THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: May 2, 2008 12:00 PM Friday;
Millie meeting at Kaiser to review progress on clinical trial at UCSF.
2...Examination Agenda Develop Integrated Work Plan Kaiser UCSF
3...Prozac Not Needed Emotional Stress Relieved Favorable Results
4...Emotional Stress Subsides Health Care Referral Coordination Improve
5...Arm Left Cellulitis Lymphedema Subside after Keflex Treatment
6...Cellulitis Inflammation Lymphedema Swelling Ended Treatment Effective
7...Lymphedema Cellulitis Subside No Evidence Disease Keflex Effective
8...Coordinate Medication Changes Between Kaiser and UCSF
9...Medication Current List Coordinate Kaiser UCSF Referral Care
10...Current Medications Comprehensive Care Coordinate Kaiser Referral UCSF
11...Kaiser Medication History Issued 080502
12...Current Medication Comments on Frequency of Use
13...Arm Right Xray Evaluate Injury Fall 080125
14...Xray Ordered Evaluate Injury Fall 080125 Right Arm Discomfort
15...Fall 080125 Right Arm Discomfort Xray Ordered Evaluate Injury
16...IBC Subsiding Demonstrates Response to Treatment 4th Relapse
17...Responding Treatment Despite Only 50% Prescribed Medication Dose
18...Carboplatin 50% Prescribed Treatment Due to Low Blood Counts
19...Low Blood Counts Reduce Carboplatin to 50% of Prescribed Treatment
20...Neupogen Prescribed Increase Blood Counts Enable Complete Treatment
21...Black Box Knowledge Management Processing Kaiser Pharmacy
22...Neupogen Costs $600 More for Home Care than Treatment at Kaiser
23...Computer Problems Difficulty Pharmacy Providing Prescribed Medication
24...Pharmacy Difficulty Providing Prescribed Medication Computer Problems
25...Invoice Neupogen 6 Treatments $517 500% Increase from April Charges
26...CT Test Findings NED No Evidence of Disease Distant Metastasis
27...Power Port Schedule Surgery in Time for Next CT Test
28...CT Test Injection Trauma Investigate Power Port Surgery
29...Medical Chart Reports Examination Diagnosis Prescription Prognosis
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Meeting Examination Kaiser Backup Doctor Review Strategy Work Plan 3
1303 - ..
1304 - Summary/Objective
130501 - Follow up ref SDS 68 0000. ref SDS 54 0000.
130503 - Millie explained that improved health and resolution of referral
130504 - coordination issues have relieved previously elevated stress without
130505 - taking prescribed Prozac medication. ref SDS 0 KT4J The doctor found
130506 - Cellulitis and lymphedema treated in the ER on 080409 were resolved.
130507 - ref SDS 0 RM6J Referral coordination with UCSF was improved today by
130508 - correlating current medications in Kaiser's computer with the list in
130509 - the patient Medical Chart shown by another part of the computer system
130510 - for submission to UCSF. ref SDS 0 IE6M The doctor further correlated
130511 - Kaiser's Medical Chart with patient history at UCSF on starting
130512 - treatment of Carboplatin added to cetuximab on 080313. ref SDS 0 KT5G
130513 - Examination showed decreasing cancer with IBC inflammation and rash
130514 - subsiding despite getting only 50% of prescribed treatment with
130515 - Carboplatin for the first 2 cycles (8 weeks). ref SDS 0 NH4N The
130516 - doctor ordered Neupogen prescribed by UCSF yesterday to increase blood
130517 - counts so that Millie can safely get the full treatment prescribed for
130518 - Carboplatin. ref SDS 0 NL4M Problems filling the prescription for
130519 - Neupogen in the Kaiser Pharmacy require further review. ref SDS 0 NM5K
130520 - Favorable examination today showing improved prospects treating cancer
130521 - aligns with CT test on 080425 showing no distant metastasis.
130522 - ref SDS 0 N15O The doctor feels again that referral is not needed for
130523 - heart specialist to review CT test findings of increasing cardio
130524 - pulminary issues. ref SDS 0 YU6Q Resolving injury to right arm from
130525 - needle penetrations for injecting CT test contrast medium was referred
130526 - to the surgeon upgrading the port catheter to a Power Port.
130527 - ref SDS 0 WX6I
130538 - ..
1308 - Progress
130901 - Examination Agenda Develop Integrated Work Plan Kaiser UCSF
130904 - Millie's vitals are normal today: BP 127 86 Pulse 78
130906 - Pulse normal about 60; so 63 indicates calm, minimal anxiety.
130908 - ..
130909 - Agenda for the meeting today...
130911 - 1. Cellulitis resolved. ref SDS 67 6S7I
130913 - ..
130914 - 2. IBC rash significantly improved; slightly more intense today
130915 - after treatment with cetuximab yesterday.
130917 - ..
130918 - 3. Nupeogen prescription for care ordered by UCSF yesterday to
130919 - maintain treatments in clinical trial.
130921 - ..
130922 - 4. CT test on 080425. ref SDS 85 9W9I reviewed on 080428,
130923 - ref SDS 86 6V5I, shows requirement for avoiding needle
130924 - penetrations by using the port catheter to inject contrast
130925 - medium. ref SDS 85 FP6F
130927 - ..
130928 - 5. Emotional stress coping with advancing cancer, changing
130929 - treatments, fall, cellulitis recurrence, have mostly subsided
130930 - with improvement of prospects based on favorable results from
130931 - new treatment regimen.
Prozac Not Taken Current Medication Prescribed 080305 Patient Improv
400401 - ..
400402 - Prozac Not Needed Emotional Stress Relieved Favorable Results
400403 - Emotional Stress Subsides Health Care Referral Coordination Improve
400405 - Follow up ref SDS 68 KT4J.
400407 - During the prior meeting on 080305, the doctor asked how Millie was
400408 - coping with rising emotional health care issues? How was she feeling?
400409 - ref SDS 68 KT4J At that time, since things seemed to be cascading out
400410 - of control into overwhelming complex problems, the doctor prescribed
400411 - Prozac medication to relieve stress from depressing difficulties.
400412 - ref SDS 68 5L5M The next day, on 080306 UCSF concurred prescribing
400413 - Prozac to treat emotional trauma. ref SDS 69 NV5F
400415 - ..
400416 - For example, a big problem was difficulty implementing agreement for
400417 - Kaiser to pay for Millie's care on referral to UCSF, and suddenly
400418 - being confronted with extra cost of $20K, and many complicated billing
400419 - issues, reviewed on 071027. ref SDS 32 WU6M Coordination between
400420 - Kaiser and UCSF seemed to break down with people who arranged for care
400421 - frustrated by difficulties understanding billings, reported on 070907.
400422 - ref SDS 28 XH5H When UCSF was asked to explain billings they said
400423 - nobody knows the basis for charges, reported on 070823, ref SDS 25
400424 - NN71, and then threatened to terminate treatment for non-payment,
400425 - reported on 071031. ref SDS 42 KM4J Kaiser eventually resolved this
400426 - problem on 071128, ref SDS 48 TH8L, after creating significant
400427 - emotional trauma for the patient, reported on 071006, ref SDS 33 ZE9H,
400428 - and for Kaiser and UCSF hospital staff struggling to cope and
400429 - illustrated by the record on 071009, ref SDS 34 JW7M, and due to
400430 - complex, difficult, conflicting, and changing health care billing
400431 - procedures in contracts, regulations, and law, as set out on 070927.
400432 - ref SDS 32 WU6M
400434 - ..
400435 - After resolving stress from threats of terminating treatment during
400436 - July - November, in December it became evident that cancer had begun
400437 - to progress. This created anxiety about changing treatment and impact
400438 - on quality of life. For example, the CT test at Kaiser on 071210 was
400439 - reviewed at UCSF in a meeting on 071213. The test suddenly showed a
400440 - number of cancer nodes in the right axilla which were described as
400441 - enlarged from the prior test, but the report on the prior test had not
400442 - reported any nodes. This raised doubes about reliability of testing
400443 - and reporting. ref SDS 50 SS72 During this period a blood test at
400444 - Kaiser reported a big increase in the cancer marker, CA 15-3 to 78.
400445 - UCSF explained this in part as differences in test methods, but UCSF
400446 - also reported the cancer marker rising on 080110. ref SDS 53 A16M The
400447 - decision to start the 2nd arm of the clinical study adding Carboplatin
400448 - created a lot of worry reported on 080207 about ability to hold blood
400449 - counts, ref SDS 60 E14H, based on patient history listed on 060810.
400450 - ref SDS 12 HV45 Worry, anxiety, stress about blood counts being too
400451 - low for treatment was reported to Kaiser in a letter on 080307.
400452 - ref SDS 71 HS6R Emotional stress, anxiety, doubt, and worry increased
400453 - getting only 50% of prescribed treatment because of low counts,
400454 - reported today. ref SDS 0 NL9I
400456 - ..
400457 - All of these concerns justified prescribing Prozac on 080305 to
400458 - relieve emotional stress and anxiety. ref SDS 68 5L5M Research at
400459 - that time raised questions about side effects of Prozac. ref SDS 68
400460 - XP6H
400462 - [...below new problems today cause stress, emotional trauma from
400463 - "black box" experience ordering medication on Kaiser's computer.
400464 - ref SDS 0 NM4J
400466 - ..
400467 - The next day on 080306 UCSF reported blood counts NEUTS 2.75 rise
400468 - unexpectedly to highest level in over a year. This provides safety
400469 - for increasing treatment by adding Carboplatin to treat expanding
400470 - cancer (IBC), and relieves anxiety, worry, and doubt. ref SDS 69 033B
400471 - The following day on on 080307 Millie notified the primary care
400472 - physician at Kaiser of emotional relief from sudden and unexpected
400473 - rise of blood counts to highest level in over a year. ref SDS 71 HS6R
400475 - ..
400476 - On 080312 Millie reported starting Prozac treatments, ref SDS 72 RT8Y;
400477 - she felt strange after taking the first 2 pills (treatments),
400478 - ref SDS 72 RT4S; improved prospects from rising blood counts, along
400479 - with increased exercise, ref SDS 72 RT5X, have relieved a lot of
400480 - emotional stress and depression; so, she stopped taking Prozac after
400481 - the 2 treatments (pills), and does not plan to resume at this time.
400482 - ref SDS 72 RT4W
400484 - ..
400485 - On 080313 Millie reported in a letter to Kaiser that further research
400486 - indicated positive findings on Prozac. ref SDS 74 TA4U The doctor
400487 - then asked for confirmation on whether Millie is taking Prozac.
400488 - ref SDS 74 O97N
400490 - ..
400491 - Today, Millie noted that resolution of UCSF financial dispute with
400492 - Kaiser paying for care, reported on 071128, ref SDS 48 TH8L, helps
400493 - relieve worry about billing irregularities reported on 071024,
400494 - ref SDS 38 EP5W, 071026, and summarized in the record on 071026,
400495 - ref SDS 39 X18J, and together with better physical health dealing with
400496 - the 4th IBC replapse and related issues, reported today, per below,
400497 - ref SDS 0 NH4N, have relieved a lot former worries and doubts about
400498 - the future.
