CONTACTS 

SUBJECTS
Cellulitis IBC Fall Kaiser Examination Backup UCSF Clinical Trial Me

2303 -
2303 -    ..
2304 - Summary/Objective
2305 -
230501 - Follow up ref SDS 39 0000. ref SDS 31 0000.
230502 -
230503 - Primary care physician made examination of Cellulitis and lymphedema
230504 - swelling recurrence as recommended by UCSF, and found improvement with
230505 - subsiding disease. ref SDS 0 RM6J  The doctor renewed subscription for
230506 - Keflex so timely treatment can commence for future recurrence of
230507 - Cellulitis. ref SDS 0 5M3F  The doctor was very effective handling
230508 - sensitive emotions today from rising stress dealing with a series of
230509 - depressing problems. ref SDS 0 KT4J  Prozac was prescribed to moderate
230510 - trauma from stress and depression. ref SDS 0 5L5M  Coordination
230511 - required to report current medications for case management in Oncology
230512 - Department, and in the Coagulation Control Department managing
230513 - Coumadin treatment for Pulmonary Embolism. ref SDS 0 IE6M  Millie
230514 - reported continuing pain in the right arm from the fall on 080125.
230515 - The doctor ordered xray testing for fractures. ref SDS 0 5M39  Kaiser
230516 - examination today concurs with UCSF assessment that IBC disease is
230517 - progressing, ref SDS 0 N15G, and so requires increasing treatment
230518 - adding Carboplatin chemotherapy to supplement continuing treatment
230519 - with cetuximab that began on 070201. ref SDS 0 N15N  Adding
230520 - chemotherapy treatment may be delayed to complete treatment of
230521 - Cellulitis. ref SDS 0 N163  Primary care physician recommended against
230522 - referral for cardio pulmonary examination of findings in CT test on
230523 - 080212 of increased densities in the right lobe. ref SDS 0 N15O  As
230524 - well prior findings of enlarged heart were not referred for review by
230525 - a specialist. ref SDS 0 HP9T
230526 -
230527 -
230528 -
230529 -
230530 -
230531 -
230532 -
230533 -
230535 -  ..
2306 -
2307 -
2308 - Progress
2309 -
230901 - Millie's vitals are elevated today:  BP 127 86 Pulse 78
230902 -
230903 - Pulse normally about 60; so 78 indicates anxiety.
230905 -  ..
230906 - The meeting today was advanced from the schedule for examination at
230907 - Kaiser on 080314, because yesterday Millie suffered recurrence of
230908 - Cellulitis.  Kaiser and UCSF were contacted with a copy of the record
230909 - showing evolving conditions, and response to treatment. ref SDS 52
230910 - AP5J  UCSF rcommended Millie be examined by a doctor yesterday.
230911 - ref SDS 52 6S7I  Kaiser was notified of UCSF recommendation; everyone
230912 - was at lunch. ref SDS 52 PT8Q  Becky called back an hour or so later
230913 - and advised the doctor scheduled this meeting today at 1200.
230914 - ref SDS 52 UZ89
230915 -
230916 -        [On 080307 patient commends Kaiser for making time to make
230917 -        exigent examination of Cellulitis on short notice recommended
230918 -        by UCSF. ref SDS 55 GZ4H
230920 -  ..
230921 - Millie submitted a thank your card to Arlette for extra effort helping
230922 - the doctor with case management. ref SDS 52 PT8Q
230932 -  ..
230933 - Agenda for the meeting today...
230934 -
230935 -    1.  Cellulitis, per Brigid yesterday. ref SDS 52 6S7I
230937 -         ..
230938 -    2.  Right arm injury from fall on 080125, ref SDS 40 N65K,
230939 -        continues painful.
230941 -         ..
230942 -    3.  IBC rash slightly worse, seems less intense today, but has a
230943 -        history of variation.  Steady rise of CA 15-3, CT test shows
230944 -        increased nodes right axilla, per examination at UCSF on
230945 -        080219. ref SDS 50 WE6O
230947 -         ..
230948 -    4.  CT test on 080212. ref SDS 47 FP5H, reviewed on 080215.
230949 -        ref SDS 48 IX4F
230950 -
230951 -        a.  Errors rampant in CT test report. ref SDS 48 H64H
230953 -             ..
230954 -        b.  Rising adenopathy right axilla minimally enlarged,
230955 -            ref SDS 48 EO8F; but, 300% increase from prior test on
230956 -            071210, ref SDS 48 J85H; appears conflicting with clinical
230957 -            palpation reporting no findings of swelling. ref SDS 48
230958 -            RX6J
230960 -             ..
230961 -        c.  Right paratracheal adenopathy. ref SDS 48 RV70
230963 -             ..
230964 -        d.  New increased densities signal rising pulmonary embolism?
230965 -            ref SDS 48 RV78
230967 -         ..
230968 -    5.  Emotional stress coping with advancing cancer, changing
230969 -        treatments, fall, cellulitis recurrence.
230970 -
230971 -
230972 -
2310 -

