THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net
S U M M A R Y
DIARY: March 6, 2008 09:00 AM Thursday;
Rod Welch
Millie 1st treatment 1st cycle cetuximab Carboplatin for 4th relapse IBC.
1...Summary/Objective
2...546N
3...Labs Blood Test
4...Coagulation Control INR 2.2 Normal Stable PT 25.5 High
5...Cetuximab Full Dose Blood Counts Below Targets Treatment 1 Hour
..............
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CONTACTS
SUBJECTS
Cetuximab 12th Cycle 3rd Treatment 18th Total Treatment Chemotherapy
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 44 0000. ref SDS 42 0000.
040502 -
040503 -
040504 -
040506 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Begin 15 treatment cycle with cetuximab.
040902 -
040903 - This is also the 1st treatment of the 1st cycle with both cetuximab
040904 - and Carboplatin added. However, the doctor decided during the meeting
040905 - this morning to defer starting Carboplatin until next week. So, in
040906 - fact, Millie was treated today only with cetuximab, and did not get
040907 - the additional treatment of Carboplatin.
040908 -
040909 -
040910 -
040911 -
040912 -
0410 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - 546N
050403 - Labs Blood Test
050404 -
050405 - Follow up ref SDS 39 546N. ref SDS 31 BD6I.
050406 -
050407 - Millie had a blood draw at 0755 this morning in the Infusion Clinic on
050408 - the 5th floor to develop data for review by the medical team meeting
050409 - on the 2nd floor at at 0900. ref SDS 38 QY5I Diane is on vacation
050410 - today, so Stephanie did the work.
050412 - ..
050413 - Stephanie looked through Millie's medical chart on file in the
050414 - Infusion Clinic and said there was no order for a blood test today.
050415 - This conflicts with the record on 080304 notifying UCSF about ordering
050416 - a blood draw today. ref SDS 45 TN8W Administrative snafus occur from
050417 - time to time. UCSF has been effective making timely adjustments that
050418 - mitigate problems, for example on 070308. ref SDS 5 JG4G
050420 - ..
050421 - Millie explained today that Jackie usually submits the doctor's order
050422 - for blood tests to start each new treatment cycle every 4 weeks.
050423 - Millie suggested that Stephanie use the scope for the prior test on
050424 - 080207. ref SDS 39 439L
050426 - ..
050427 - Stephanie looked through the medical chart. She related that Millie
050428 - gets a full range of tests every 6 weeks, and so she cannot draw blood
050429 - to perform those tests for another 2 weeks.
050431 - ..
050432 - Millie explained that she has been on the same 4 week schedule of
050433 - blood tests for the past year, reported on 070201. ref SDS 2 XR40
050434 - There is no evidence in the record of changing the scope of labs to 6
050435 - weeks. Stephanie felt sure 6 weeks is specified in documentation she
050436 - examined in Millie's medical chart.
050438 - ..
050439 - Millie related past practice in this case for the Infusion Clinic
050440 - staff to use the scope for the last test, when there is a mixup and
050441 - the doctor's order for labs is delayed or misdirected. An example is
050442 - work on 070308. ref SDS 5 XA9I
050444 - ..
050445 - Stephanie feels there is not enough time this morning to check the
050446 - computer for the scope of prior blood tests in this case on 080207,
050447 - ref SDS 39 439L,
050449 - ..
050450 - Stephanie made an appropriate decision to resolve conflicts between
050451 - documentation in the medical chart, and limited time that prevents
050452 - calling the medical team on the 2nd floor Oncology Clinic for advice,
050453 - nor enough time to check the record on the computer for the scope of
050454 - the prior test on 080207. She decided to do minimal tests this
050455 - morning that provide data on blood counts for NEUTS (ANC at Kaiser),
050456 - which guides evaluation of safety getting treatment relative to
050457 - strength of the immune system, so that this diagnostic can reviewed in
050458 - the meeting with the doctor at 0830. During the meeting, the doctor
050459 - will clarify scope, and submit new instructions for the lab testing
050460 - protocol. This will delay treatment, but will relieve the Infusion
050461 - Clinic staff of having to check the computer for the blood test scope
050462 - last month on 080207. ref SDS 39 439L
050464 - ..
050465 - During the meeting at 0830 with the doctor on the 2nd floor, Jackie
050466 - submitted the order for the blood tests, which had been misdirected to
050467 - the Lab on the 1st floor, because Jackie was out of the office
050468 - yesterday and asked someone to deliver the order for her, who was not
050469 - familiar with blood being drawn for Millie by the Infusion Clinic on
050470 - the 5th floor. ref SDS 46 EX4I
050471 -
050472 - [On 080402 coordination starting next cycle of treatment in the
050473 - clinical trial reminds medical team to send the order for blood
050474 - tests to the Infusion Clinic on the 5th floor, rather than the
050475 - Lab on the 1st floor. ref SDS 48 Q24T
050477 - ..