400500 - ..
400501 - Millie further cited working out at the gym, and hiking at Lafayette
400502 - reservoir help dissipate emotional stress. As a result, she has not
400503 - taken Prozac, and will hold the prescription in reserve for use when
400504 - needed, if things change again.
400506 - ..
400507 - The doctor related today that he, too, enjoys the natural habitat at
400508 - Lafayette reservoir, and so recognizes how hiking the trails has good
400509 - effects resolving emotional issues without taking Prozac medication.
400511 - [...below Millie reports tolerating adding chemothearpy that
400512 - enables increased exercise, which helps maintain blood counts for
400513 - getting treatment for cancer, and dissipates emotional stress.
400514 - ref SDS 0 ZD9O
400516 - ..
400517 - The natural calming of Lafayette Reservoir noted by the doctor today
400518 - was used previously on 040520 to tell Millie about diagnosis of IBC
400519 - discovered in the biopsy report received from Kaiser on 040607.
400520 - ref SDS 9 0001
Cellulitis Arm Left Lymphedema Diagnosed 080409 Examination No Evide
580401 - ..
580402 - Arm Left Cellulitis Lymphedema Subside after Keflex Treatment
580403 - Cellulitis Inflammation Lymphedema Swelling Ended Treatment Effective
580404 - Lymphedema Cellulitis Subside No Evidence Disease Keflex Effective
580406 - Follow up ref SDS 68 RM6J, ref SDS 67 UZ89.
580408 - On 080305 the doctor prescribed 10 day treatment with Keflex for
580409 - Cellulitis and swelling from rising lymphedema, ref SDS 68 RM6J,
580410 - diagnosed the day before on 080304, ref SDS 67 0001 The next day on
580411 - 080306 examination at UCSF shows Cellulitis and lymphedema improved
580412 - and nearly resolved. ref SDS 69 NV42 On 080313 Millie completed
580413 - 10-day treatment with Keflex for Cellulitis, and reported to the
580414 - medical team no visible inflammation or swelling that signal
580415 - Cellulitis and lymphedema. ref SDS 74 MQ4I
580417 - ..
580418 - On 080409 Millie suffered another, more serious, recurrence of
580419 - Cellulitis with temperature 101.9. ref SDS 83 V45J Millie required
580420 - treatment in Kaiser ER, ref SDS 83 0R4H, and was released after 8
580421 - hours of treatment with IV antibiotics, ref SDS 83 FY4L, and other
580422 - care to reduce temperature to normal. ref SDS 83 F194 Home care for
580423 - 14 days was prescribed with Keflex.
580425 - ..
580426 - Millie reported in a letter to the team on 080423 that the 14-day
580427 - treatment with Keflex was completed, and the condition appears
580428 - resolved.
580430 - ..
580431 - Today, the doctor examined Millie's left arm and observed no evidence
580432 - of Cellulitis. Lymphedema swelling has mostly subsided to levels
580433 - associated with chronic condition from removal of lymphatics during
580434 - two surgeries on the left side.
580436 - [On 080520 Millie suffered another recurrence Cellulitis with
580437 - minimal lymphedema, ref SDS 93 OU5J; doctor prescribed 10 day
580438 - treatment with Keflex. ref SDS 93 1K7H
580440 - ..
580441 - [On 080606 surgeon indicated diminished lymphatic system from
580442 - removing cancerous lymph nodes may eventually strengthen
580443 - because remaining lymph nodes become more robust, which reduces
580444 - occurance of lymphadema and Cellulitis. ref SDS 96 4P7L
580446 - ..
580447 - Since Kaiser added another prescription to treat Cellulitis with
580448 - Keflex for 14 days on release from the ER department, reported 080409,
580449 - ref SDS 83 F142, Millie still has the 20-day prescription of Keflex on
580450 - 080305 to treat future recurrence. ref SDS 68 5M3F
580452 - [...below, Medical Chart work plan reports patient "continue
580453 - Keflex," which reflects the fact that Millie is not taking
580454 - Keflex, but has treatment medication on hand for future
580455 - episodes. ref SDS 0 CO3H
Medications Coordinate Kaiser Coagulation Department Notify Changes
770401 - ..
770402 - Coordinate Medication Changes Between Kaiser and UCSF
770403 - Medication Current List Coordinate Kaiser UCSF Referral Care
770404 - Current Medications Comprehensive Care Coordinate Kaiser Referral UCSF
770406 - Follow up ref SDS 68 IE6M.
770408 - Millie related work at UCSF yesterday to maintain a record of current
770409 - medications, ref SDS 88 QK4G, which aligns with Kaiser's practice
770410 - reported in the Medical Chart for the meeting on 080305. ref SDS 68
770411 - 7Y6F This makes progress on the coordination referral plan discussed
770412 - at UCSF on 070222. ref SDS 21 VK5N
770414 - ..
770415 - On 080307 Millie notified the medical team at UCSF and Kaiser to
770416 - update current medications, ref SDS 71 RW3T, based on Millie's medical
770417 - chart received from Kaiser on 080305. ref SDS 68 7Y6F
770419 - ..
770420 - Today, the doctor displayed the Medical Chart on the computer in the
770421 - examination room. The list seemed incomplete.
770423 - ..
770424 - The doctor searched through Kaiser's computer and found parts of the
770425 - case management software that lists current medications. He then
770426 - updated the list in Millie's Medical Chart, as shown below.
770427 - ref SDS 0 7Y6F
770429 - ..
770430 - The doctor advised that cetuximab and Carboplatin are not shown in
770431 - Kaiser's list of current medications because Kaiser believed that
770432 - these cancer treatments are given orally by a pill, like capecitibine
770433 - (Xeloda), and this method of treatment (oral) does not meet criteria
770434 - for listing in Kaiser's record of patient history.
770436 - ..
770437 - Millie corrected the record. She advised that both cetuximab and
770438 - Carboplatin are IV injection treatments.
770440 - ..
770441 - The doctor added these to the list, as shown below. ref SDS 0 UK9G
770443 - ..
770444 - After the meeting, further review of UCSF documents shows additional
770445 - treatments are part of care at UCSF. ref SDS 0 NA6L
770447 - ..
770448 - After the meeting, the doctor found more listings in Kaiser's computer
770449 - on Millie's medications. He printed these on paper, rather than enter
770450 - into the Medical Chart. The doctor handed the 4 pages of medication
770451 - lists to Millie for coordination with UCSF on Millie's referral care.
770452 - Review shows that 2 of these 4 pages are identical so there are only 3
770453 - pages. Medications are mostly listed chronologically in descending
770454 - order, with the most recent date at the top of the list. For
770455 - consistency the entire list is rendered in that order to help make
770456 - sense of medication history in relation to patient history...
770458 - ..
770459 - Accordingly, to determine Millie's current medications a medical
770460 - professional should correlate the separate supplemental list received
770461 - from the doctor listed here under "Kaiser Medication History..." with
770462 - the list in the doctor's medical chart, listed below. ref SDS 0 7Y6F
770465 - ..
770466 - Kaiser Medication History Issued 080502
770468 - This listing of medications received from the doctor after the meeting
770469 - today, supplements the list in the medical chart, ref SDS 0 7Y6F, and
770470 - as further explained below. ref SDS 0 SQ5M
770472 - MTZRAJ: 05/02/08 12:32
770474 - ..
770475 - Note: Patient has outside referral for Doctor Rugo in San
770476 - Francisco 3/6/08 ms
770478 - (+) 2/21/08 per Doctor Robert R Johnson OK to change benzaclin to
770479 - benzamycin, change patient ba....
770481 - ..
770482 - Allergies: No Known Allergy
770484 - ..
770485 - Cap: $4,051 Spent: $150.40
770487 - ..
770488 - Legend - A:D-DETAIL R-REFILL S:# RECEIVED F-FILLED RF:X-EXPIRED D
770489 - * = Not in Formulary I R
770490 - S A
770491 - ..
770492 - A Medication Dose Unit Freq Qty SRVDATE RF S Provider P R
770493 - --------------------------
770494 - NEUPOGEN *480 MCG/1, 6ML* -1 0 UD 1.6 05/02/08 5 F JOHNSON 0
770495 - SYRINGE-NEEDLE, DISP, 26gx5/ 0 1 05/02/08 1 F LAMSIN 0
770496 - SYRINGE-NEEDLE, DISP, 26gx5/ 0 1 05/02/08 X R LAMSIN 0
770497 - NEUPOGEN *480 MCG/1, 6ML* -1 0 UD 1.6 04/18/08 X R JOHNSON 0
770498 - ..
770499 - WARFARIN 4 MG TABLETS 0 UD 100 04/12/08 2 JOHNSON 5 Y
770500 - ..
770501 - CEPHALEXIN 500 MG CAPSULES 1 CAP QID 56 04/09/08 0 PUJOLL 1
770502 - ..
770503 - NEUPOGEN *480 MCG/1, 6ML* -1 0 UD 1.6 04/07/08 X R JOHNSON 0
770504 - ..
770505 - GASTROGRAFIN 66/10 SOLUTION 0 20 04/05/08 X BHUTAN 1
770506 - NEUPOGEN *480 MCG/1, 6ML* -1 0 UD 1.6 04/05/08 X JOHNSON 1
770507 - SYRINGE-NEEDLE, DISP, 26gx5/ 0 1 04/05/08 X LAMSIN 1
770508 - ..
770509 - ONDANSETRON 8 MG TABLETS 1 TAB Q8H 12 03/13/08 2 JOHNSON 1
770510 - ..
770511 - PROCHLORPERAZINE 100 MG TABLETS 1 TAB Q6H 30 03/13/08 2 JOHNSON 1
770512 - ..
770513 - PROCHLORPERAZINE 100 MG TABLETS 1 TAB Q6H 30 03/07/08 X RUGO 1
770514 - ..
770515 - ONDANSETRON 8 MG TABLETS 1 TAB Q8H 12 03/07/08 X RUGO 1
770516 - CEPHALEXIN 500 MG CAPSULES 1 CAP QID 80 03/05/08 X JOHNSON 1
770517 - FLUOXETINE 20 MG CAPSULES 1 CAP QD 100 03/05/08 X JOHNSON 1
770518 - ERYTHROMYCIN-BENZOYL GEL 0 BID 46.6 02/25/08 0 JOHNSON 1
770519 - GASTROGRAFIN 66/10 SOLUTION 0 20 02/13/08 X R BHUTAN 0
770520 - GASTROGRAFIN 66/10 SOLUTION 0 20 02/08/08 X DAVIDS 1
770521 - ..