SUBJECTS
Prozac Prescribed Cope Emotional Trauma IBC Relapse Cellulitis Relap

3803 -
380401 -  ..
380402 - FLUOXETINE 20 MG CAPSULES Prozac to Treat Stress Depression
380403 - Prozac Prescribe Cope Emotional Trauma IBC Relapse Cellulitis Relapse
380404 - Emotional Coping Difficult IBC Relapse Severe Fall Cellulitis Relapse
380405 -
380406 - The doctor asked how Millie is coping emotionally, following up
380407 - referral to Mental Health Department during the meeting on 080118,
380408 - ref SDS 39 X14J, and previously the prescription for Ativan on 070921
380409 - to treat panic attacks. ref SDS 21 N98J  Case study on 070105 shows
380410 - background emotional trauma, stress, and anxiety from Millie's long
380411 - term cancer care. ref SDS 11 Y642
380413 -  ..
380414 - Millie related good experience working with Jacqueline in the Mental
380415 - Health Department, most recently on 080211. ref SDS 46 N65K  Millie
380416 - does not have another meeting scheduled, but is thinking about going
380417 - back to Jacqueline, because a lot of things seem to be piling up that
380418 - increase confusion and doubt about the future.
380420 -  ..
380421 - A fall on 080125 with severe bruising shocked the medical team at UCSF
380422 - during examination on 080207. ref SDS 45 6V4L  This event compounds
380423 - worry about rising IBC, indicated by recent CT test on 080212 reviewed
380424 - on 080215. ref SDS 48 J85H  Later on 080219, Doctor Rugo at UCSF
380425 - diagnosed IBC relapse. ref SDS 50 3J4I  This requires increasing
380426 - treatment by adding Carboplatin chemotherapy, concurred today by
380427 - Kaiser per below. ref SDS 0 N15G
380429 -  ..
380430 - Adding chemotherapy increases fatigue, which reduces exercise.  The
380431 - doctor explained on 030606 that exercise maintains blood counts at
380432 - levels needed for safe chemotherapy treatments. ref SDS 4 JP7G
380433 - Millie's letter to UCSF on 080219, with a copy to Kaiser, cited
380434 - persistant low blood counts the past 6 months. ref SDS 49 1K4P  Adding
380435 - chemotherapy therefore makes maintaining blood counts seem very
380436 - difficult, reviewed at UCSF on 080219. ref SDS 50 I34K, citing prior
380437 - analysis on 080207. ref SDS 45 E14H
380438 -
380439 -        [On 080306 blood counts NEUTS 2.75 rise unexpectedly to highest
380440 -        level in over a year provides safety for increasing treatment
380441 -        by adding Carboplatin to treat expanding cancer (IBC), and
380442 -        relieves anxiety, worry, and doubt. ref SDS 53 033B
380444 -  ..
380445 - These unknowns seem overwhelming at times.  Emotional release briefly
380446 - paused discussion at this part of the meeting.
380447 -
380448 -        [On 080307 letter to primary care physician at Kaiser confirms
380449 -        worry about blood counts; reports relief from sudden and
380450 -        unexpected rise to highest level in over a year. ref SDS 55
380451 -        HS6R
380453 -  ..
380454 - The doctor prescribed Prozac (FLUOXETINE 20 MG CAPSULES) to treat
380455 - stress and depression, per above. ref SDS 0 KT4J  He explained that
380456 - cancer, treatments, and other issues can deplete some biological
380457 - elements in the brain, and this loss can compound depression from
380458 - emotional stress.  The doctor indicated loss of biological elements
380459 - can be restored to the brain with medication to help maintain natural
380460 - ability to cope with emotional stress.  The role of Prozac in relation
380461 - to Ativan prescribed on 070921 for treating emotional stress causing
380462 - "panic attacks," ref SDS 21 N98J, was not presented during the meeting
380463 - today.  Ativan was removed today from the treatment plan, ref SDS 0
380464 - CO3H, so perhaps Prozac is a replacement.
380466 -             ..
380467 -            [...below, Prozac is not added to medications; Ativan was
380468 -            never listed, ref SDS 0 7Y6F, Prozac is added to the
380469 -            Treatment plan, and Ativan was removed. ref SDS 0 CO3H
380471 -             ..
380472 -            [On 080306 UCSF indicated Prozac is prescribed for treating
380473 -            depression. ref SDS 53 NV5F
380475 -             ..
380476 -            [On 080312 Millie reported starting Prozac treatments,
380477 -            ref SDS 56 RT8Y; she felt strange after taking the first 2
380478 -            pills (treatments), ref SDS 56 RT4S; improved prospects
380479 -            from rising blood counts, along with increased exercise,
380480 -            ref SDS 56 RT5X, have relieved a lot of emotional stress
380481 -            and depression, so she stopped taking Prozac after the 2
380482 -            treatments, and does not plan to resume at this time.
380483 -            ref SDS 56 RT4W
380485 -             ..
380486 -            [On 080313 Millie reported to Kaiser further research with
380487 -            Wellness Community cancer support group revealed favorable
380488 -            results taking Prozac with minimal side effects.
380489 -            ref SDS 58 TA4U
380491 -             ..
380492 -            [On 080313 primary care physician requests confirmation on
380493 -            whether Millie is taking Prozac. ref SDS 58 UE5N
380495 -             ..
380496 -            [On 080403 meeting at UCSF Millie confirms she is not
380497 -            taking Prozac; emotional trauma subsides with improving
380498 -            health, better medical management and coordination,
380499 -            increased exercise. ref SDS 61 336H
380501 -             ..
380502 -            [On 080502 meeting at Kaiser Millie notified the doctor
380503 -            that she is not taking Prozac because issues causing former
380504 -            emotional stress have subsided, and exercise helps relieve
380505 -            routine stress. ref SDS 64 HH4I
380507 -  ..