050478 - When Millie returned to the 5th floor, she submitted the doctor's
050479 - order to Catherine, who then drew blood for the complete scope, and
050480 - sent it to the lab for testing.
050482 - ..
050483 - During treatment, Catherine submitted results of the test. The prior
050484 - test on 080214 was an interim evaluation, ref SDS 40 QD9I, that
050485 - followed up the regularly scheduled test on 080207. ref SDS 39 439L
050486 -
050501 - ..
050502 - Log#: 080306 08:25
050503 - <----------------------- U C S F -----------------------> <------------- Kaiser -------------->
050504 - Type Results Units Normal ACRO Type Units Normal
050506 - ..
050507 - CBC with DIFF & PLT CT CBCD
050508 - ..
050509 - WBC COUNT 4.9 x10E9/L 3.4 - 10 WBC WBC x10-3 K/uL 3.4 - 10.0
050510 - RBC COUNT 4.55 x10E12/L 4 - 5.2 RBC RBC x10-6 M/uL 3.60 - 5.70
050511 - HEMOGLOBIN 14.5 g/dL 12 - 15.5 HGB Hemoglobin g/dL 11.5 - 15.0
050512 - HEMATOCRIT 41.7 PERCENT 36 - 46 HCT Hematocrit % 34.0 - 46.0
050513 - MCV 92 fL 80 - 100 MCV MCV fL 80.0 - 100.0
050514 - MCH 31.7 pg 26 - 34 MCH
050515 - MCHC 34.7 g/dL 31 - 36 MCHC
050516 - PLATELETS 223 x10E9/L 140 - 450 PLT Plt x10-3 K/uL 140 - 400
050517 - ..
050518 - (posted 080313, ref SDS 47 T25I)
050519 - CA 15-3 H* 59 U/mL < 33 CA15-3 CA 15-3 < 39
050520 -
050521 - Note new reference range [<33 changed from <31] and change in
050522 - methodology effective March 1, 2008. Performed using the
050523 - Siemens Centaur Chemiluminesence method. CA 15-3 result using
050524 - the Roche Elecsys assay is 75 U/mL. Ref range <31 U/mL. This
050525 - rebaseline value provided at no additional charge.
050527 - ..
050528 - This new note updates explanation of tests prior to 080301,
050529 - e.g., on 080207. ref SDS 39 A16M
050531 - ..
050532 - Prior test on 080207 CA 15-3 63. ref SDS 39 A16M
050533 - ..
050534 - (NEUTS x 1000 = ANC for Kaiser)
050535 - NEUTS 2.75 x10E9/L 1.8 - 6.8 N-A ANC 1500
050536 - Neutrophils Not Reported Neutrophils % 50 - 70
050538 - ..
050539 - LYMPHS 1.42 x10E9/L 0.9 - 2.9 L-A Lymphocytes % 20 - 50
050540 - MONOS 0.44 x10E9/L 0.1 - 0.6 M-A Monocyte % 0 - 11
050541 - EOS 0.23 x10E9/L 0 - 0.4 E-A Esoinophils % 1 - 5
050542 - BASOS 0.09 x10E9/L 0 - 0.1 B-A Basophil % 0 - 2
050543 - 0 - 5
050544 - ..
050545 - <----------------------- U C S F -----------------------> <------------- Kaiser -------------->
050546 - Type Results Units Normal ACRO Type Units Normal
050547 - ..
050548 - PT H 23.0 S 12.5 - 16.0 PT PT, patient sec 8.9 - 11.1
050549 - INL NRM Ratio H 2.0 0.9 - 1.2 INR PT INR sec 2.0 - 3.0
050550 - PARTIAL
050551 - THROMBOPLASTIN Not Reported S 22.4 - 33.3 PTT
050552 -
050553 - [On 080226 INR 2.4 results submitted to Kaiser for Coumadin
050554 - management pulmonary embolism. ref SDS 37 LZ9H
050556 - ..
050557 - ELECTROLYTE PANEL LYTE
050558 - SODIUM 135 mmol/L 134 - 143 NA Sodium mEq/L 137 - 145
050559 - POTASSIUM 3.9 mmol/L 3.4 - 4.9 K Potassium mEq/L 3.5 - 5.3
050560 - CHLORIDE 103 mmol/L 98 - 107 CL
050561 - * CARBON DIOX TOTAL L 20 mmol/L 23 - 32 CO2
050562 - ANION GAP 12 3 - 14 ANGA
050564 - ..