770522 - TIMOLOL MALEATE 0.5% EYE DR 1 DRP BID 20 01/18/08 0 POS 4
770523 - GASTROGRAFIN 66/10 SOLUTION 0 20 12/05/07 X JOHNSON 1
770524 - LORAZEPAM 1 MG TABLETS 1 TAB TID 100 11/20/07 0 SIMMON 1
770525 - GASTROGRAFIN 66/10 SOLUTION 0 UD 20 09/25/07 X JOHNSON 1
770526 - * BENZACLIN GEL 0 BID 25 07/24/07 X JOHNSON 1
770527 - CEPHALEXIN 500 MG CAPSULES 1 CAP QID 80 07/20/07 X JOHNSON 1
770528 - GASTROGRAFIN 66/10 SOLUTION 0 UD 20 07/18/07 X JOHNSON 1
770529 - ACYCLOVIR 800 MB TABLETS 1 TAB Q4H 35 06/15/07 X RUGO 1
770530 - ACYCLOVIR 400 MB TABLETS 1 TAB BID 60 06/15/07 X RUGO 1
770531 - LORAZEPAM 1 MG TABLETS 1 TAB TID 100 05/19/07 X SUYEHI 1
770532 - GASTROGRAFIN 66/10 SOLUTION 0 UD 20 05/11/07 X JOHNSON 1
770536 - ..
770537 - Current Medication Comments on Frequency of Use
770539 - Some medications are prescribed but not taken. Others are given in
770540 - combinations routinely, but only if Millie gets Carboplatin. Some are
770541 - prescribed for both IV injection and home care, but are not taken at
770542 - home, or taken occassionally. Some are prescribed only occassionally.
770543 - Accordingly listing only prescribed medications does not identify
770544 - medications taken and frequency. Thus, the above list can be
770545 - segmented according context...
770547 - a. Daily treatments not prescribed...
770549 - 1. Glucosimine Chrondrotin
770552 - ..
770553 - b. Daily treatments prescribed and taken...
770555 - 1. TIMOLOL MALEATE 0.5% eye drops............, ref SDS 0 8Q9L POS 4
770557 - 2. WARFARIN 4 MG TABLETS............ Coumadin, ref SDS 0 8Q8F JOHNSON 5 Y
770560 - ..
770561 - c. Daily treatments prescribed and taken occassionally, e.g., less
770562 - than 1 once per month...
770564 - ..
770565 - 1. PROCHLORPERAZINE 10 MG.......... Compazine
770566 - Compazine....................... PROCHLORPERAZINE 10 MG
770568 - ..
770569 - Compazine was prescribed by UCSF for daily oral treatment
770570 - at home as needed to relieve side effects of nausea from
770571 - chemotherapy treatment with Carboplatin. UCSF made the
770572 - prescription during a meeting on 080306, ref SDS 69 FA4H
770573 - Millie notified Kaiser in a letter the next day on 080307
770574 - to order the prescription and to update the list of current
770575 - medications in the Medical chart. ref SDS 71 RW5V Later in
770576 - the day on 080307 Millie went to the Kaiser Pharmacy and
770577 - got the prescription for Compazine, as shown in Kaiser's
770578 - documents received today, per above. ref SDS 0 0553
770580 - ..
770581 - On 080313, the primary care physician placed a 2nd order
770582 - for Compazine duplicating response to Millie's letter on
770583 - 080307, and so reflecting a mixup in communication
770584 - coordinating medication prescriptions. ref SDS 0 II8G
770586 - ..
770587 - As a result, Millie has on hand a supply of 2 prescriptions
770588 - of Compazine.
770590 - ..
770591 - Today, 080502, the day after treatment with Carboplatin at
770592 - UCSF, Millie was not feeling well and so in the late
770593 - afternoon, she took a Compazine pill. This may have
770594 - related to emotional stress and depression coordinating
770595 - efficient and economic procurement of medication from the
770596 - Kaiser Pharmacy for prescribed treatment with Neupogen, per
770597 - below. ref SDS 0 NM5K
770600 - ..
770601 - 2. ONDANSETRON 8 MG TABLETS........ Zofran
770602 - Zofran.......................... ONDANSETRON 8 MG TABLETS
770604 - ..
770605 - Zofran was prescribed by UCSF for daily oral treatment at
770606 - home as needed to relieve side effects of nausea from
770607 - chemotherapy treatment with Carboplatin, and to complement
770608 - treatment with Compazine reported above. ref SDS 0 IJ3I
770609 - Oral home treatment with Zofran supplements IV treatment
770610 - with Zofran given in the Infusion Clinic with Carboplatin
770611 - on Thursdays. UCSF made the prescription during a meeting
770612 - on 080306, ref SDS 69 FA4H Millie notified Kaiser in a
770613 - letter the next day on 080307 to order the prescription and
770614 - to update the list of current medications in the Medical
770615 - chart. ref SDS 71 RW5V Later in the day on 080307 Millie
770616 - went to the Kaiser Pharmacy and got the prescription for
770617 - Zofran, as shown in Kaiser's documents received today, per
770618 - above. ref SDS 0 II8I
770620 - ..
770621 - On 080313, the primary care physician placed a 2nd order
770622 - for Zofran duplicating response to Millie's letter on
770623 - 080307, and so reflecting a mixup in communication
770624 - coordinating medication prescriptions. ref SDS 0 II7O
770626 - ..
770627 - Millie took a Zofran pill the day after getting the first
770628 - treatment with Carboplatin. She has not felt a need to
770629 - take more of this medication, though today, she took a
770630 - Compazine, per above. ref SDS 0 IJ5H
770632 - ..
770633 - As a result, Millie has on hand a supply of 2 prescriptions
770634 - of Zofran.
770637 - ..
770638 - 3. FLUOXETINE 20 MG CAPSULES....... Prozac
770639 - Prozac.......................... FLUOXETINE 20 MG CAPSULES
770641 - ..
770642 - Prozac was prescribed by Kaiser on 080305 to relieve rising
770643 - anxiety, stress, and depression from mounting health care
770644 - problems. UCSF concurred the next day on 080306, reviewed
770645 - today, per above, ref SDS 0 KT4J; Millie tried Prozac on 2
770646 - consecutive days, and suffered debilitating side effects;
770647 - also causes of anxiety, stress, and depression have
770648 - subsided, and Millie has found ordinary stress disipates
770649 - from increasing exercise. As a result Millie quit taking
770650 - Prozac, as reported above. ref SDS 0 U66L
770652 - ..
770653 - New emotional problems suffered today assisting Kaiser
770654 - achieve efficiency and economy filling a prescription for
770655 - Neupogen, reported below, ref SDS 0 NM5K, were treated with
770656 - Compazine, per above. ref SDS 0 IJ5H
770659 - ..
770660 - d. Prescribed for daily treatment but not taken...
770663 - ..
770664 - e. Occassional treatments...
770666 - 1. GASTROGRAFIN 66/10 SOLUTION............ ref SDS 0 T38N BHUTAN 1
770668 - This is prescribed for contrast medium required for CT
770669 - tests, and so is only taken an hour or so prior to each
770670 - test about every 8 weeks. Most recently Gastrofrafin was
770671 - taken for the CT test on 080425. ref SDS 85 XM30 The list
770672 - of medications in the medical chart today does not list
770673 - Gastrografin. ref SDS 0 WZ5N
Xray Ordered Arm Right Evaluate Discomfort Lift Arm Laterally Full V
900401 - ..
900402 - Arm Right Xray Evaluate Injury Fall 080125
900403 - Xray Ordered Evaluate Injury Fall 080125 Right Arm Discomfort
900404 - Fall 080125 Right Arm Discomfort Xray Ordered Evaluate Injury
900406 - Follow up ref SDS 68 5M39.
900408 - On 080305 the doctor ordered an xray of the right arm to assess damage
900409 - from fall on 080125. ref SDS 68 5M4K On 080307 Millie received the
900410 - report on the xray showing no evident fracture or injury. ref SDS 71
900411 - IT8N
900413 - ..
900414 - On 080312 Millie notified Kaiser of subsiding discomfort in right arm,
900415 - and so MRI is not required at this time. ref SDS 72 RU3S At that time
900416 - on 080307 Kaiser was commended for timely submission of xray test
900417 - results. ref SDS 71 GZ4H
IBC Examination Expanding Cancer Disease Diagnose 4th Relapse Recomm
A40401 - ..
A40402 - IBC Subsiding Demonstrates Response to Treatment 4th Relapse
A40403 - Responding Treatment Despite Only 50% Prescribed Medication Dose
A40405 - Follow up ref SDS 68 N15G.
A40407 - During the prior meeting on 080305 the doctor observed expanding IBC
A40408 - rash. ref SDS 68 N15G The next day on 080306 Doctor Rugo at UCSF
A40409 - concurred and determined Millie suffered progression of IBC disease.
A40410 - After 13 months treatment with cetuximab alone. the 4th relapse of IBC
A40411 - seems evident, ref SDS 69 NW3N, confirming prior findings in the
A40412 - meeting on 080219. ref SDS 65 3J4I
A40414 - ..
A40415 - On 080312 Millie's letter to UCSF with copy to Kaiser reports IBC rash
A40416 - seems to subside before starting new treatment with Carboplatin added
A40417 - to existing treatment with cetuximab. ref SDS 72 RU4U
A40419 - ..
A40420 - During the meeting today, the doctor asked when Carboplatin was added
A40421 - to weekly treatments at UCSF?
A40423 - ..
A40424 - Millie explained that her letter to the medical team at UCSF and
A40425 - Kaiser on 080312 reported she would have the first treatment with
A40426 - Carboplatin on 080313 to begin the 2nd arm of the clinical study.
A40427 - ref SDS 72 BH5O The doctor recalled receiving Millie's letter and
A40428 - asked if she actually had the treatment, since there have been
A40429 - reports of continuing low blood counts?
A40431 - ..
A40432 - Millie advised that she had treatment on 080313, adding Carboplatin
A40433 - chemotherapy to cetuximab, which Millie has been getting since 070201.
A40434 - as reported in the record of patient history. ref SDS 73 TZ8I
A40435 - Millie's letter the next day to the medical team on 080314 confirmed
A40436 - have received this treatment, and being pleased to feel energetic the
A40437 - following day. ref SDS 75 KO6Y Millie further commended Kaiser and
A40438 - UCSF for improving communications coordinating her care. ref SDS 75
A40439 - EX5H
A40441 - ..
A40442 - The doctor reported in the Medical Chart today that Carboplatin was
A40443 - added on 080313, per below. ref SDS 0 NN8I
A40445 - ..
A40446 - On 080331 photographs support explanation of expanding disease.
A40447 - ref SDS 77 9Q4I
A40449 - ..
A40450 - The doctor examined IBC on the left arm, chest, and lower stomach
A40451 - areas. He was very pleased to see reduced IBC inflammation and rash,
A40452 - reversing findings from the examination on 080305, prior to starting
A40453 - expanded treatment with Carboplatin. ref SDS 68 N15G This finding
A40454 - aligns with examination at UCSF yesterday on 080501 that reported good
A40455 - response to treatment with full dose of Carboplatin, and despite
A40456 - getting only 50% of prescribed treatments due to low blood counts.
A40457 - ref SDS 88 JJ3N
A40459 - ..