380508 - There was not enough time today for presenting side effects from
380509 - taking Prozac medication.  This aligns with past practice not
380510 - explaining side effects of breast surgery that increases risks of
380511 - lymphedema and Cellulitis recurrence with routine exercise and minor
380512 - trauma associated with the left arm, shown by the record on 050923.
380513 - ref SDS 7 G49M
380515 -  ..
380516 - After the meeting, Millie visited the Kaiser Pharmacy at Park
380517 - Shadelands in Walnut Creek CA, and received the prescription for
380518 - Prozac.
380520 -  ..
380521 - The attendant advised that patients begin feeling effects and benefits
380522 - after taking Prozac for 6 weeks.  There was also warning of side
380523 - effects about drowsiness and dizzienss, and that alcohol may intensify
380524 - this effect.  The attendant said to contact the doctor immediately if
380525 - side effects occur, including mood changes, such as new or worsening
380526 - feelings of sadness, dpression or fear.
380528 -  ..
380529 - Side effects...
380531 -  ..
380532 - After the meeting at Kaiser, Millie performed independent research
380533 - canvasing friends.  Several (Peggy and Janna, a surgical technician)
380534 - cautioned about difficult side effects taking Prozac.
380535 -
380536 -            [On 080306 UCSF did not discuss side effects of Prozac for
380537 -            treating depression. ref SDS 53 LD7O
380539 -             ..
380540 -            [On 080312 Millie reported to the medical team feeling
380541 -            badly after taking 2 pills of Prozac; this reaction
380542 -            together with research showing bad side effects led to
380543 -            ending Prozac treatment, ref SDS 56 RT9U; subsequently
380544 -            professional care by the primary care physician and Doctor
380545 -            Rugo at UCSF, and increased exersice have helped relieve
380546 -            former depression. ref SDS 56 RT9U
380547 -
380549 -  ..
380550 - Research on the Internet found a "Linden" report...
380551 -
380552 -              http://www.panic-anxiety.com/articles/prozac-fluoxetine/
380553 -
380554 - ...which is marketing an alternative to Prozac called the "Linden
380555 - Method," and says in part...
380556 -
380557 -    Prozac (Fluoxetine) has become widely prescribed for treating
380558 -    depression, obsessive-compulsive and panic disorders.  It is the
380559 -    oldest SSRI (Selective Serotonin Reuptake Inhibitor, meaning it
380560 -    works by altering the action of the neurotransmitter, serotonin in
380561 -    the brain), with twenty years of research behind it.
380563 -  ..
380564 - Altering brain action seems to align with explanation of objectives
380565 - discussed by the doctor, per above. ref SDS 0 5L5M
380567 -  ..
380568 - Prozac research continues...
380569 -
380570 -    Prozac has few side effects compared to other anti-depressant
380571 -    drugs.  Some side effects may subside within a few weeks even
380572 -    though use continues, because the body adjusts.
380573 -
380574 -            [On 080312 Millie reported to the medical team feeling
380575 -            badly after taking 2 pills of Prozac; this reaction
380576 -            together with research showing bad side effects led to
380577 -            ending Prozac treatment, ref SDS 56 RT9U; subsequently
380578 -            professional care by the primary care physician and Doctor
380579 -            Rugo at UCSF, and increased exersice have helped relieve
380580 -            former depression. ref SDS 56 RT9U
380582 -  ..
380583 - Another source says....
380584 -
380585 -              http://www.goaskalice.columbia.edu/0817.html
380587 -     ..
380588 -    In some people, the effectiveness of Prozac seems to diminish with
380589 -    time, and an increase in dosage is necessary. In these cases, talk
380590 -    with your prescribing doctor, who may alter your medication.
380592 -  ..
380593 - Research from Linden Internet location continues...
380595 -     ..
380596 -    Common Side Effects
380597 -
380598 -
380599 -        1.  Allergic or Toxic - Rash, Pruritus (skin inflammation)
380600 -
380601 -        2.  Neurological - Headache, Tremor, Dizziness, Asthenia
380603 -             ..
380604 -        3.  Behavioral - Insomnia, Anxiety, Nervousness, Agitation,
380605 -            Abnormal dreams, Drowsiness and fatigue
380607 -             ..
380608 -            Another web site describes...
380609 -
380610 -               Unwanted head feelings!
380611 -
380612 -                  [On 080312 Millie reported to the medical team
380613 -                  feeling badly after taking 2 pills of Prozac; this
380614 -                  reaction together with research showing bad side
380615 -                  effects led to ending Prozac treatment, ref SDS 56
380616 -                  RT9U; subsequently professional care by the primary
380617 -                  care physician and Doctor Rugo at UCSF, and increased
380618 -                  exersice have helped relieve former depression.
380619 -                  ref SDS 56 RT9U
380621 -             ..
380622 -        4.  Autonomic - Excessive sweating
380624 -             ..
380625 -        5.  Gastrointestinal - Nausea, Disturbances of appetite,
380626 -            Diarrhea
380628 -             ..
380629 -        6.  Respiratory - Bronchitis, Rhinitis (inflammation of the
380630 -            nasal mucous membranes), Yawning
380632 -             ..
380633 -        7.  Endocrine - Weight loss
380635 -             ..
380636 -        8.  Musculoskeletal - Muscle pain, Back pain, Joint pain
380638 -             ..
380639 -        9.  Urogenital - Painful menstruation, Sexual dysfunction,
380640 -            Urinary tract infection, Frequent micturition
380642 -             ..
380643 -       10.  Miscellaneous - Chills
380644 -
380645 -
380646 -
3807 -

