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: July 23, 2008 04:10 PM Wednesday; Rod Welch

CT test July 18th for Millie received from Kaiser favorable report.

1...Summary/Objective
2...CT Test Report Delayed from Kaiser Not Enough Time to Be Prepared
3...Delay CT Test Report Kaiser Submitting for People to Be Prepared
4...Kaiser Delay Submitting CT Test Report for People to Be Prepared
5...CT Test Report Remind Kaiser Submit Enable People to Be Prepared
6...CT Test on 080718 Report Received from Kaiser
........Test History No Evidence Distant Metastasis
........Distant Metastasis No Evidence 5 Years Imaging Tests
....1...Patient
....2...CT OF THE CHEST, ABDOMEN AND PELVIS
7...Errors Omissions Comparisons Patient History Trend Analysis
8...Patient History Comparison PE Cor Pulmonale Esophigitis Enlarged Heart
....3...HISTORY
....4...TECHNIQUE:
....5...COMPARISON:
9...Findings Contrast Medium Extravasation
10...Power Port Tip Junction SVC Right Atrium Contrst Medium Overflow
11...Contrast Medium Large Collection Right Chest Outside Venous System
....6...FINDINGS
12...Findings Stable No Progression Lymphadenophathy Since February
13...Right Axillary 3 Lymph Node Stable No Evidence Progression Disease
14...Stable Lymphadenophathy No Progression of Cancer CT Test 080425
15...Distant Metastasis No Evidence Disease NED Stable No Progression
16...Left Axilla Stable No Evidence Disease NED Unchanged Prior Test
17...Pretracheal Paratracheal Evidently Same Region
18...Paratracheal Adenopathy Unchanged Prior Study 3 Nodes Identified
19...Thyroid Gland Findings Described Unchanged Not Presented in Prior Test
20...Heart Normal Change from 071210
21...Lungs 4 Nodes Appear Smaller than Prior Studies
22...Pulmonary Embolism Findings CT Test 080718 Similar 080425
23...Cetuximab Side Effects Interstitial Disease CT Test Finding
24...Interstitial Disease Lungs Mostly Reduced Right Lower Lobe Increased
25...Case Study Interstitial Disease Patient History CT Tests
26...Spleen Calcifications Granulamatous Disease
27...Granulamatous Disease Spleen Calcifications
28...Kidneys Appear Unchanged
29...Colon Bowel Hiatal Hernia Diverticulitis No evidence
30...Bowel Colon Hiatal Hernia Diverticulitis No evidence
31...Diverticulitis No evidence Colon Bowel Hiatal Hernia
32...Hiatal Hernia Diverticulitis No evidence Colon Bowel
33...Abdominal Aorta No Aneurysm
34...Splenic Artery Calcification Aneurysms
35...Spine Lower Lumbar Degenertive Changes in Disks Facet Joints
36...May be Increased Lymph Nodes Right Axilla Interstitial Disease
....7...IMPRESSION

ACTION ITEMS.................. Click here to comment!

1...Has Millie now been diagnosed with "interstitial lung
2...Does calcification of splenic artery with dilatation align with the
3...What is the signficance of artery aneurysms and infection in the

