 -
640694 -    7.  IMPRESSION
640695 -
640696 -        1.  Slight interval increase in size of right axillary lymph
640697 -            nodes compared with previous exam.
640699 -             ..
640700 -        2.  New ill defined areas of hyperdensity in the right middle
640701 -            lobe along the minor fissure of uncertain significance.
640703 -             ..
640704 -        3.  No other significant interval change.
640705 -
640706 -
640707 -
640708 -
640709 -
640710 -
640711 -
640712 -
640713 -
640714 -
640715 -
6408 -