SUBJECTS
Cellulitis Left Arm Examination Lymphedema Swelling Subsiding Red Ra

6303 -
630401 -  ..
630402 - Arm Left Cellulitis Lymphedema Subsiding Continue Treatment
630403 - Cellulitis Inflammation Subsiding Lymphedema Swelling Reduced by Icing
630404 -
630405 - Follow up ref SDS 52 UZ89.
630406 -
630407 - After prescribing and explaining Prozac, per above, ref SDS 0 5L5M,
630408 - the doctor examined Cellulitis inflammation and lymphedema swelling on
630409 - the left arm.  He seemed aware of work starting a 10-day treatment
630410 - with Keflex reported in the record yesterday, ref SDS 52 106G, from
630411 - reviewing correspondence submitted to the medical team. ref SDS 52
630412 - AP5J  The doctor feels Cellulitis and lymphedema are recovering well
630413 - with symptoms of red rash and swelling only moderate to mild, as
630414 - result of starting treatment immediately with Keflex on hand from
630415 - prior prescription, reported yesterday on 080304, ref SDS 52 106G, and
630416 - icing the arm to reduce swelling, following instructions to treat
630417 - prior episodes of Cellulitis and lymphedema. ref SDS 52 010G
630419 -      ..
630420 -     [On 080306 examination at UCSF shows Cellulitis and lymphedema
630421 -     improved and nearly resolved. ref SDS 53 NV42
630423 -      ..
630424 -     [On 080307 Millie reports to medical team that Cellulitis has
630425 -     responded to treatment with Keflex. ref SDS 55 HS6W
630427 -      ..
630428 -     [On 080312 report to medical team Kaiser and UCSF that Cellulitis
630429 -     seems completely subsided. ref SDS 56 AR5K
630431 -      ..
630432 -     [On 080313 Millie completed 10-day treatment with Keflex for
630433 -     Cellulitis; no visible inflammation or swelling that signal
630434 -     Cellulitis and lymphedema. ref SDS 58 MQ4I
630436 -      ..
630437 -     [On 080314 possible Cellulitis relapse; difficult to distinguish
630438 -     from inflammation caused by cetuximab treatments for cancer;
630439 -     Millie begins another 10 day treatment. ref SDS 59 XS82
630441 -      ..
630442 -     [On 080409 Cellulitis recurrence, temperature 101.9, ref SDS 62
630443 -     V45J, Millie treated in Kaiser ER, ref SDS 62 0R4H, and released
630444 -     after 8 hours of care. ref SDS 62 F194
630446 -      ..
630447 -     [On 080520 Millie suffers recurrence Cellulitis left arm,
630448 -     begins 10 day treatment with Keflex. ref SDS 65 OU5J
630450 -      ..
630451 -     [On 080606 surgeon indicated diminished lymphatic system from
630452 -     removing cancerous lymph nodes may eventually strengthen
630453 -     because remaining lymph nodes become more robust, which reduces
630454 -     occurance of lymphadema and Cellulitis. ref SDS 66 4P7L
630455 -
630457 -  ..
630458 - Coordination Failed Kaiser Cannot Access UCSF Correspondence
630459 -
630460 - The doctor reported failure to access the copy of correspondence UCSF
630461 - sent to the patient on 080304 (yesterday), recommending examination of
630462 - Cellulitis by a doctor, but not specifying same day review, shown by
630463 - the letter the patient received from UCSF. ref SDS 52 B18J
630464 -
630465 -        [...below, doctor was asked to submit the medical chart on
630466 -        examination today to UCSF for coordinated treatment; but, could
630467 -        not do so because new procedures were too complicated for busy
630468 -        professional people to apply in the time available for getting
630469 -        things done for the next patient. ref SDS 0 PZ6K
630471 -         ..
630472 -        [On 080306 during the meeting at UCSF, the medical team
630473 -        disclosed that UCSF management has mandated using a UCSF email
630474 -        channel for secure communication, rather than provide timely,
630475 -        accurate communication requested by the patient. ref SDS 53
630476 -        JT66
630477 -
630479 -  ..
630480 - Keflex Prescribed Treat Cellulitis Future Relapse
630481 -
630482 - The doctor advised that he has already prescribed refill of Keflex, so
630483 - that Millie will have inventory on hand for future recurrence, as
630484 - requested in the letter to the medical team yesterday. ref SDS 52 TN7W
630486 -  ..
630487 - The prescription is for 20 days, so this makes 2 10-day treatments
630488 - in reserve.
630489 -
630490 -        [On 080314 possible Cellulitis relapse; difficult to
630491 -        distinguish from normal inflammation caused by cetuximab
630492 -        treatments for cancer; Millie begins another 10 day treatment.
630493 -        ref SDS 59 XS82
630495 -         ..
630496 -        [On 080409 Cellulitis recurrence diagnosed, ref SDS 62 V45J;
630497 -        Millie begins taking Keflex from prescription today.
630498 -        ref SDS 62 106G
630500 -         ..
630501 -        [On 080409 Kaiser prescribes 14 day treatment with Keflex,
630502 -        keeping 20-day prescription ordered today in reserve.
630503 -        ref SDS 62 F149
630505 -  ..
630506 - Prescriptions for Prosac and Keflex can be picked up at the Kaiser
630507 - Park Shadelands pharmacy after the meeting today.
630508 -
630509 -
630510 -
6306 -

SUBJECTS
Medications Coordinate Kaiser Coagulation Department Notify Changes

8203 -
820401 -  ..
820402 - Coordinate Medication Changes Coumadin Treatment Pulmonary Embolism
820403 - Pulmonary Embolism Treatment Warfarin Coumadin Coordinate Medications
820404 -
820405 -
820406 - Prozac and Keflex medications need to be coordinated with Gloria in
820407 - the Kaiser Coagulation Control Department that manages treatment for
820408 - pulmonary embolism with Coumadin (Warfarin).
820409 -
820410 -        [...below, Medical Chart today shows continuing challenge
820411 -        keeping an accurate record of current medications. ref SDS 0
820412 -        7Y6F
820414 -         ..
820415 -        [On 080307 notified Kaiser Coagulation Control Department, and
820416 -        the Oncology Department to update list of current medications.
820417 -        ref SDS 55 Y57K
820419 -         ..
820420 -        [On 080501 UCSF starts new case management project to track
820421 -        current medications for patients based on memory from personal
820422 -        mental maps. ref SDS 63 QK4G
820423 -
820424 -
820425 -
820426 -
820427 -
8205 -

SUBJECTS
Xray Ordered Arm Right Evaluate Discomfort Lift Arm Laterally Full V

9503 -
950401 -  ..
950402 - Arm Right Xray Evaluate Injury Fall 080125
950403 - Xray Ordered Evaluate Injury Fall 080125 Right Arm Discomfort
950404 - Fall 080125 Right Arm Discomfort Xray Ordered Evaluate Injury
950405 -
950406 - Millie complained of continued pain in the right arm and shoulder from
950407 - the fall on 080125. ref SDS 40 N65K  We reviewed findings from
950408 - examination at Kaiser in the Minor Injury Clinic downstairs on 080204.
950409 - ref SDS 44 JQ8N  Review on 080304 discussed delayed reaction to fall
950410 - on 080125 as possible cause of Cellulitis recurrence. ref SDS 52 H132
950412 -  ..
950413 - The doctor ordered an xray test to examine for fracture.  He explained
950414 - that MRI could be considered later based on results of xray test and
950415 - if pain continues in the right arm.
950417 -         ..
950418 -        [On 080312 notified Kaiser of subsiding discomfort in right
950419 -        arm, and so MRI not required at this time. ref SDS 56 RU3S
950420 -
950422 -  ..
9505 -
9506 -
9507 - 1404
9508 -
950801 - After meeting with the doctor in the Oncology Department, we went to
950802 - the Imaging Department on the basement level, and Millie got the xray
950803 - to evaluate pain in the right arm, per above. ref SDS 0 5M39
950805 -         ..
950806 -        [On 080307 xray report shows no fracture, and alignment is
950807 -        maintained. ref SDS 55 IT8N
950809 -         ..
950810 -        [On 080307 Kaiser commended timely submission xray test
950811 -        results. ref SDS 55 GZ4H
950812 -
950813 -
950814 -
950815 -
9509 -