CONTACTS 

SUBJECTS
CT Test 080718 Report Received Condition Stable Right Axilla Possibl

1103 -
1103 -    ..
1104 - Summary/Objective
1105 -
110501 - Follow up ref SDS 53 0000. ref SDS 52 0000.
110502 -
110503 -
110504 -
110505 -
110506 -
110507 -
110509 -  ..
1106 -
1107 -
1108 - Progress
1109 -
110901 - CT Test Report Delayed from Kaiser Not Enough Time to Be Prepared
110902 - Delay CT Test Report Kaiser Submitting for People to Be Prepared
110903 - Kaiser Delay Submitting CT Test Report for People to Be Prepared
110904 - CT Test Report Remind Kaiser Submit Enable People to Be Prepared
110905 -
110906 - Follow up ref SDS 53 6V5I, ref SDS 48 6V5I.
110907 -
110908 - Millie has not received the report on the CT test performed at Kaiser
110909 - on 080718. ref SDS 61 0001
110911 -  ..
110912 - Called Kaiser this morning and talked to Arlette.
110914 -  ..
110915 - Arlette said that Kaiser received Millie's letter on 080718 explaining
110916 - the CT test and requesting the report by yesterday or today in order
110917 - to prepare for the meeting tomorrow at UCSF. ref SDS 61 PU7P  Arlette
110918 - recalled also receiving Millie's letter on Monday, 080721 reminding
110919 - Kaiser to submit the CT test report. ref SDS 62 CW9R
110921 -  ..
110922 - Today, Arlette asked the doctor about sending the CT test report to
110923 - UCSF and the patient.  She learned that the CT Department was late
110924 - submitting the report for the test on 080718.  The doctor has called,
110925 - and she is following up to send the report in time for everyone to be
110926 - prepared for Millie's meeting at UCSF tomorrow.
110927 -
110928 -            [On 080724 UCSF did not get the CT test report from Kaiser
110929 -            in time to prepare for the meeting. ref SDS 64 VE8O
110930 -
110931 -
110933 -  ..
1110 -
1111 -
1112 - 1704
1113 -
111301 - CT Test on 080718 Report Received from Kaiser
111302 -
111303 - Follow up ref SDS 61 2U6L.
111304 -
111305 - Millie received, ref DRT 1 0001, a letter from the primary care
111306 - physician at Kaiser transmitting the CT test on 080718. ref SDS 61
111307 - 2U6L Her prior test was on 080425, ref SDS 52 9W9I, and the report was
111308 - received from Kaiser on 080428. ref SDS 53 6V5I
111309 -
111310 -    1.  [Here is the report on the CT test performed at Kaiser on July
111311 -        18th, 2008, ref SDS 61 2U6L, and as requested in your letter on
111312 -        July 18th, ref SDS 61 PU7P, and mentioned again in your follow
111313 -        up letter to Kaiser on July 21. ref SDS 63 9W9I  The report was
111314 -        received in the afternoon today after your call this morning to
111315 -        Arlette in my office.]
111317 -  ..
111318 - The primary care physician at Kaiser responds to the letter Millie
111319 - submitted to the medical team, with Kaiser the primary addressee in
111320 - the evening after the test on 080718. ref SDS 61 PU7P
