THE WELCH COMPANY
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San Francisco, CA 94111-2496
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S U M M A R Y
DIARY: March 5, 2008 12:00 PM Wednesday;
Millie meeting at Kaiser to review progress on clinical trial at UCSF.
2...FLUOXETINE 20 MG CAPSULES Prozac to Treat Stress Depression
3...Prozac Prescribe Cope Emotional Trauma IBC Relapse Cellulitis Relapse
4...Emotional Coping Difficult IBC Relapse Severe Fall Cellulitis Relapse
....Common Side Effects
5...Arm Left Cellulitis Lymphedema Subsiding Continue Treatment
6...Cellulitis Inflammation Subsiding Lymphedema Swelling Reduced by Icing
7...Coordination Failed Kaiser Cannot Access UCSF Correspondence
8...Keflex Prescribed Treat Cellulitis Future Relapse
9...Coordinate Medication Changes Coumadin Treatment Pulmonary Embolism
10...Pulmonary Embolism Treatment Warfarin Coumadin Coordinate Medications
11...Arm Right Xray Evaluate Injury Fall 080125
12...Xray Ordered Evaluate Injury Fall 080125 Right Arm Discomfort
13...Fall 080125 Right Arm Discomfort Xray Ordered Evaluate Injury
14...IBC Expanding Diagnose 4th Relapse Recommnd Increase Treatment
15...Intensity IBC Inflammation Appears Subsiding Rash Expanding
16...CT Test Finding Support Diagnosis IBC 4th Relapse
17...Cardio Pulmonary Referral CT Test Finding Enlarged Heart
18...Medical Chart Reports Examination Diagnosis Prescription Prognosis
19...Secure Email UCSF Prevents Timely Communication Collaboration
20...Communication Health Care Fails Patient Care Suffers UCSF Secure Email
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Cellulitis IBC Fall Kaiser Examination Backup UCSF Clinical Trial Me
2303 - ..
2304 - Summary/Objective
230501 - Follow up ref SDS 39 0000. ref SDS 31 0000.
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
230535 - ..
2308 - Progress
230901 - Millie's vitals are elevated today: BP 127 86 Pulse 78
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
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...
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
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.
Prozac Prescribed Cope Emotional Trauma IBC Relapse Cellulitis Relap
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
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
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.
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.
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
380549 - ..
380550 - Research on the Internet found a "Linden" report...
380552 - http://www.panic-anxiety.com/articles/prozac-fluoxetine/
380554 - ...which is marketing an alternative to Prozac called the "Linden
380555 - Method," and says in part...
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...
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.
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....
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
380599 - 1. Allergic or Toxic - Rash, Pruritus (skin inflammation)
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...
380610 - Unwanted head feelings!
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
Cellulitis Left Arm Examination Lymphedema Swelling Subsiding Red Ra
630401 - ..
630402 - Arm Left Cellulitis Lymphedema Subsiding Continue Treatment
630403 - Cellulitis Inflammation Subsiding Lymphedema Swelling Reduced by Icing
630405 - Follow up ref SDS 52 UZ89.
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
630457 - ..
630458 - Coordination Failed Kaiser Cannot Access UCSF Correspondence
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
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
630479 - ..
630480 - Keflex Prescribed Treat Cellulitis Future Relapse
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.
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.
Medications Coordinate Kaiser Coagulation Department Notify Changes
820401 - ..
820402 - Coordinate Medication Changes Coumadin Treatment Pulmonary Embolism
820403 - Pulmonary Embolism Treatment Warfarin Coumadin Coordinate Medications
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).
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
Xray Ordered Arm Right Evaluate Discomfort Lift Arm Laterally Full V
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
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
950422 - ..
9507 - 1404
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
IBC Examination Expanding Cancer Disease Diagnose 4th Relapse Recomm
A90401 - ..
A90402 - IBC Expanding Diagnose 4th Relapse Recommnd Increase Treatment
A90403 - Intensity IBC Inflammation Appears Subsiding Rash Expanding
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
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.
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
CT Test 080212 Findings Support Diagnosis IBC Progression Disease 4t
AS0401 - ..
AS0402 - CT Test Finding Support Diagnosis IBC 4th Relapse
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
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.
AS0439 - [On 080619 UCSF called and indicated the doctor changed CT
AS0440 - test frequency back from 12 to 8 weeks. ref SDS 67 O39F
AS0443 - ..
AS0444 - Cardio Pulmonary Referral CT Test Finding Enlarged Heart
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
CT Test 080212 Findings Support Diagnosis IBC Progression Disease 4t
BB0401 - ..
BB0402 - Medical Chart Reports Examination Diagnosis Prescription Prognosis
BB0404 - Follow up ref SDS 39 YT5N, ref SDS 31 YT5N.
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,
BB0434 - [On 080331 photographs support explanation of expanding
BB0435 - disease. ref SDS 60 9Q4I
BB0437 - ..
BB0438 - Medical Chart continues...
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...
BB0455 - 3. Current Medications
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
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...
BB0482 - 4. Physical Examination
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...
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
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
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...
BB0569 - 5. Imaging
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...
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...
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...
BB0614 - 6. Impression
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...
BB0647 - 7. Plan
BB0649 - 1. Continue Clinical Trial on Erbitux
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 - ..
Default Null Subject Account for Blank Record
BP0401 - ..
BP0402 - Secure Email UCSF Prevents Timely Communication Collaboration
BP0403 - Communication Health Care Fails Patient Care Suffers UCSF Secure Email
BP0405 - Follow up ref SDS 52 0T8F.
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
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
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.
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.