SUBJECTS
IBC Examination Expanding Cancer Disease Diagnose 4th Relapse Recomm

A903 -
A90401 -  ..
A90402 - IBC Expanding Diagnose 4th Relapse Recommnd Increase Treatment
A90403 - Intensity IBC Inflammation Appears Subsiding Rash Expanding
A90404 -
A90405 - The doctor examined IBC and commented on evident expanding rash,
A90406 - though still very slowly.  Progression of disease shown by expanding
A90407 - rash aligns with CT test on 080212, reported below. ref SDS 0 N66K
A90409 -  ..
A90410 - Today, the rash actually seems noticably less intense than in recent
A90411 - weeks, including on 080219 when UCSF considered adding Carboplatin.
A90412 - ref SDS 50 WE6O
A90413 -
A90414 -            [On 080306 Doctor Rugo determines Millie suffering
A90415 -            progression of IBC disease, the 4th relapse. ref SDS 53
A90416 -            NW3N
A90418 -             ..
A90419 -            [On 080312 letter to UCSF with copy to Kaiser reports IBC
A90420 -            rash seems to subside before starting new treatment with
A90421 -            Carboplatin added to existing treatment with cetuximab.
A90422 -            ref SDS 56 RU4U
A90424 -             ..
A90425 -            [On 080331 photographs support explanation of expanding
A90426 -            disease. ref SDS 60 9Q4I
A90428 -  ..
A90429 - The doctor concurs with UCSF considerations to add Carboplatin for the
A90430 - treatment protocol that began on 070201 with cetuximab, as discussed
A90431 - with Doctor Rugo on 080219, ref SDS 50 3J4I, and a few weeks earlier
A90432 - on 080207. ref SDS 45 GH5H
A90434 -  ..
A90435 - The doctor noted today that recurrence of Cellulitis may require
A90436 - deferring the change treating IBC by adding Carboplatin until Keflex
A90437 - treatment resolves current symptoms Cellulitis.  This aligns with
A90438 - prior practice on 040315 when treatment for cancer with Bevacizumab
A90439 - (Avastin) and Taxotere was delayed for several weeks to treat
A90440 - inflammation on the left breast for Cellulitis. ref SDS 5 IM6J
A90441 - Carboplatin is a more conventional chemotherapy that can impact blood
A90442 - counts, lowering strength of immune system.
A90443 -
A90444 -            [...below medical chart lists "Cellulitis" under
A90445 -            "Impression," there is no confirmation that this episode
A90446 -            may delay starting chemotherapy treatment tomorrow with
A90447 -            Carboplatin at UCSF. ref SDS 0 WA5G
A90449 -             ..
A90450 -            [On 080306 blood counts NEUTS (ANC at Kaiser) rises to
A90451 -            highest level ever at UCSF the past year, and indicates
A90452 -            sufficient recovery from Cellulitis to begin teatment by
A90453 -            adding Carboplatin to cetuximab. ref SDS 53 NW5L
A90455 -             ..
A90456 -            [On 080306 Doctor Rugo decides to start Carboplatin
A90457 -            chemotherapy treatment with cetuximab the following week on
A90458 -            080313. ref SDS 53 NW7K
A90460 -             ..
A90461 -            [On 080313 Millie gets 1st treatment with Carboplatin
A90462 -            chemotherapy added to cetuximab. ref SDS 57 TZ8I
A90463 -
A90464 -
A90465 -
A90466 -
A905 -

SUBJECTS
CT Test 080212 Findings Support Diagnosis IBC Progression Disease 4t

AS03 -
AS0401 -  ..
AS0402 - CT Test Finding Support Diagnosis IBC 4th Relapse
AS0403 -
AS0404 - Discussed findings from the CT test on 080212 reviewed on 080215
AS0405 - showing...
AS0407 -             ..
AS0408 -        1.  New adenopathy and increased size of nodes right axilla.
AS0409 -            ref SDS 48 J85H
AS0411 -             ..
AS0412 -        2.  Right paratracheal adenopathy. ref SDS 48 RV70
AS0414 -             ..
AS0415 -        3.  New increased densities in right middel lobe along the
AS0416 -            fissure signal rising pulmonary embolism? ref SDS 48 RV78
AS0418 -  ..
AS0419 - The doctor feels no referral is needed at this time, based on Millie
AS0420 - not exhibiting clinical symptoms of cardio pulmonary complications.
AS0421 - He explained the CT test report provides an alert to look for trends
AS0422 - related to right paratracheal, and PE issues.   This aligns with
AS0423 - planning on 080118 deferring investigation of findings for the prior
AS0424 - CT test. ref SDS 39 Q15H
AS0425 -
AS0426 -           [...below doctor comments in Medical Chart. ref SDS 0 N29N
AS0428 -  ..
AS0429 - The doctor commented that the CT test on 080212, means that the test
AS0430 - previously scheduled for 080316 can be cancelled.  Millie will confirm
AS0431 - this with Doctor Rugo during the meeting at UCSF tomorrow.
AS0433 -  ..
AS0434 - Another issue is whether to schedeule CT tests every 8 weeks now that
AS0435 - progression of disease has been determined, and to better assess
AS0436 - results of adding Carboplatin as called out in the clinical trial
AS0437 - protocol.
AS0438 -
AS0439 -           [On 080619 UCSF called and indicated the doctor changed CT
AS0440 -           test frequency back from 12 to 8 weeks. ref SDS 67 O39F
AS0441 -
AS0443 -  ..
AS0444 - Cardio Pulmonary Referral CT Test Finding Enlarged Heart
AS0445 -
AS0446 - We discussed again referral for cardio pulmonary examination to review
AS0447 - findings of slightly enlarged heart shown in the report for the CT
AS0448 - test on 071130 that was received at UCSF on 071213. ref SDS 35 SR5I
AS0449 - How does this new condition relate to prior findings in the CT test at
AS0450 - Kaiser on 060930 of enlarged right ventricle, reported on 061012.
AS0451 - ref SDS 9 7E5L
AS0452 -
AS0453 -
AS05 -