111321 -
111323 -         ..
111324 -        Test History No Evidence Distant Metastasis
111325 -        Distant Metastasis No Evidence 5 Years Imaging Tests
111326 -
111327 -        Follow up ref SDS 53 GM3N, ref SDS 48 GM3N.
111328 -
111329 -        Type    Date           Received          Source
111330 -         CT     080718 reported on 080723........... ref SDS 0 DA6Q
111331 -         CT     080425 reported on 080428........... ref SDS 53 DA6Q
111332 -         CT     080212 reported on 080215........... ref SDS 48 DA6Q
111333 -         CT     071210 reported on 071213........... ref SDS 39 UG4L
111334 -         CT     070930 reported on 071018........... ref SDS 36 VK8L
111335 -         CT     070723 reported on 070802........... ref SDS 33 IM6M
111336 -         CT     070520 reported on 070524........... ref SDS 32 DA6Q
111337 -         CT     070326 reported on 070329........... ref SDS 31 DA6Q
111338 -         CT     070131 reported on 070202........... ref SDS 29 1Y8G
111339 -         PET/CT 061227 reported on 070102........... ref SDS 25 1Y8G
111340 -         CT     060930 reported on 061012........... ref SDS 23 284J
111341 -         MRI    060708 reported on 060711........... ref SDS 21 PT4K
111342 -         Xray   060623 reported on 060711........... ref SDS 21 WJ6G
111343 -         CT     060505 reported on 060523........... ref SDS 20 E355
111344 -         PET    060414 reported on 060428........... ref SDS 19 WJ6G
111345 -         PET    060120 reported on 060126........... ref SDS 18 WJ6G
111346 -         PET/CT 051005 reported on 051007........... ref SDS 16 WJ6G
111347 -         CT     050530 reported on 050610........... ref SDS 15 G75L
111348 -         CT     050325 reported on 050422........... ref SDS 14 G75L
111349 -         CT     041217 reported on 041230........... ref SDS 13 G75L
111350 -         CT     041103 reported on 041104........... ref SDS 12 WV7H
111351 -         CT     040921 reported on 041005........... ref SDS 10 NL4N
111352 -         CT     040710 reported on 040811........... ref SDS 9 H85S
111353 -         CT     040410 reported on 040416........... ref SDS 7 LK5L
111354 -         CT     040307 reported on 040318........... ref SDS 6 LK5L
111355 -         CT     031031 reported on 031205........... ref SDS 5 IG9K
111356 -         CT     030626 reported on 030710........... ref SDS 4 AL6N
111357 -         CT     030428 reported on 030508........... ref SDS 3 LK5L
111358 -         PET    021218 reported on 030109........... ref SDS 2 LK5L
111359 -         PET    020529 reported on 020603........... ref SDS 1 0001
111361 -         ..
111362 -    1.  Patient
111370 -         ..
111371 -    2.  CT OF THE CHEST, ABDOMEN AND PELVIS
111376 -         ..
111377 -        Date:  080718 1037
111379 -         ..
111380 -        Performed in:  WCR
111381 -
111385 -
111386 -
111387 -
111388 -
111389 -
1114 -