A40460 - The doctor was pleased Millie has tolerated well adding chemotherapy
A40461 - shown by the report to the medical team at UCSF yesterday of increased
A40462 - exercise. ref SDS 88 FW5J and improved times hiking 3 miles a day 4 -
A40463 - 5 times a week. This helps maintain blood counts along with Neupogen
A40464 - treatments (e.g., reduces the amount of Neupogen required), so that
A40465 - Millie can get all of the prescribed chemotherpay treatments, cited by
A40466 - the doctor on 030606, ref SDS 5 JP7G, and regular exercise helps
A40467 - dissipate emotional stress, discussed above. ref SDS 0 QU4M
A40469 - [...below, Neupogen ordered to maintain blood counts so that
A40470 - Millie can get prescribed treatment for IBC. ref SDS 0 L84I
A40472 - ..
A40473 - [...below, Medical Chart reports improvement treating IBC with
A40474 - decreasing erythema from lesions subsiding. ref SDS 0 1Z6O
A40476 - ..
A40477 - [On 080520 Millie reported in a letter to the Medical team
A40478 - again further increased energy and exercise showing
A40479 - continued tolerance of chemotherapy Carboplatin treatments
A40480 - at UCSF. ref SDS 92 TV6U
A40482 - ..
A40483 - [On 080520 Millie suffered recurrence Cellulitis and lymphedema
A40484 - treatment with Keflex, ref SDS 93 OU5J; reported Cellulitis
A40485 - recurrence to medical team, ref SDS 93 VN4O; primary care
A40486 - physician at Kaiser prescribed 10 day treatment. ref SDS 93
A40487 - 1K7H
A40489 - ..
A40490 - [On 080528 Millie sent another letter to the medical team
A40491 - reporting rising energy and exercise. ref SDS 95 XY9J
A40493 - ..
A40494 - The doctor feels that examination today of subsiding IBC inflammation
A40495 - correlates with the CT test findings of no distant metastatis, per
A40496 - below. ref SDS 0 N15O
Default Null Subject Account for Blank Record
A50401 - ..
A50402 - Carboplatin 50% Prescribed Treatment Due to Low Blood Counts
A50403 - Low Blood Counts Reduce Carboplatin to 50% of Prescribed Treatment
A50404 - Neupogen Prescribed Increase Blood Counts Enable Complete Treatment
A50406 - The doctor had received Millie's letter yesterday reporting low blood
A50407 - counts at UCSF on 080501.
A50409 - ..
A50410 - Millie explained during the meeting today that despite low blood
A50411 - counts, Doctor Rugo approved treatment with Carboplatin yesterday, but
A50412 - also prescribed treatment with Neupogen to increase the counts so that
A50413 - Millie can be assured of getting treatment next week.
A50415 - ..
A50416 - Reviewed patient history of low blood counts during the past 8 weeks
A50417 - (2 cycles) that caused Millie to get only 50% - 3 of 6 - treatments
A50418 - prescribed for Carboplatin. The doctor explained that persistent low
A50419 - blood counts, called "neupropenic," are common for patients, like
A50420 - Millie, who have had a lot of chemotherapy. Millie has been treated
A50421 - with chemotherapy for 7 years. Cumulative damage from chemotherapy
A50422 - side effects reduces ability of bone marrow to replenish blood in the
A50423 - usual manner, explained by the doctor during the meeting on 030606.
A50424 - ref SDS 5 JP7G
A50426 - ..
A50427 - The doctor feels significant recovery observed today showing IBC
A50428 - subsiding shows good initial response to treatment despite getting
A50429 - only 50% of prescribed treatments due to low blood counts. He noted
A50430 - favorable response to treatment in the medical chart, per below.
A50431 - ref SDS 0 NN8I
A50433 - ..
A50434 - Millie related that yesterday UCSF initially prescribed 2 treatments
A50435 - per week with Neupogen to maintain blood counts. Brigid then checked
A50436 - patient history and discovered that 1 treatment with Neupogen
A50437 - prescribed on 080403 had increased blood counts to the highest level
A50438 - ever (ANC over 6000 on Kaiser's scale), by the following week on
A50439 - 080410. ref SDS 84 QY6H
A50441 - ..
A50442 - As a result, UCSF changed the prescription from 2 to just 1 treatment
A50443 - with Neupogen per week in order to maintain blood counts at a level
A50444 - safe to get chemotherapy treatments with Carboplatin. ref SDS 88 M658
A50446 - ..
A50447 - Today, the doctor ordered on the computer in the examination room
A50448 - Neupogen for 6 treatments. This is enough for 2 cycles of 1 treatment
A50449 - per week for 3 weeks per cycle of infusion treatments with
A50450 - Carboplatin.
A50453 - ..
A50454 - Black Box Knowledge Management Processing Kaiser Pharmacy
A50456 - Millie asked about placing the order today using the procedure for
A50457 - getting treatment in the Infusion Clinic, which the doctor ordered
A50458 - last month on 080404, ref SDS 80 JW6J, implementing suggestion from
A50459 - Brigid at UCSF, earlier that day on 080404, ref SDS 80 O152, and as
A50460 - set out in Millie's letter to Kaiser also on 080404. ref SDS 80 V39U
A50462 - ..
A50463 - The doctor apologized for confusion and problems getting treatment at
A50464 - Kaiser the next day on 080405, ref SDS 81 7E5L, as reported in
A50465 - Millie's letter to Kaiser on 080409. ref SDS 82 W19Q
A50467 - ..
A50468 - The doctor explained that ordering medications on Kaiser's computer
A50469 - system presents a "black box" mystery about how the order will
A50470 - actually be filled by the Kaiser Pharmacy. Confusion ordering and
A50471 - getting medications creates a lot of stress and emotional trauma for
A50472 - the patient, discussed above, ref SDS 0 K99G, and the for doctor
A50473 - worrying about what to do that yields effective care.
A50475 - [...below, something went wrong again in the Pharmacy.
A50476 - ref SDS 0 NM6J
A50478 - ..
A50479 - "Black Box" technology is the only form of "Knowledge Management"
A50480 - people have discovered, reported on 000113. ref SDS 3 3380
A50482 - [...above, Millie forced to take Compazine to relieve anxiety
A50483 - from handling cancer treatments and management problems.
A50484 - ref SDS 0 IJ5H
A50486 - ..
A50487 - The doctor was running late today for another meeting off-site. There
A50488 - wasn't enough time to study the computer system on placing orders for
A50489 - treatments, nor to call for assistance by the Technical Department,
A50490 - nor to ask Arlette for help to figure out how to use the computer to
A50491 - order Millie's treatment in the Infusion Clinic.
A50493 - ..
A50494 - Millie was worried about having more problems today that occurred on
A50495 - 080405. ref SDS 81 158O
A50497 - ..
A50498 - The doctor proposed filling out the form on Kaiser's computer using
A50499 - "intuition," and see what happens. He feels previous problem on
A50500 - 080405, when the Pharmacy told Millie the Infusion Clinic was closed
A50501 - on Saturday, ref SDS 81 XQ76, may be solved because the Infusion
A50502 - Clinic is now open on Saturday, He explained that, if there are any
A50503 - problems getting treatment this time, then Millie can come back, and
A50504 - the doctor will make adjustments to make sure Millie gets the correct
A50505 - treatment.
A50507 - [On 080609 confusion using Kaiser computer to order Neupogen
A50508 - occurred again. ref SDS 99 837J
A50510 - ..
A50511 - Limited time at Kaiser for placing an order with the computer system
A50512 - to provide patient treatment, reflects wider problem applying
A50513 - "cognitive overhead" explained in NWO, ref OF 13 LH6K, and further
A50514 - aligns with practice at UCSF Comprehensive Cancer Center, reported on
A50515 - 080306. ref SDS 78 IM87 Challenge of accuracy to save lives, time,
A50516 - and money was further illustrated in NWO. ref OF 13 VP7L
A50518 - ..
A50519 - Millie asked what to do if something goes wrong today? She asked the
A50520 - doctor about calling the Pharmacy to make sure the order will be
A50521 - processed as he intends, since there are obvious doubts about how the
A50522 - order was placed on the computer, per above. ref SDS 0 NM4J
A50524 - [...below, something went wrong in the Pharmacy. ref SDS 0 NM6J
A50526 - ..
A50527 - The doctor said it is not easy to call the Pharmacy and order drugs
A50528 - for patients. There are a lot of buttons to punch. The sequence is
A50529 - changed over weeks and months, and explanations are changed on which
A50530 - buttons to use. If the doctor gets to the right place, there can be
A50531 - long waits getting the right person, then more waiting while the
A50532 - pharmacist checks to find the medication. The computer makes this
A50533 - fast and easy for the doctor, but things don't always turn out
A50534 - correctly, as mentioned a moment ago, per above. ref SDS 0 NM4J
A50536 - ..
A50537 - The doctor explained that there is not enough time to call the
A50538 - pharmacy today, because he is already late for a meeting off-site at
A50539 - another hospital. He suggested that, if problems occur filling the
A50540 - order he just placed with the Pharmacy using the computer, ref SDS 0
A50541 - VM6J, then Millie can send a him letter explaining what happened, and
A50542 - he will use the computer to adjust the order, or if everything fails,
A50543 - he will call the pharmacy when there is enough time to solve the
A50544 - problem. The doctor feels that, since Millie does not need to take
A50545 - the treatment until Monday, this gives 3 days for making any needed
A50546 - adjustments. Hopefully, everything will be okay as is.
A50548 - [...below, Pharmacy attendant could not contact doctor to
A50549 - correct problem ordering medication. ref SDS 0 NM7F
A50553 - ..
A508 - 1319
A50901 - Neupogen Costs $600 More for Home Care than Treatment at Kaiser
A50902 - Computer Problems Difficulty Pharmacy Providing Prescribed Medication
A50903 - Pharmacy Difficulty Providing Prescribed Medication Computer Problems
A50905 - Millie went to the Pharmacy on the 1st floor for the prescription of 6
A50906 - Neupogen treatments. Normally this takes 10 - 20 minutes depending on
A50907 - the number of customers waiting for their prescriptions.
A50909 - ..
A50910 - Today, Millie spent about 90 minutes in the Pharmacy trying to get the
A50911 - Neupogen. The Pharmacist said he had to call the doctor because
A50912 - something was wrong with the way the order was entered in the
A50913 - computer, about 20 minutes ago, per above. ref SDS 0 NL4M
A50915 - ..
A50916 - Millie explained the doctor had left the hospital for a meeting
A50917 - of -site. ref SDS 0 6J5J The Pharmacist told Millie to go sit down
A50918 - and wait while he calls the doctor to discuss the problem with the
A50919 - order for Neupogen. He never came back.
A50921 - ..
A50922 - Eventually, Millie went to the counter and talked to another person,
A50923 - and then got the 6 bottles of Neupogen prescribed by UCSF for the next
A50924 - 2 cycles of treatment with Carboplatin, per above. ref SDS 0 NL4M
A50926 - ..
A50927 - She had go through the same problem again of explaining she needs
A50928 - needles and how to figure out the amount of Nuepogen for each
A50929 - treatment, that occurred for the previous cycle, reported on 080405.
A50930 - ref SDS 81 158O
A50932 - [On 080607 Millie had problems with self-injection of
A50933 - Neupogen and treatment failed. ref SDS 97 Q67I
A50935 - ..