SUBJECTS
CT Test 080212 Findings Support Diagnosis IBC Progression Disease 4t

BB03 -
BB0401 -  ..
BB0402 - Medical Chart Reports Examination Diagnosis Prescription Prognosis
BB0403 -
BB0404 - Follow up ref SDS 39 YT5N, ref SDS 31 YT5N.
BB0405 -
BB0406 - Received the doctor's report in the medical chart for the meeting
BB0407 - today...
BB0409 -         ..
BB0410 -    1.  Received:
BB0411 -        3/5/08 1:10 PM
BB0413 -         ..
BB0414 -    2.  This is a 72 year old woman with a history of inflammatory
BB0415 -        cancer of left breast who was initially diagnosed 03/04/02.
BB0416 -        She had recurrent disease noted initially in the cervical LN's
BB0417 -        03/03/04. She has been treated on several salvage regimes. On
BB0418 -        E2100 Study with Avastin, she had a PE noted on CT 11/03/2004.
BB0419 -        She was placed on anticoagulation therapy for one year. Then,
BB0420 -        because of progression of disease, the patient was started on
BB0421 -        Taxotere and Xeloda 4/15/05. She had a total of 8 cycles
BB0422 -        ending 9/16/05. She had a palliative left mastectomy performed
BB0423 -        10/21/05. Then her left chest lesions began expanding again.
BB0424 -        The patient started Taxotere and Xeloda again 07/21/06 for 7
BB0425 -        cycles. She was started on a Clinical Trial 02/01/07 at UCSF
BB0426 -        and was randomized to the Erbitux only (no Carbo) Arm.
BB0428 -  ..
BB0429 - "Progression of skin lesions" should be clarified to report IBC
BB0430 - disease spreading at specific sites and amounts from prior
BB0431 - examination, ref SDS 0 N15G, and supported by CT test on 080212
BB0432 - showing increased adenopathy right axillary, ref SDS 0 N15O,
BB0433 -
BB0434 -            [On 080331 photographs support explanation of expanding
BB0435 -            disease. ref SDS 60 9Q4I
BB0437 -  ..
BB0438 - Medical Chart continues...
BB0439 -
BB0440 -        She has had a fall and injured her right arm 01/25 but still
BB0441 -        has persisting pain.  She also has progression of skin lesions.
BB0442 -        She just developed cellulitis of the LUE.  She started Keflex
BB0443 -        and it has improved.  She denies fever or chills.
BB0445 -  ..
BB0446 - "Developed cellulitis" should be clarified by citing patient report
BB0447 - Cellulitis started on 080304, ref SDS 52 0001, shown by the record
BB0448 - submitted to Kaiser at that time. ref SDS 52 AP5J  Denies fever or
BB0449 - chills, should be clarified by citing the record on 080304 that
BB0450 - reports actual temperature. ref SDS 52 H18Q
BB0452 -  ..
BB0453 - Medical Chart continues...
BB0454 -
BB0455 -    3.  Current Medications
BB0456 -
BB0457 -        TIMOLOL MALEATE 0.5% EYE DR
BB0458 -        WARFARIN 4MG TABLETS
BB0459 -        ACYCLOVIR 800MG TABLETS
BB0460 -        LORAZEPAM 1 MG TABLETS
BB0461 -        ERBITUX
BB0463 -  ..
BB0464 - Corrections to current medications should now list Keflex to treat
BB0465 - Cellulitis, started on 080304, per the record above, ref SDS 0 RM6J
BB0466 - and noted in the Medical Chart, ref SDS 0 N19N, and Prozac prescribed
BB0467 - today for emotional care. ref SDS 0 5L5M
BB0468 -
BB0469 -            [On 080306 UCSF prescribed additional medications that
BB0470 -            includes Carboplatin starting on 080313, ref SDS 53 NW7K,
BB0471 -            Compazine, and Zofran. ref SDS 53 FA4H
BB0473 -             ..
BB0474 -            [On 080307 letter to primary care physician reports
BB0475 -            corrections to current medications in medical chart at
BB0476 -            Kaiser so that primary care physician can provide effective
BB0477 -            medical opinion to backup care at UCSF. ref SDS 55 RW3T
BB0479 -  ..
BB0480 - Medical Chart continues...
BB0481 -
BB0482 -    4.  Physical Examination
BB0483 -
BB0484 -        Performance Status: 0
BB0485 -        Lymph nodes: negative palpation
BB0486 -        Chest wall: increasing erythema on lower left chest wall
BB0487 -        Ext: LUE edema with patch of erythema involving upper arm; LUE
BB0488 -        measured at 31 cm
BB0490 -  ..
BB0491 - There was no palpation examination made today.  This merely repeats
BB0492 - content of prior examination on 080118. ref SDS 39 1Z6O
BB0494 -  ..
BB0495 - The doctor did not measure LUE today; this part of the report repeats
BB0496 - prior findings on 080118. ref SDS 39 1Z6O
BB0498 -  ..
BB0499 - Medical Chart continues...
BB0500 -
BB0501 -        Lab:
BB0502 -        CA 15-3
BB0504 -         ..
BB0505 -        75 H
BB0506 -        74 H
BB0507 -        56 H
BB0508 -        52 H
BB0509 -        55 H
BB0510 -        56 H
BB0511 -        52 H
BB0512 -        68 H
BB0513 -        56 H
BB0514 -        74 H
BB0515 -
BB0516 -            [On 080306 new labs performed at UCSF for starting new
BB0517 -            cycle of treatment on referral for clinical trial.
BB0518 -            ref SDS 54 439L
BB0520 -             ..
BB0521 -            [On 080307 report for laboratory blood test at UCSF was
BB0522 -            submitted to primary care physician at Kaiser. ref SDS 55
BB0523 -            ZX4K
BB0525 -  ..
BB0526 - Lab report listed in the chart today repeats mistakes from the report
BB0527 - for the meeting on 080118, ref SDS 39 417N, by repeating results from
BB0528 - the meeting 4 months ago on 071116, ref SDS 31 U574, for blood tests
BB0529 - at Kaiser, on 071017, and received from Kaiser on 071023. ref SDS 23
BB0530 - UW5J  Tests at Kaiser use different calibration methods from tests