050565 - UREA NITROGEN 13 mg/dL 8 - 23 BUN BUN mg/dL 7 - 17
050566 - CALCIUM L 8.3 mg/dL 8.7 - 10.1 CA Calcium mg/dL 8.4 - 10.2
050567 - MAGNESIUM 2.1 mg/dL 1.8 - 2.3 MG Magnesium mg/dL 1.6 - 2.3
050569 - ..
050570 - CREAT with eGFR
050571 - CREATININE 0.56 mg/dL 0.42 - 1.06 CR Creatinine mg/dL 0.6 - 1.2
050572 -
050573 - Note: Creatinine assay changed to IDMS standardization on
050574 - February 4, 2008 causing decrease in results of approximately
050575 - 0.09 mg/dL
050577 - ..
050578 - eGFR if Caucasian >60 mL/min GFRC
050579 - eGFR if African Amer >60 mL/min GFRA
050581 - ..
050582 - GLUCOSE 89 mg/dL 70 - 199 GLU Glucose mg/dL ? - ?
050583 - AST H 54 U/L 16 - 41 AST AST (SGOT) U/L 14 - 36
050584 - ALT 43 U/L 11 - 54 ALT ALT (SGPT) U/L 11 - 66
050585 - BILIRUBIN TOTAL 0.6 mg/dL 0.3 - 1.3 BILT Bili Total mg/dL 0.2 - 1.3
050586 - ALKALINE PHOSPHATASE 55 U/L 29 - 111 ALKP Alkaline Ph U/L 38 - 126
050587 - PROTEIN TOTAL in Lab g/dL 5.8 - 8.0 TP Protein, Total g/dL 6.3 - 8.2
050588 - ALBUMIN in Lab g/dL 3.4 - 4.7 ALB Albumin g/dL 3.4 - 4.8
050589 -
050590 -
050591 -
050592 -
050593 -
0506 -
SUBJECTS
Default Null Subject Account for Blank Record
1503 -
150401 - ..
150402 - Coagulation Control INR 2.2 Normal Stable PT 25.5 High
150403 -
150404 - Follow up
150405 -
150406 - The test today shows PT 23.0 and INR 2.0, per above. ref SDS 0 PU7Y
150408 - ..
150409 - This shows INR continues stable, indicating the current regimen is
150410 - effective, and so supports continuing testing once a month, per review
150411 - on 070329, ref SDS 6 IL6G, citing planning on 070308, ref SDS 5 CS6J,
150412 - and communication with Gloria the day before on 070307. ref SDS 4 IY6I
150414 - ..
150415 - This is a bit anomalous compared to the past 6 months showing INR
150416 - generally between 2.3 - 2.7.
150417 -
150418 - INR
150419 - 2.0............................. 080306, ref SDS 0 PU7Y
150420 - 2.4............................. 080207, ref SDS 39 PU7Y
150421 - 2.3............................. 080110, ref SDS 30 PU7Y
150422 - 2.3............................. 071213, ref SDS 22 PU7Y
150423 - 2.7............................. 071115, ref SDS 17 PU7Y
150424 - 2.3............................. 071018, ref SDS 15 T18I
150425 - 2.7............................. 070920, ref SDS 14 PU7Y
150426 - 2.1............................. 070816, ref SDS 13 PU7Y
150427 - 2.5............................. 070719, ref SDS 12 PU7Y
150428 - 2.1............................. 070621, ref SDS 11 PU7Y
150429 - 2.2............................. 070524, ref SDS 9 PU7Y
150430 - 2.7............................. 070426, ref SDS 7 PU7Y
150431 - 2.4............................. 070329, ref SDS 6 PU7Y
150432 - 2.5............................. 070301, ref SDS 3 PU7Y
150433 - 1.6............................. 070201, ref SDS 2 SE6N
150434 -
150435 -
150436 -
150437 -
150438 -
1505 -
SUBJECTS
Default Null Subject Account for Blank Record
2403 -
2404 -
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240402 -
240403 -
240404 -
240405 -
240406 -
2405 -
SUBJECTS
Default Null Subject Account for Blank Record
3603 -
360401 - ..
360402 - Cetuximab Full Dose Blood Counts Below Targets Treatment 1 Hour
360403 -
360404 - Follow up ref SDS 9 4N5M, ref SDS 8 4N5M.
360405 -
360406 - Cetuximab started.
360407 -
360408 - Verify chemotherapy order for 070208.
360410 - ..
360411 - Chemotherapy order calls for cetuximab to start 30 - 60 minutes after
360412 - Beyadryl pre-tretment, reported on 070201. ref SDS 2 555H
360413 -
360414 -
360415 -
360416 -
360417 -
360418 -
360419 -
360420 -
360421 -
360422 -
360423 -
360424 -
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3605 -