A50936 - [On 080625 Kaiser reported the protocol for Neupogen
A50937 - prescribed by UCSF required 2 injections for each
A50938 - treatment, rather than just 1. ref SDS A3 Q74G
A50942 - ..
A50943 - Invoice Neupogen 6 Treatments $517 500% Increase from April Charges
A50945 - Follow up ref SDS 81 L86O.
A50947 - Millie was shocked that the price was $517 for 6 treatments of
A50948 - Neupogen, nearly 10 times the cost of $12 per treatment on 080405.
A50949 - ref SDS 81 L86O Millie asked if there was some mistake?
A50951 - [On 080609 Millie shocked $2,000 charge; 400% increase
A50952 - from today for 6 treatments of Neupogen. ref SDS 99 028F
A50954 - ..
A50955 - Kaiser Invoice
A50957 - ..
A50958 - Kaiser Permanente
A50959 - WCR Main Pharmacy
A50960 - 1425 South Main St 1st Floor
A50961 - Walnut Creek, CA 94596
A50962 - 925 295 4460
A50964 - ..
A50965 - Board A
A50966 - Claim Check #
A50970 - ..
A50971 - Patient...
A50975 - ..
A50976 - Date: 080502
A50978 - ..
A50979 - Medical Record...
A50983 - ..
A50984 - Your Durg Benefit Saved You: $1,546.16
A50985 - YTD Pharmacy Charges Applied to Troop/TDC
A50987 - Bal 689.79 Bal 2757.25
A50989 - ..
A50990 - Kaiser Permanente
A50992 - ..
A50993 - Rx# 511 4507810................... 2061.55 $ 515 39
A50995 - Neupogen 6 treatments
A50997 - ..
A50998 - Rx# 511 4507812................... 1.40 1.40
A51000 - Self-injection needles
A51003 - ..
A51004 - Total Rx price................................ $ 516.79
A51005 - Non-PIMS Rx Total
A51006 - Taxable OTC Total
A51007 - Non-taxable OTC Total
A51008 - Sales tax
A51010 - ..
A51011 - Total......................................... $ 516.79
A51013 - [On 080609 Millie shocked Neupogen $2,000, 400% increase
A51014 - from today. ref SDS 99 028F
A51016 - ..
A51017 - The pharmacist, Patricia Chin (925 295 4461), explained that
A51018 - prescribing Neupogen treatment by injection in the Infusion Clinic,
A51019 - rather than doing home care injection is paid by Millie's insurance
A51020 - premiums, and thus saves the charge of $586. This practice has been
A51021 - effective treating Millie with Magnesium, Neupogen, and other drugs.
A51022 - For example on 061031
A51024 - ..
A51025 - When Millie returned home from Kaiser, she was feeling anxiety,
A51026 - stress, and depression assisting Kaiser with efficient and economic
A51027 - management of the Neupogen medication transaction processed through
A51028 - the "Black Box" computer ordering system that prevented efforts to
A51029 - resolve problems proactively. ref SDS 0 NM4J
CT Test 080212 Findings Support Diagnosis IBC Progression Disease 4t
AO0401 - ..
AO0402 - CT Test Findings NED No Evidence of Disease Distant Metastasis
AO0404 - Follow up ref SDS 68 N15O.
AO0406 - Discussed findings from the CT test on 080425 reviewed on 080428
AO0407 - showing...
AO0409 - ..
AO0410 - 1. Stable adenopathy no increase size of nodes right axilla.
AO0411 - ref SDS 86 EO8F
AO0413 - ..
AO0414 - 2. Right paratracheal adenopathy stable, no evidence of
AO0415 - advancing disease. ref SDS 86 RV70
AO0417 - ..
AO0418 - 3. Increased opacity in right middle lobe may signal rising
AO0419 - pulmonary embolism? ref SDS 86 RV78
AO0421 - ..
AO0422 - The doctor feels again today that no referral is needed at this time,
AO0423 - based on Millie not exhibiting clinical symptoms of cardio pulmonary
AO0424 - complications. He explained the CT test report provides an alert to
AO0425 - look for trends related to right paratracheal, and PE issues. This
AO0426 - aligns with planning on 080305, ref SDS 68 YU6K, citing work on 080118
AO0427 - deferring investigation of findings for the prior CT test. ref SDS 54
AO0428 - Q15H
AO0430 - ..
AO0431 - [On 080507 Millie reports spike in heart beat (pulse)
AO0432 - while laying down in bed; case study shows occassional
AO0433 - spike in pulse reported by heart monitor during
AO0434 - exercise, evaluated previously as defective equipment.
AO0435 - ref SDS 90 CK4K
CT Test 080425 Evaluate Diagnosis IBC Progression Disease 4th Relaps
B70401 - ..
B70402 - Power Port Schedule Surgery in Time for Next CT Test
B70403 - CT Test Injection Trauma Investigate Power Port Surgery
B70405 - Follow up ref SDS 88 766K.
B70407 - The doctor examined Millie's right arm and observed excessive (4)
B70408 - needle penetrations that caused injury, pain, and suffering required
B70409 - to inject contrast medium for the CT test on 080425. ref SDS 85 9W9I
B70411 - ..
B70412 - Millie explained further today problems technicians have putting
B70413 - needles in her arm and moving the needle within the arm without
B70414 - anesthetic in order to find a position where blood flows sufficient
B70415 - for CT test contrast medium injection, as set out in the record on
B70416 - 080425. ref SDS 85 I76K
B70418 - ..
B70419 - On 080429 the doctor notified Millie that Kaiser is investigating the
B70420 - use of a "Huber" needle with Millie's current port catheter to avoid
B70421 - problems making injections of contrast medium for CT tests.
B70422 - ref SDS 87 1H6Y
B70424 - ..
B70425 - Research at that time on 080428, ref SDS 87 Y86F, seems to support the
B70426 - procedure using a port catheter to inject contrast medium for CT
B70427 - tests. ref SDS 87 RE6F
B70429 - ..
B70430 - Millie explained understandings from the meeting at UCSF yesterday,
B70431 - that Millie's port can be replaced with a a Power Port that can
B70432 - withstand pressures from CT test injections of contrast medium,
B70433 - ref SDS 88 TQ6F During the meeting, UCSF seemed to indicate that
B70434 - surgery to replace the port presents risks that outweigh benefits.
B70435 - ref SDS 88 TQ8P Review of patient history raises questions that
B70436 - should be presented to Kaiser's surgery team in assessing solutions to
B70437 - the current problem. ref SDS 88 R59F
B70439 - ..
B70440 - UCSF further reported yesterday that in some cases UCSF uses the
B70441 - standard port catheter, already implanted for Millie, to do the CT
B70442 - test injections. ref SDS 88 JJ9N This presents 3 options...
B70444 - 1. Do nothing and continuing worsening damage to Millie's
B70445 - arm, with spreading complications.
B70447 - ..
B70448 - 2. Try using the current port with slower injection rate that
B70449 - reduces the pressure on the port.
B70451 - ..
B70452 - 3. Surgery to remove the current port and replace with a
B70453 - Power Port.
B70455 - ..
B70456 - The doctor asked when the next CT test is needed?
B70458 - ..
B70459 - Reviewed the meeting with UCSF yesterday showing the most recent test
B70460 - on 080425 was 12 weeks after the prior test on 080212. Using the same
B70461 - time indicates the next CT test is needed in mid-July on or about
B70462 - 080718, ref SDS 88 SQ5J Surgery for the Power Port is therefore
B70463 - needed a week or so prior to 080718. If UCSF changes the period of CT
B70464 - testing back to 8 weeks, then everything moves forward a month. That
B70465 - still leaves 2 - 3 months for Kaiser to do the surgery in time for the
B70466 - next CT test.
B70468 - ..
B70469 - During the meeting today, the doctor sent a letter using Kaiser's
B70470 - email system to ask Doctor Riley-Paul about doing follow up surgery in
B70471 - the next 4 - 6 weeks to remove and replace the port catheter implanted
B70472 - on 040419, ref SDS 7 PPSW, with a new Power Port device, cited during
B70473 - the meeting at UCSF yesterday. ref SDS 88 TQ6F This referral provides
B70474 - time to schedule the CT test in either 8 or 12 weeks.
B70476 - ..
B70477 - 1. [...below Medical Chart reports work plan to discuss
B70478 - with the surgeon consideration of Power Port surgery.
B70479 - ref SDS 0 CO3H
B70481 - ..
B70482 - 2. [On 080502 Millie submitted a letter to the medical team
B70483 - and Kaiser and UCSF confirming the doctor's referral for
B70484 - Millie to get a Power Port in time for the next CT test
B70485 - in 2 - 3 months. ref SDS 89 GN8P
B70487 - ..
B70488 - 3. [On 080508 Millie asks primary care physician about
B70489 - progress scheduling surgery to upgrade the port catheter
B70490 - to a Power Port for injecting contrast medium in time
B70491 - for the next CT test. ref SDS 91 GO8G
B70493 - ..
B70494 - 4. [On 080520 Kaiser did not respond; Millie sent follow up
B70495 - letter asking Kaiser to coordinate with the Surgery
B70496 - department on expediting Power Port surgery, ref SDS 92
B70497 - GS8K, in time for next CT test expected in 4 weeks.
B70498 - ref SDS 92 TV4S
B70500 - ..
B70501 - 5. [On 080523 Millie received a letter from Kaiser advising
B70502 - that the surgeon reports Kaiser can upgrade Millie's
B70503 - port catheter to a Power Port, and he made a referral
B70504 - for this work to be performed, ref SDS 94 MG6F; this
B70505 - will solve the problems reported on 080425 injecting
B70506 - contrast medium for CT tests. ref SDS 85 FP6F
B70508 - ..
B70509 - 6. [On 080528 Millie's letter to the medical team
B70510 - coordinated planning required for surgery to implant a
B70511 - Power Port, ref SDS 95 IJ6W, and for CT test department
B70512 - to use the Power Port for Millie's next test.
B70513 - ref SDS 95 IK4Q
B70515 - ..
B70516 - 7. [On 080606 Millie meets with surgeon who makes
B70517 - arrangements for surgery to upgrade the port catheter to
B70518 - a Power Port in order to avoid further injury to
B70519 - Millie's arm with needle punctures for injecting CT test
B70520 - contrast medium by using the Power Port access with a
B70521 - Huber needle for these injections. ref SDS 96 IT6M
B70523 - ..
B70524 - 8. [On 080608 Millie sent a letter to the surgeon using
B70525 - Kaiser's internal email system, because the doctor is
B70526 - not included in distribution for referral coordination
B70527 - with the medical team at Kaiser and UCSF; and notifying
B70528 - the surgeon of requirements to coordinate surgery to
B70529 - implant the Power Port and to access the new port with a
B70530 - Huber needle to enable CT testing within the next few
B70531 - days after surgery. ref SDS 98 XS4S
B70533 - ..
B70534 - 9. [On 080609 Kaiser Surgery Department notified the
B70535 - patient that requirements for coordination of Power Port
B70536 - surgery in time for the next CT test were presented to
B70537 - the Schedule Department. ref SDS 92 MG5I
B70539 - ..