BB0531 - performed at UCSF, and so direct correlations can be misleading.
BB0533 -  ..
BB0534 - Millie has had two additional blood tests since 071116.  Labs for test
BB0535 - at UCSF on 080110 showed CA 15-3 was 51, ref SDS 38 A16M, up 3 points
BB0536 - from the prior test at UCSF on 071213. ref SDS 36 A16M  Millie had a
BB0537 - more recent blood test at UCSF on 080207 when CA 15-3 increased
BB0538 - dramatically to 63.
BB0540 -  ..
BB0541 - Problems of medical Chart mistakes on laboratory blood testing for
BB0542 - referral patients can be avoided by adding to the referral
BB0543 - coordination plan a process of transmitting blood test reports to the
BB0544 - referring hospital and entering the information into the medical chart
BB0545 - with notiations showing source and how the data was transmitted, who
BB0546 - entered it, and the date of entry, so that both the data and quality
BB0547 - of the data can be taken into account.
BB0549 -  ..
BB0550 - Planning for referral coordination between UCSF and Kaiser was
BB0551 - proposed by UCSF on 070222. ref SDS 14 VK5N  At that time, maintaining
BB0552 - accurate test results, ref SDS 14 TU8L, including laboratory blood
BB0553 - tests, ref SDS 14 WY6J, was identified for coordination.
BB0554 - Communication between Kaiser and UCSF has proven difficult to
BB0555 - integrate diverse cultures, shown by follow up in the record on
BB0556 - 070222. ref SDS 14 626J
BB0557 -
BB0558 -            [On 080307 report for laboratory blood test at UCSF was
BB0559 -            submitted to primary care physician at Kaiser. ref SDS 55
BB0560 -            JY5K
BB0562 -  ..
BB0563 - Millie will have another blood test tomorrow at UCSF to start the
BB0564 - next cycle of treatment.
BB0566 -  ..
BB0567 - Medical Chart continues...
BB0568 -
BB0569 -    5.  Imaging
BB0570 -
BB0571 -        02/12/08 CT THORAX, ABDOMEN, PELVIS W CONTRAST - increased
BB0572 -        right axillary LN; infiltrate RML fissure
BB0574 -  ..
BB0575 - Kaiser deserves credit for starting to comment in the Medical Cart on
BB0576 - test findings.  This minimal effort is a start on using the record to
BB0577 - manage the work, called out in NWO for working intelligently.
BB0578 - ref OF 11 A56M
BB0580 -  ..
BB0581 - The doctor added comment today on tracking new findings in the CT test
BB0582 - on 080212 that seem related to possible rising PE issues, per above,
BB0583 - ref SDS 0 N15O, citing review on 080215. ref SDS 48 RV78
BB0585 -  ..
BB0586 - For some reason the doctor does not comment on findings of right
BB0587 - paratracheal issues, also, per above, ref SDS 0 N15O, based on the
BB0588 - same CT test on 080212, reviewed on 080215. ref SDS 48 RV70
BB0590 -  ..
BB0591 - Medical Chart continues...
BB0592 -
BB0593 -        12/10/07 CT THORAX, ABDOMEN, PELVIS W CONTRAST - increased
BB0594 -        right axillary LN
BB0596 -  ..
BB0597 - Repeats omission of enlarged heart shown in test reviewed at UCSF on
BB0598 - 071213, ref SDS 35 SR5I, and cited in the record meeting at Kaiser on
BB0599 - 080118 in connection with this test. ref SDS 39 Q89J
BB0601 -  ..
BB0602 - Medical Chart continues...
BB0603 -
BB0604 -        09/30/07 CT ABDOMEN, PELVIS, THORAX W CONTRAST
BB0605 -        05/20/07 CT THORAX, ABDOMEN, PELVIS W CONTRAST - no change
BB0606 -        12/27/06 BASE SKULL TO MIDTHIGH PET/CT
BB0607 -        10/16/06 HAND, TWO VIEWS
BB0608 -        10/13/06 MAMMOGRAPHY UNILATERAL
BB0609 -        07/08/06 MRI BRAIN WO/W CONTRAST(STD)- negative
BB0611 -  ..
BB0612 - Medical Chart continues...
BB0613 -
BB0614 -    6.  Impression
BB0615 -
BB0616 -        1.  Metastatic breast cancer (IBC)lung, lymph node and chest
BB0617 -            wall
BB0618 -        2.  Right axillary LN increase
BB0619 -        3.  Depression
BB0620 -        4.  Cellulitis
BB0621 -        5.  Right arm pain after trauma
BB0623 -  ..
BB0624 - Kaiser's unitary comment under "Impression" saying only "Cellulitis,"
BB0625 - would be helpful noting level of severity observed, say on a scale of
BB0626 - 1 - 10, or perhaps saying mild, minimal, moderate... that conveys
BB0627 - level of effort required to address the problem in relation to current
BB0628 - treatment regimen of Keflex and icing, and with respect to starting
BB0629 - chemotherapy treatment tomorrow at UCSF.  The doctor seemed to comment
BB0630 - today during discussion that starting Carboplatin might be delayed
BB0631 - until Cellulitis subsides, per above. ref SDS 0 N163  Stating this in
BB0632 - the record makes referral coordination much more effective.
BB0634 -  ..
BB0635 - Doctor notes today with comment on CT test performed 080212 infiltrate
BB0636 - RML fissure, per above. ref SDS 0 Q89J  This "Impression" part of the
BB0637 - Medical Cart can be strengthened by noting risks being monitored and
BB0638 - factors that would signal rising problems that require action.
BB0640 -  ..
BB0641 - There is no discussion of rising CA 15-3, because Kaiser is not
BB0642 - reporting tests at UCSF, per above. ref SDS 0 417N
BB0644 -  ..
BB0645 - Medical Chart continues...
BB0646 -
BB0647 -    7.  Plan
BB0648 -
BB0649 -        1.  Continue Clinical Trial on Erbitux
BB0650 -
BB0651 -        2.  UCSF will add Carbo tomorrow? because of progression of
BB0652 -            skin lesions; cellulitis present
BB0654 -             ..
BB0655 -        3.  Right humeral xray
BB0656 -        4.  Start Prozac
BB0657 -        5.  Continue Keflex
BB0658 -        6.  RTC 8 weeks
BB0660 -         ..
BB0662 -
BB0663 -
BB0664 -
BB07 -