SUBJECTS
CT Test 080718 Report Errors Omissions Comparisons Patient History T

4703 -
470401 -  ..
470402 - Errors Omissions Comparisons Patient History Trend Analysis
470403 - Patient History Comparison PE Cor Pulmonale Esophigitis Enlarged Heart
470404 -
470405 - Follow up ref SDS 53 IX4F, ref SDS 48 IX4F.
470406 -
470407 - CT test 080718 report continues...
470409 -         ..
470410 -    3.  HISTORY
470411 -
470412 -        72 year old with history of metastatic breast cancer.  On
470413 -        clinical trial at UCSF.
470414 -        ref DRT 1 F58N
470416 -         ..
470417 -        Status post left mastectomy. ref DRT 1 XD5L
470419 -  ..
470420 - The "history" section provides less context than the report for the
470421 - prior test on 080212, as shown on 080215. ref SDS 48 IX4F  This is
470422 - comparable to work on the test for 080425, received on 080428.
470423 - ref SDS 53 IX4F
470425 -  ..
470426 - The report today repeats errors and omissions listed in the report for
470427 - the test on 080212, shown in the review on 080215. ref SDS 48 IX4L
470429 -  ..
470430 - Failure to track patient history denies the analyst an agenda to
470431 - investigate changes on issues identified as critical to patient
470432 - health.
470434 -  ..
470435 - CT test 080718 report continues...
470436 -
470437 -    4.  TECHNIQUE:
470438 -
470439 -        The patient has a power port in place.  It was canulated by a
470440 -        nurse in conventional services.  Injection of contrast was
470441 -        made, but quickly developed swelling in the right chest wall
470442 -        and injection was stopped.
470444 -  ..
470445 - This report aligns with the record of work at Kaiser on 080718,
470446 - ref SDS 61 LK3R
470447 -
470448 -            [On 080912 report for CT test at Kaiser in Oakland says
470449 -            contrast medium was injected through Power Port without
470450 -            complications. ref SDS 68 EO5N
470452 -  ..
470453 - CT test 080718 report continues...
470454 -
470455 -        Further attempts to access the power port for injection were
470456 -        not successful either. ref DRT 1 0F9L
470458 -  ..
470459 - This report aligns with the record of work at Kaiser on 080718,
470460 - ref SDS 61 A26Y
470462 -  ..
470463 - CT test 080718 report continues...
470464 -
470465 -        A peripheral vein in the right upper extremity was canulated
470466 -        and contrast was injected for the CT scan. A CT scan of the
470467 -        chest, abdomen and pelvis was then performed during the
470468 -        injection of the IV contrast.  Oral contrast had been given
470469 -        earlier.  No untoward reaction to contrast material.
470470 -        ref DRT 1 IF4I
470472 -  ..
470473 - This report aligns with the record of work at Kaiser on 080718,
470474 - ref SDS 61 A363
470476 -  ..
470477 - CT test 080718 report continues...
470478 -
470479 -    5.  COMPARISON:
470480 -
470481 -        Please compare to 4/25/2008 CT. ref DRT 1 PE9J
470483 -  ..
470484 - Test on 080425 was received from Kaiser and reviewed on 080428.
470485 - ref SDS 53 RV49
470487 -  ..
470488 - The report today provides several specific comparisions on the right
470489 - axilla, per below, continuing practice for the previous test on
470490 - 080425, reported on 080428, ref SDS 53 CA5M, and correcting failure to
470491 - perform comparisions in the prior test, reported on 080215.
470492 - ref SDS 48 EO7F  Failure to list patient history, causes comparisons
470493 - in this report to omit critical issues, per above, ref SDS 0 9W8J,
470494 - which repeats omissions in the test report on 080215. ref SDS 48 EO7F
470496 -  ..
470497 - Errors and omissions performing test comparisons reported in case
470498 - study on 061012. ref SDS 23 A55J
470500 -  ..
470501 - Case study on medical mistakes reported on 040416. ref SDS 7 GN7J
470502 -
470503 -
470504 -
4706 -