B70540 - 10. [On 080617 Kaiser schedules surgery for Power Port on
B70541 - 080708. ref SDS A0 DF8N
B70543 - ..
B70544 - 11. [On 080617 Kaiser CT Department schedules the test on
B70545 - 080718; notifies Millie to contact the Infusion Clinic
B70546 - about accessing the new Power Port with a Huber needle
B70547 - on the day of the test so that Millie arrives at the CT
B70548 - Department ready to inject CT contrast medium, and
B70549 - thereby avoid further injury to Millie's arm from
B70550 - conventional needle puncture wounds. ref SDS A0 DF55
B70552 - ..
B70553 - 12. [On 080617 Infusion Clinic seems to indicate CT test
B70554 - technicians lack training and professional skills to use
B70555 - a Huber needle to access Millie's Power Port for
B70556 - injecting CT contrast medium, and proposes instead using
B70557 - conventional needle puncture that has caused continuous
B70558 - injury and trauma for the patient. ref SDS A0 5S6L
B70560 - ..
B70561 - 13. [On 080619 Millie notified medical team at Kaiser and
B70562 - UCSF that CT test is scheduled to use the Power Port on
B70563 - 080718, ref SDS A1 YU6X; cites requirements to resolve
B70564 - protocol and certification issues over next 4 weeks.
B70565 - ref SDS A1 YV4R
B70567 - ..
B70568 - 14. [On 080625 Millie's letter to medical team at UCSF and
B70569 - Kaiser confirms planning for CT test to use the Power
B70570 - Port for saving time and money that meets requirements
B70571 - cost containment. ref SDS A2 IU7R
B70573 - ..
B70574 - 15. [On 080708 Millie gets surgery for Power Port.
B70575 - ref SDS A4 IT77
B70577 - ..
B70578 - 16. [On 080711 Millie was notified that CT Test department
B70579 - has not coordinated with Infusion Clinic to arrange for
B70580 - Millie's CT test on 080718 using the Power Port for
B70581 - injecting contrast medium. ref SDS A5 PP5J
B70583 - ..
B70584 - 17. [On 080711 CT Department advises Millie is not scheduled
B70585 - for a test with Huber needle and Power Port, ref SDS A5
B70586 - PP6O; CT Department did not receive manufacturer's Power
B70587 - Port Instructions for Use, ref SDS A5 RH5O; coordination
B70588 - at Kaiser "fell through the cracks," ref SDS A5 PP7O; CT
B70589 - Department starting to train staff, certification will
B70590 - take time, ref SDS A5 JQ55; Kaiser proposes delaying CT
B70591 - test already 4 weeks later than required by protocol.
B70592 - ref SDS A5 JR30; Kaiser plans to investigate doing
B70593 - Millie's CT test with Power Port a week later as
B70594 - scheduled. ref SDS A5 JR7Y
B70596 - ..
B70597 - 18. [On 080711 develop alternate work plans for performing
B70598 - CT test to meet requirements of clinical trial protocol.
B70599 - ref SDS A5 JR88
B70601 - ..
B70602 - 19. [On 080712 Millie notifies primary care physician of
B70603 - possible delays performing CT test, ref SDS A6 KZ5S;
B70604 - requests coordinating Kaiser to implement one of many
B70605 - possible work plans. ref SDS A6 K13Q
B70607 - ..
B70608 - 20. [On 080715 Arlette called and reported the doctor solved
B70609 - coordination problems by arranging for a nurse in
B70610 - radiology with certificate to support CT testing with
B70611 - Power Ports; Millie's CT test is good to go on 080718.
B70612 - ref SDS A7 RB4N
B70614 - ..
B70615 - 21. [On 080716 Ike called and confirmed that Kaiser has made
B70616 - arrangements for Millie to get a CT test using her Power
B70617 - Port. ref SDS A8 PZ4L
B70619 - ..
B70620 - 22. [On 080718 CT test failed using Interventional Radiology
B70621 - staff assigned to access Power Port, ref SDS A9 2U8V;
B70622 - during procedure, Nora requests manufacturer's
B70623 - Instructions for Use on Power Injection of contrast
B70624 - medium, ref SDS A9 NM5V, which was submitted to Kaiser
B70625 - on 080709, review was requested on 080712, ref SDS A6
B70626 - K13Q, and again on 080715, ref SDS A7 RB3T;
B70627 - complications occurred on power injection, contrast
B70628 - medium overflowed Power Port, CT test failed.
B70629 - ref SDS A9 LK3R
B70631 - ..
B70632 - 23. [On 080718 Millie notifies medical team of problems
B70633 - getting CT test, ref SDS A9 I43R; plans recovery to
B70634 - avoid more problems that could prevent getting treatment
B70635 - for cancer. ref SDS A9 I45R
B70637 - ..
B70638 - 24. [On 080721 Millie notifies Kaiser to begin planning for
B70639 - correcting CT test problems in time to perform next test
B70640 - scheduled in 8 weeks. ref SDS B0 CW9U
B70642 - ..
B70643 - 25. [On 080801 Millie notified Bard the manufacturer of the
B70644 - Power Port to investigate for product defect or damage
B70645 - related to failed CT test at Kaiser on 080718,
B70646 - ref SDS B2 F44M; and to begin planning for next test in
B70647 - 6 weeks. ref SDS B2 PY6R
B70649 - ..
B70650 - 26. [On 080801 Julie, Bard Power Port representative, offes
B70651 - to consult during Millie's next CT test to avoid further
B70652 - use problems. ref SDS B2 OW41
B70654 - ..
B70655 - 27. [On 080804 Bard reports that Kaiser in Oakland has
B70656 - experience performing CT tests using Power Port with
B70657 - Huber needle technology. ref SDS B3 5U7G
B70659 - ..
B70660 - 28. [On 080811 Paula at Kaiser Infusion Clinic investigating
B70661 - solutions to support CT Department for Millie's next
B70662 - test OA 080912; issue has been elevated, but no progress
B70663 - from management reported at this time, ref SDS A0 LD3H;
B70664 - there seems to be at least three (3) solutions.
B70665 - ref SDS A0 CW3O Paula coordinating with primary care
B70666 - physician about contacting Kaiser Oakland to perform
B70667 - Millie's next CT test. ref SDS A0 DE79
B70669 - ..
B70670 - 29. [On 080821 Doctor Rugo advises that Millie can get CT
B70671 - test same day after chemotherapy treatment at UCSF;
B70672 - testing on 080911 would occur after treatment with
B70673 - cetuximab which is less severe than chemotherapy.
B70674 - ref SDS B5 MF5L
B70676 - ..
B70677 - 30. [On 080822 Kaiser notifies Millie that CT test using
B70678 - Power Port and Huber needle technology is scheduled for
B70679 - Kaiser in Oakland on 080911. ref SDS B6 N66E
B70681 - ..
B70682 - 31. [On 080826 Kaiser CT Department in Walnut Creek called
B70683 - and advised that the Kaiser CT Department in Oakland
B70684 - sent Millie's case back to the CT Department at Kaiser
B70685 - in Walnut Creek. ref SDS B7 VG6N
B70687 - ..
B70688 - 32. [On 080929 Paula confirms Kaiser CT Department in Walnut
B70689 - Creek not ready to perform tests using Power Port and
B70690 - Huber needle technology, ref SDS B8 RP7S; primary care
B70691 - physician re-ordered test at Oakland CT department which
B70692 - has experience using Power Port and Huber needle
B70693 - devices. ref SDS B8 RP7V
B70695 - ..
B70696 - 33. [On 080903 discuss with Kaiser CT Department in Oakland
B70697 - leaving Huber needle access Power Port for chemotherapy
B70698 - treatment at UCSF so the needle can be used again for CT
B70699 - test at Oakland; schedule attendant asks Millie to
B70700 - notify primary care p[hysician at Kaiser to request
B70701 - procedure. ref SDS B9 S289
B70703 - ..
B70704 - 34. [On 080903 Millie notifies medical team of plans to use
B70705 - Huber needle for treatment at UCSF, later the same day
B70706 - at Kaiser for CT test. ref SDS B9 IO5T
B70708 - ..
B70709 - 35. [On 080904 Catherine seemed say that nurses must select
B70710 - from a range of different Huber needles available for
B70711 - treatment in the Infusion Clinic, per Angiodynamics
B70712 - manufacturer's Lifeguard Safety needles listed on
B70713 - 080724, ref SDS B1 N79U; Catherine plans to use the
B70714 - needle specified for high pressure injections to treat
B70715 - Millie at UCSF on the day when the same needle will be
B70716 - used later in the same day at Kaiser for a CT test.
B70717 - ref SDS C0 V64G
B70719 - ..
B70720 - 36. [On 080905 notify Bard manufacturer of Power Port that
B70721 - next CT test is scheduled at Kaiser in Oakland.
B70722 - ref SDS C1 OU8G; confirms Bard is satisfied that the
B70723 - Power Port has no product defects nor damage based on
B70724 - record of failed test on 080718, ref SDS C1 Y76S,
B70725 - requests comment on using Lifeguard Safety Infusion Set
B70726 - Huber needle for power injection of contrast medium with
B70727 - the Bard Power Port for Millie's CT test at Kaiser.
B70728 - ref SDS C1 Y83V
B70730 - ..
B70731 - 37. [On 080905 Steve advises that Bard is satisfied that the
B70732 - Power Port should be safe for Millie's CT test on
B70733 - 080911. ref SDS C1 4Q7V
B70735 - ..
B70736 - 38. [On 080911 Millie gets treatment at UCSF for cancer;
B70737 - Catherin and Diane coordinate on selecting Huber needle
B70738 - for treatment that also meets requirements for power
B70739 - injection needed for Millie's CT test, ref SDS C2 V64G,
B70740 - Diane leaves Lifeguard Huber needle inserted in Power
B70741 - Port for use after treatment later in the day at Kaiser
B70742 - to perform CT test. ref SDS C2 O55I
B70744 - ..
B70745 - 39. [On 080911 Angela at CT Department with Kaiser in
B70746 - Oakland asked for Millie's Power Port ID card; after
B70747 - learning Millie has the Bard Power Port, she advised
B70748 - that training by Bard personnel a day or so earlier
B70749 - resolved issues, ref SDS C3 JX60; and so did not need
B70750 - the Power Port ID card to check flow rates and flushing
B70751 - instructions, and did not need to change settings on CT
B70752 - test equipment; this resulted in successful CT test
B70753 - using Bard Power Port. ref SDS C3 LK3R
B70755 - ..
B70756 - [On 080912 notified Bard of successful CT test using Power
B70757 - Port at Kaiser in Oakland thanks to Bard training; will
B70758 - need support for doing CT test with Power Port at Kaiser in
B70759 - Walnut Creek in 6 weeks. ref SDS C4 VI8I
B70761 - ..
B70762 - 40. [On 080917 Millie notifies medical team of successful CT
B70763 - test at Kaiser using Bard Power Port with Lifeguard
B70764 - Huber needle accessed at UCSF, ref SDS C5 SG9T, commends
B70765 - team care with referral coordination at Kaiser, UCSF,
B70766 - and Bard. ref SDS C5 SH5Y
B70768 - ..