SUBJECTS
Default Null Subject Account for Blank Record

BP03 -
BP0401 -  ..
BP0402 - Secure Email UCSF Prevents Timely Communication Collaboration
BP0403 - Communication Health Care Fails Patient Care Suffers UCSF Secure Email
BP0404 -
BP0405 - Follow up ref SDS 52 0T8F.
BP0406 -
BP0407 - Asked the doctor to submit his report today to Doctor Rugo for guiding
BP0408 - discussion of the meeting tomorrow.
BP0410 -  ..
BP0411 - The doctor said UCSF has introduced new and complex communication
BP0412 - procedures using "secure email."  He could not open UCSF's letter
BP0413 - yesterday, per above, ref SDS 0 7V4M, and similar to experience
BP0414 - reported in patient history, also, yesterday on 080304. ref SDS 52
BP0415 - 0T8F  Doctor Johnson explained having tried to send and receive
BP0416 - corresondence using the new UCSF "secure email" system, but everything
BP0417 - got mixed up trying to figure out which buttons to press; so, whatever
BP0418 - UCSF is now doing, prior smooth communication, noted by the doctor on
BP0419 - 070610, ref SDS 17 OG7F, has been disrupted by the new "secure mail"
BP0420 - system.
BP0422 -  ..
BP0423 - This may align with Becky's report yesterday that Arlette, who usually
BP0424 - coordinates Millie's care with UCSF and the primary care physician was
BP0425 - too busy to work on Millie's case yesterday, because she was tied up
BP0426 - working with technicians to solve a problem using the computer system.
BP0427 - ref SDS 52 MH4F
BP0428 -
BP0429 -        [On 080306 during the meeting at UCSF, the medical team
BP0430 -        disclosed that UCSF management has mandated using a UCSF email
BP0431 -        channel for secure communication, rather than provide timely,
BP0432 -        accurate communication requested by the patient. ref SDS 53
BP0433 -        JT66
BP0435 -         ..
BP0436 -        [On 081103 Millie received "secure email" correspondence from
BP0437 -        Kaiser, ref SDS 68 XO8J, alleged to be sent by the primary care
BP0438 -        physician, but which could not be accessed, and which the
BP0439 -        doctor indicated not having actually sent the letters.
BP0440 -        ref SDS 68 E59N
BP0442 -         ..
BP0443 -        [On 081103 letter to Kaiser notifies the doctor that another
BP0444 -        letter came through that could not be opened. ref SDS 68 4Q6K
BP0446 -         ..
BP0447 -        [On 090205 1318 primary care physician at Kaiser requests using
BP0448 -        the Kaiser closed, proprietary email system that has more
BP0449 -        limitations than the UCSF system, and for the purpose of
BP0450 -        increasing productivity by preveinting details from falling
BP0451 -        through the cracks. ref SDS 69 278T
BP0453 -         ..
BP0454 -        [On 100107 1327 Millie received a letter from Doctor Johnson at
BP0455 -        Kaiser using "secure email" which prevented access, similar to
BP0456 -        Doctor Johnson being unable to open "secure email" sent to him
BP0457 -        by UCSF. ref SDS 70 CX9G
BP0459 -         ..
BP0460 -        [On 100108 0852 Millie notifies medical team that Kaiser's
BP0461 -        "secure email" presented same problems preventing access by the
BP0462 -        patient that previously prevented Doctor Johnson from opening a
BP0463 -        secure email which UCSF submitted to Doctor Johnson at Kaiser.
BP0464 -        ref SDS 71 MW4P
BP0466 -  ..
BP0467 - The doctor suggested that Millie print a copy of the report he sends
BP0468 - to the patient and hand this to the doctor tomorrow.
BP0470 -  ..
BP0471 - Giving busy people documentation during a meeting almost ensures there
BP0472 - will no time for review to be prepared for a productive meeting,
BP0473 - illustrated by work at Kaiser on 040517. ref SDS 6 6T5G
BP0474 -
BP0475 -        [On 080306 during the meeting at UCSF, the medical team
BP0476 -        disclosed that UCSF management has mandated using a UCSF email
BP0477 -        channel for secure communication, rather than provide timely,
BP0478 -        accurate communication requested by the patient. ref SDS 53
BP0479 -        JT66
BP0481 -  ..
BP0482 - After the meeting, Millie stopped at the front desk.  The clerk
BP0483 - scheduled the next meeting for 080502 1200.
BP0484 -
BP0485 -        [On 080502 after meeting with the doctor at Kaiser, the
BP0486 -        scheduling clerk said that Kaiser's computer would not allow
BP0487 -        entering the schedule ordered by the doctor, and that the
BP0488 -        patient would have to call back in a week or so to implement
BP0489 -        the doctor's order. ref SDS 64 YU5G
BP0491 -  ..
BP0492 - This gets us back to meeting the day after meetings with the medical
BP0493 - team at UCSF.
BP0494 -
BP0495 -
BP0496 -
BP0497 -
BP0498 -
BP0499 -
BP05 -