B70769 - 41. [On 081017 Paula reports further discussion with Kaiser
B70770 - management making progress on arrangements for Millie's
B70771 - next CT test on 081113 at Kaiser in Walunt Creek using
B70772 - procedures for injecting contrast medium with Power Port
B70773 - technology that was done successfully at Oakland.
B70774 - ref SDS C6 707L
B70776 - ..
B70777 - 42. [On 081017 Kaiser in Walnut Creek investigating how Kaiser
B70778 - in Oakland handled laws about accessing a central venous
B70779 - artery with CT test equipment using a Power Port,
B70780 - ref SDS C6 8Y4N, and seemed to indicate that if legal
B70781 - issues are resolved, and the Power Port is accessed by
B70782 - qualified nurses in the Infusion Clinic, then support from
B70783 - the Power Port manufacturer is not needed. ref SDS C6 035K
B70785 - ..
B70786 - 43. [On 081019 Millie letter confirms Kaiser is working on
B70787 - scheduling the next CT test on 081113 using Millie's power
B70788 - port at Walnut Creek, as requested by the primary care
B70789 - physician. ref SDS C7 DZ6R
B70791 - ..
B70792 - 44. [On 081024 primary care physician ordered CT test at Kaiser
B70793 - in Walnut Creek on 081107 1300, and asked Millie to
B70794 - coordinate arrangements for the CT Department to use the
B70795 - Power Port, based on success doing the prior CT at Kaiser
B70796 - in Oakland. ref SDS C8 V58K
B70798 - ..
B70799 - 45. [On 081024 Dennis in the CT Department asks about assigning
B70800 - a nurse to support Millie's CT test on 081107 using the
B70801 - Bard Power Port to inject contrast medium; Dennis indicated
B70802 - the manager of the Radiology Department is coordinating to
B70803 - find out how Kaiser in Oakland did Millie's CT test using
B70804 - the Power Port and attended only by a CT Technician.
B70805 - ref SDS C8 2061
B70807 - ..
B70808 - 46. [On 081028 Millie's letter to Dennis at Kaiser in Walnut
B70809 - Creek submitted background on the CT test in Oakland on
B70810 - 080911. ref SDS C9 PE8X
B70812 - ..
B70813 - 47. [On 081029 Florida confirms Kaiser CT department in Walnut
B70814 - Creek approves doing test using Millie's Power Port, access
B70815 - scheduled in Infusion Clinic 081107 1230. ref SDS D1 4E3G
B70817 - ..
B70818 - 48. [On 081029 called Dennis to coordinate arrangements for
B70819 - Millie's CT test on 081107; Dennis plans to read Millie's
B70820 - letter and call if he has any questions. ref SDS D0 QK7M
B70822 - ..
B70823 - 49. [On 081030 telecon Steve at Bard he has coordinated with
B70824 - Agenal who did CT test using Millie's Power Port
B70825 - successfully on 080911 at Kaiser in Oakland, ref SDS D2
B70826 - XN9C; and has further talked to Dennis at the CT Department
B70827 - at Kaiser in Walnut Creek; feels Dennis's team at Walnut
B70828 - Creek is good to go for doing Millie's CT test with the
B70829 - Bard Power Port on 081107. ref SDS D2 UF5H
B70831 - ..
B70832 - 50. [On 081106 Virginia in the CT Department called and ordered
B70833 - another blood draw for Millie to get the CT test on 081107,
B70834 - because the Kaiser computer did not have the record on
B70835 - Pat's work today that determined the test at UCSF on 081023
B70836 - is sufficient for Millie to get the CT test at Kaiser on
B70837 - 081107. ref SDS C0 ED6H
B70839 - ..
B70840 - 51. [On 081106 Millie subitted a letter to Dennis reminding of
B70841 - requirements for doing the CT test on 081107 with Power
B70842 - Port technology. ref SDS D4 4J3Q
B70844 - ..
B70845 - 52. [On 081107 Cassandra in the CT Department applied policy
B70846 - for Kaiser in Walnut Creek that Technicians cannot connect
B70847 - pressure infusion equipment for contrast medium to Power
B70848 - Ports accessed with a Huber needle. ref SDS D5 2F56
B70850 - ..
B70851 - 53. [On 081107 Dennis, CT Department supervisor at Kaiser in
B70852 - Walnut Creek, was not available to manage use of new
B70853 - technology for the 2nd time to correct problems the first
B70854 - time, ref SDS D5 VR4L; Pat who had worked on Millie's CT
B70855 - test using the Power Port for the 1st time, and had
B70856 - scheduled the 2nd test, did not remember Millie nor that
B70857 - the test would use Bard Power Port technology, ref SDS D5
B70858 - MX4L; Steve, District Manager for Bard, who had talked to
B70859 - Dennis and said Kaiser was "good to go" using the Bard
B70860 - Power Port for the CT test, and Julie, who had offered to
B70861 - be on-site for the test, did not have time to support the
B70862 - 2nd attempt using Bard equipment, which had failed on the
B70863 - 1st attempt, ref SDS D5 2F6S; nobody seemed to be prepared
B70864 - for applying manufacturer's instructions; communication to
B70865 - collaborate on coordinating the work failed by relying on
B70866 - memory of very talented, dedicated people under stress with
B70867 - limited time. ref SDS D5 2F32
B70869 - ..
B70870 - 54. [On 081108 Steve asks how the test went at Kaiser using the
B70871 - Bard Power Port; explains Bard could not support the Power
B70872 - Port customer on 081107, proposed by Bard on 080801,
B70873 - ref SDS B2 OW41, requested by customer on 081028, and
B70874 - reminded on 081106, because Bard was busy attending a class
B70875 - to support future customers for Bard radiographic
B70876 - technology. ref SDS D6 4P4K
B70878 - ..
B70879 - 55. [On 081111 Millie notifies medical team with copy to Bard
B70880 - that CT test was completed on 081107, ref SDS D7 WP8G,
B70881 - Kaiser trying to improve the work to smooth out the rough
B70882 - edges using Bard Power Port technology. ref SDS D7 2F3R
B70884 - ..
B70885 - 56. [On 081111 Steve District Manager asks how Bard can help
B70886 - Kaiser smooth out the "rough edges" on technology transfer
B70887 - using the Bard Power Port. ref SDS D8 4Q3H
B70889 - ..
B70890 - 57. [On 081117 Steve explains Bard did not attend Millie's CT
B70891 - test on 081107 because Kaiser told Bard not to attempt
B70892 - further help for Kaiser because CT tests can be done for
B70893 - all patients without using Power Port technology.
B70894 - ref SDS D9 M559
B70896 - ..
B70897 - 58. [On 081210 the doctor called and scheduled the CT test on
B70898 - 081230 1020. ref SDS E0 H44N Clarified scope of test for
B70899 - referral to CT department scheduled on 081230 1020.
B70900 - ref SDS E0 H44N
B70902 - ..
B70903 - 59. [On 081211 Arlette called and left a message saying Millie
B70904 - is scheduled for port access in the Infusion Clinic on
B70905 - 081230 1000 for Millie's test later in the CT Department at
B70906 - 1020. ref SDS E1 IG54
B70908 - ..
B70909 - 60. [On 081211 Millie's letter to Kaiser with copies to the
B70910 - primary care physician in Oncology, the assistant Arlette,
B70911 - also in Oncology, and to the supervisor of the CT
B70912 - Department, Dennis, confirms doctor's order for the CT test
B70913 - on 081230 1020 to use Millie's Power Port, to coordinate
B70914 - with IS for power injection of contrast medium, and for the
B70915 - scope of the test to include the neck. ref SDS E1 PQ9P
B70917 - ..
B70918 - 61. [On 081229 notification problems occurred again,
B70919 - ref SDS D0 5F5M, but were resolved in a meeting the day
B70920 - before the test. ref SDS D0 MR6K
B70922 - ..
B70923 - 62. [On 081230 Millie's CT test took about 20 minutes using the
B70924 - Bard Power Port for pressure injection of contrast medium,
B70925 - rather than conventional IV procedures. ref SDS E3 DU52
CT Test 080212 Findings Support Diagnosis IBC Progression Disease 4t
BQ0401 - ..
BQ0402 - Medical Chart Reports Examination Diagnosis Prescription Prognosis
BQ0404 - Follow up ref SDS 68 YT5N.
BQ0406 - Received the doctor's report in the medical chart for the meeting
BQ0407 - today...
BQ0409 - ..
BQ0410 - 1. Received: 5/2/08 12:42 PM
BQ0412 - ..
BQ0413 - 2. .... [patient] is a 72 Y female with a history of inflammatory
BQ0414 - cancer of left breast who was initially diagnosed 03/04/02.
BQ0415 - She had recurrent disease noted initially in the cervical LN's
BQ0416 - 03/03/04. On E2100 Study with Avastin, but she had a PE noted
BQ0417 - on CT 11/03/2004. Then, because of progression of disease, the
BQ0418 - patient was started on Taxotere and Xeloda 4/15/05. She had a
BQ0419 - total of 8 cycles ending 9/16/05. She had a palliative left
BQ0420 - mastectomy performed 10/21/05. Then her left chest lesions
BQ0421 - began expanding again. The patient started Taxotere and Xeloda
BQ0422 - again 07/21/06 for 7 cycles. She was started on a Clinical
BQ0423 - Trial 02/01/07 at UCSF and was randomized to the Erbitux only
BQ0424 - (no Carbo) Arm.
BQ0426 - ..
BQ0427 - She had weekly Carboplatinum added 03/13/08 because of
BQ0428 - progression of disease. She has had to skip 3 treatments
BQ0429 - because off low counts. She has required Neupogen support.
BQ0430 - She just developed cellulitis of the LUE again 04/09/08 and was
BQ0431 - treated with Keflex through the ER. She has
BQ0433 - ..
BQ0434 - The end of the report shows incomplete thought... "She has..."
BQ0436 - ..
BQ0437 - This might add that "She has responded to treatment despite getting
BQ0438 - only 50% of prescribed regimen with Carboplatin. Patient tolerates
BQ0439 - adding chemotherapy well, reporting increased exercise and improved
BQ0440 - times hiking 3 miles a day 4 - 5 times a week."
BQ0442 - ..
BQ0443 - Change spelling "Carboplatinum" to "Carboplatin." ref SDS 0 NN8I
BQ0445 - ..
BQ0446 - Medical Chart continues...
BQ0448 - 3. Current Medications
BQ0450 - PROCHLORPERAZINE 10MG....... Compazine. 080313, ref SDS 69 FA4H
BQ0451 - ONDANSETRON 8 MG TABLETS.... Zofran.... 080313, ref SDS 69 FA4H
BQ0452 - CEPHALEXIN 500 MG CAPSULES.. Keflex.... 080409, ref SDS 83 F142
BQ0453 - FLUOXETINE 20 MG CAPSULES... Prozac.... 080305, ref SDS 68 5L5M
BQ0454 - NEUPOGEN 480MCG/1.6ML.................. 080502, ref SDS 0 NL4M ,
BQ0455 - WARFARIN 4 MG TABLETS....... Coumadin.. 061002, ref SDS 13 MI5I
BQ0456 - TIMOLOL MALEATE 0.5% EYE.... Eye drops
BQ0457 - ACYCLOVIR 800MG............. Zoviraxe.. 070614 (no record prescribed by Doctor Rugo to treat cold sore on lip)
BQ0458 - LORAZEPAM 1 MG.............. Ativan.... 070921, ref SDS 30 3N8J
BQ0460 - ..
BQ0461 - For some reason, the medical chart does not include contrast medium
BQ0462 - treatment used for CT tests, per above. ref SDS 0 SY4M
BQ0464 - GASTROGRAFIN 66/10 SOLUTION............ 080425, ref SDS 85 XM30
BQ0466 - ..
BQ0467 - During the meeting Millie reported new UCSF requirements presented
BQ0468 - yesterday on 080501 for coordinating referral patients by listing
BQ0469 - current medications. Millie asked the doctor today to check Kaiser's
BQ0470 - computer for current medications. The doctor found additional data in
BQ0471 - the computer and updated the list in the Medical Chart for submission
BQ0472 - to UCSF, as explained above on coordinating referral care. ref SDS 0
BQ0473 - IE6M
BQ0475 - ..
BQ0476 - Millie suggested that the doctor add to data in Kaiser's computer
BQ0477 - listing the following medications prescribed by UCSF...
BQ0479 - ..
BQ0480 - Cetuximab................... Erbitux... 070201, ref SDS 20 4N5M
BQ0481 - CARBOPLATIN................. .......... 080313, ref SDS 73 TZ8I
BQ0483 - ..
BQ0484 - After the meeting today, review of UCSF documents shows additional
BQ0485 - medications are part of weekly treatments...
BQ0487 - Dexamethasone............... Decadron.. 080313, ref SDS 73 2N43
BQ0488 - Diphenhydramine............. Benedryl.. 080313, ref SDS 73 NX4N
BQ0490 - ..
BQ0491 - This updates Millie's letter on 080307 to Kaiser reporting corrections
BQ0492 - to current medications in medical chart at Kaiser so that primary care
BQ0493 - physician can provide effective medical opinion to backup care at
BQ0494 - UCSF. ref SDS 71 RW3T
BQ0496 - ..
BQ0497 - After the meeting, the doctor printed another list of medications, per
BQ0498 - above. ref SDS 0 E43I To determine Millie's current medications, a
BQ0499 - medical professional should review both the list in the medical chart,
BQ0500 - ref SDS 0 7Y6F, and the supplemental listing on history of medications
BQ0501 - received after the meeting. ref SDS 0 E43I Review should include
BQ0502 - frequency of use, also discussed above. ref SDS 0 N84O Medications
BQ0503 - might be prescribed that are not being taken, but present risks of
BQ0504 - conflicts with future prescriptions, since taking such medications is
BQ0505 - at the will of the patient.
BQ0508 - ..
BQ0509 - Medical Chart continues...
BQ0511 - 4. Physical Examination
BQ0513 - Performance Status: 0
BQ0514 - Lymph nodes: negative palpation
BQ0515 - Chest wall: decreasing erythema on lower left chest wall
BQ0516 - Ext: LUE edema with decreasing erythema involving upper arm
BQ0517 - measured at 31 cm
BQ0519 - ..
BQ0520 - The doctor explained that "Performance Status "0" means Millie has
BQ0521 - evident full mobility and demonstrates no loss of normal functioning.
BQ0523 - ..
BQ0524 - Decreasing erythema reported in the Medical Chart reflects examination
BQ0525 - today, per above, ref SDS 0 NH4N, and shows significant improvement
BQ0526 - from examination on 080305 that found increasing IBC. ref SDS 68 1Z6O
BQ0528 - ..
BQ0529 - Medical Chart continues...
BQ0531 - Lab:
BQ0533 - WBC H 12.9 K/uL
BQ0534 - RBC 4.19 M/uL
BQ0535 - Hemoglobin 13.4 g/dL
BQ0536 - Hematocrit 37.9 %
BQ0537 - MCV 91 fL
BQ0538 - RDW H 14.4 %
BQ0539 - Plt L 136 K/uL
BQ0541 - ..
BQ0542 - BUN 10 mg/dL
BQ0543 - Chloride 100 mEq/L
BQ0544 - CO2 24 mEq/L
BQ0545 - Creatinine 0.45 mg/dL
BQ0546 - Glucose Random 117 mg/dL
BQ0547 - Potassium 3.5 mEq/L
BQ0548 - Sodium L 134 mEq/L
BQ0549 - Anion Gap 10 mEq/L
BQ0550 - Lactic Acid 1.5 mmol/L
BQ0552 - ..
BQ0553 - The doctor found results of the lab from Millie's treatment in the ER
BQ0554 - department on 080409. ref SDS 83 S18F
BQ0556 - ..
BQ0557 - There was discussion during the meeting to enter the effective date of
BQ0558 - the blood test results entered in the Medical Chart. The doctor said
BQ0559 - he can capture dates from Kaiser's computer system and add to the
BQ0560 - Medical Chart, but this option presents a very awkward listing that
BQ0561 - doesn't look good, and so he prefers to just do the list, and if it
BQ0562 - become important to know when the test was done, this can be looked up
BQ0563 - elsewhere in the computer sytem.
BQ0565 - ..
BQ0566 - It was not clear during the meeting why an entry could not be made
BQ0567 - stating the blood test was done at Kaiser on 080409, since that is
BQ0568 - where the doctor got the list to enter in the file.
BQ0570 - ..
BQ0571 - Scope and procedure for the Medical Chart is discussed further below.
BQ0572 - ref SDS 0 OG7G
BQ0574 - ..
BQ0575 - Medical Chart continues reporting Labs...
BQ0577 - CA 15-3
BQ0579 - 75 H
BQ0580 - 74 H
BQ0581 - 56 H
BQ0582 - 52 H
BQ0583 - 55 H
BQ0584 - 56 H
BQ0585 - 52 H
BQ0586 - 68 H
BQ0587 - 56 H
BQ0588 - 74 H
BQ0590 - ..
BQ0591 - CA 15-3 listing is from a test on 071017, ref SDS 35 OS5K, reported in
BQ0592 - the record on 071018. ref SDS 36 6N9F
BQ0594 - ..
BQ0595 - Millie has had about 8 tests for the cancer marker since 071017.
BQ0597 - ..
BQ0598 - Medical Chart continues...
BQ0600 - 5. Imaging
BQ0602 - 04/25/08 CT THORAX, ABDOMEN, PELVIS W CONTRAST - no change
BQ0604 - ..
BQ0605 - Kaiser deserves credit for starting to comment in the Medical Cart on
BQ0606 - test findings, as reported on 080305. ref SDS 68 Q89J
BQ0608 - ..
BQ0609 - Continued minimal analysis can be strengthened with minimal additional
BQ0610 - effort. ref SDS 68 MF4T
BQ0612 - ..
BQ0613 - Medical Chart continues...
BQ0615 - 04/09/08 CHEST, TWO VIEWS
BQ0616 - 03/05/08 HUMERUS 2+ VIEWS - normal
BQ0617 - 02/12/08 CT THORAX, ABDOMEN, PELVIS W CONTRAST - increased
BQ0618 - right axillary LN; infiltrate RML fissure
BQ0621 - ..
BQ0622 - 6. Imp:
BQ0624 - 1. Metastatic breast cancer (IBC)lung, lymph node and chest wall
BQ0625 - 2. Leukopenia
BQ0626 - 3. Depression
BQ0627 - 4. Cellulitis
BQ0628 - 5. Lymphedema
BQ0630 - ..
BQ0631 - During the meeting there was discussion of why the Medical Chart
BQ0632 - reports "depression." Millie reported today good progress with
BQ0633 - reduction of IBC. This was observed during examination today by the
BQ0634 - doctor, per above, ref SDS 0 NH4N, and reported in the Medical Chart.
BQ0635 - ref SDS 0 1Z6O
BQ0637 - ..
BQ0638 - Kaiser's CT test shows no advance of disease. ref SDS 0 N15O Millie
BQ0639 - is somewhat depressed by injury to her arm and failure to solve the
BQ0640 - problem making injections for CT tests, per above. ref SDS 0 WX6I
BQ0641 - This was addressed today by the doctor planning to investigate by
BQ0642 - contacting the surgeon. ref SDS 0 VG5J
BQ0644 - ..
BQ0645 - Millie confirmed today that feelings of "depression" which led to
BQ0646 - prescribing Prozac on 080305, quickly subsided due to a combination of
BQ0647 - good news on her health care, and with increased exercise, so she has
BQ0648 - not needed to take this treatment, per above. ref SDS 0 2R5N
BQ0650 - ..
BQ0651 - The doctor explained that issues of depression are complex. It takes
BQ0652 - time to write this up so it makes sense of the record. He feels it is
BQ0653 - faster and easier to just leave "depression" in the Medical Chart even
BQ0654 - though there is no evidence to support the report. The doctor feels
BQ0655 - this is more of a note to continue checking this on future visits, and
BQ0656 - so causes no confusion by being incorrect. The doctor noted that the
BQ0657 - Medical Chart for Millie has a lot more documentation of patient
BQ0658 - history than other occurs in the Medical Charts prepared by other
BQ0659 - doctors for their patients. He noted there is not enough time to
BQ0660 - clarify inconsequential details.
BQ0662 - ..
BQ0663 - Issues of limited time preparing an accurate Medical Chart are also
BQ0664 - discussed above. ref SDS 0 NP9K
BQ0666 - ..
BQ0667 - Medical Chart continues...
BQ0669 - 7. Plan
BQ0671 - 1. Continue Clinical Trial on Erbitux with weekly Carbo
BQ0672 - 2. Consider Power Port?? Will discuss with Surgery
BQ0673 - 3. Continue Neupogen support
BQ0674 - 4. Continue Keflex
BQ0675 - 6. RTC 8 weeks
BQ0677 - ..
BQ0678 - The plan to investigate replacing the port catheter with a Power Port
BQ0679 - catheter and by contacting the surgeon, was reported during the
BQ0680 - meeting, per above. ref SDS 0 VG5J
BQ0682 - ..
BQ0683 - Millie is not actually taking Keflex for Cellulitis and lymphedema.
BQ0684 - She has Keflex medication on hand to treat future episodes, per above.
BQ0685 - ref SDS 0 IP8N
BQ0687 - ..
BQ0690 - ..
BQ0691 - After the meeting, Millie stopped at the front desk. The clerk said
BQ0692 - Kaiser's computer cannot schedule meeting in 8 weeks ordered by the
BQ0693 - doctor. ref SDS 0 CO3H She will enter a note to schedule the next
BQ0694 - meeting for Millie on 080627 1200, after the computer allows entering
BQ0695 - this objective in the computer.
BQ0697 - ..
BQ0698 - This is a new procedure. Millie has been schedulig meetings 2 months
BQ0699 - ahead for years. This is the first time, there has been notice the
BQ0700 - the computer cannot accomplish the doctor's order, shown by the record
BQ0701 - of the prior meeting on 080305. ref SDS 68 YU5G