SUBJECTS
Right Axillary Lymph Nodes 3 Stable CT Test 080718 Findings Lymphade

6103 -
610401 -  ..
610402 - Findings Contrast Medium Extravasation
610403 - Power Port Tip Junction SVC Right Atrium Contrst Medium Overflow
610404 - Contrast Medium Large Collection Right Chest Outside Venous System
610405 -
610406 - Follow up ref SDS 53 EO8F, ref SDS 48 EO8F.
610408 -  ..
610409 - CT test 080718 report continues...
610410 -
610411 -    6.  FINDINGS
610412 -
610413 -        a.  There is a large collection of contrast material in the
610414 -            right chest wall, apparently due to injection of contrast
610415 -            outside the venous system. ref DRT 1 NI5I
610417 -  ..
610418 - This aligns with the report on 080718 that contrast medium overflowed
610419 - the Power Port during the injection process. ref SDS 61 NW5M
610421 -  ..
610422 - The "Impression" section of the test report mentions "extravasation,"
610423 - see below. ref SDS 0 DC5G
610425 -  ..
610426 - CT test 080718 report continues...
610427 -
610428 -        b.  Bone window show the power port catheter and its tip is at
610429 -            the junction of the SVC with the right atrium. ref DRT 1
610430 -            NC4G
610432 -             ..
610433 -            This comment is at the end of the CT test report.
610435 -             ..
610436 -        c.  A RRF form was completed. ref DRT 1 KJ5N
610438 -  ..
610439 - What is an RRF form; need copy from Kaiser.
610441 -  ..
610442 - CT test 080718 report continues...
610444 -  ..
610445 - Findings Stable No Progression Lymphadenophathy Since February
610446 - Right Axillary 3 Lymph Node Stable No Evidence Progression Disease
610447 - Stable Lymphadenophathy No Progression of Cancer CT Test 080425
610448 - Distant Metastasis No Evidence Disease NED Stable No Progression
610449 -
610450 - Follow up ref SDS 53 EO8F, ref SDS 48 EO8F.
610451 -
610452 -        d.  In the right axilla, there are two prominent lymph nodes
610453 -            which measure 1.7 x 1.5 cm and 1.3 x 1.3 cm.  Inferiorly,
610454 -            there is a lymph node which measures about 1.1 x 0.8 cm.
610455 -            On 4/25/2008 CT, these lymph nodes measured 1.4 x 1.1 cm,
610456 -            1.1 x 1.1 cm, and 1.0 x 0.5 cm.  On 4/12/2008 CT scan,
610457 -            these lymph nodes measured 1.9 x 0.9 cm, 1.3 x 1.1 cm, and
610458 -            1.0 x 0.5 cm.  Thus, I suspect that there is enlargement of
610459 -            one or more of these lymph nodes. ref DRT 1 NN6J
610460 -
610461 -                [On 080821 palpation during examination at UCSF
610462 -                reported feeling a slight lump in left supraclavicular
610463 -                region. ref SDS 66 4C6O
610465 -  ..
610466 - This is helpful work comparing node for node with prior test reported
610467 - on 080428. ref SDS 53 OO6M
610469 -  ..
610470 - Suspicion that 1 or more nodes have increased can be supported by data
610471 - comparison, which may also indicate decrease in nodes...
610472 -
610473 -                Current Test          Prior Test        Prior Test
610474 -                   080718              080425              080212
610475 -
610476 -             1.  1.70 x 1.50 cm .... 1.90 x 1.10 cm .... 1.90 x 0.90
610477 -             2.  1.30 x 1.30 cm .... 1.30 x 1.20 cm .... 1.27 x 1.13
610478 -             3.  1.10 x 0.80 cm .... 1.00 x 1.00 cm .... 1.00 x 1.00
610480 -  ..
610481 - This analysis comparing the past 3 tests seems to indicate at least a
610482 - stable condition, i.e., without significant change, and that
610483 - differences are attributible to test methods (see "Impression," below,
610484 - ref SDS 0 DC5G), which equally suggests there could have been actual
610485 - decline, i.e., improvement in the condition.
610486 -
610487 -                [On 080724 examination at UCSF clinical palpation seems
610488 -                to align with CT test finding no strong evidence
610489 -                indicating progressoin of adenopathy. ref SDS 64 FH8P
610491 -  ..
610492 - The report uses consistent units of measure, i.e., all "cm,"
610493 - correcting the prior report on 080215. ref SDS 48 GU8K
610495 -  ..
610496 - Problems with image test reporting were previously reviewed on 040416,
610497 - and reflect continuing quality issues. ref SDS 7 PTSX
610498 -
610499 -
610500 -
610501 -
6106 -

SUBJECTS
Left Axillary Stable CT Test 080718 Findings Lymphadenopathy No Evid

7303 -
730401 -  ..
730402 - Left Axilla Stable No Evidence Disease NED Unchanged Prior Test
730403 -
730404 - Follow up ref SDS 53 WM9L.
730405 -
730406 - CT test 080718 report continues...
730407 -
730408 -        e.  Left axilla shows no significant lymphadenopathy.
730409 -            ref DRT 1 3Z3I
730411 -  ..
730412 - No findings were reported in left axilla on prior test on 080425 shown
730413 - in the record on 080428. ref SDS 53 WM9L
730414 -
730415 -
730416 -
7305 -

SUBJECTS
Default Null Subject Account for Blank Record

7403 -
740401 -  ..
740402 - Pretracheal Paratracheal Evidently Same Region
740403 - Paratracheal Adenopathy Unchanged Prior Study 3 Nodes Identified
740404 -
740405 - Follow up ref SDS 53 RV70, ref SDS 48 RV70.
740407 -  ..
740408 - CT test 080718 report continues...
740409 -
740410 -        f.  Paratracheal and prevascular
740412 -  ..
740413 - Small right paratracheal and prevascular lymph nodes cited in the test
740414 - on 080425, and reported on 080428, ref SDS 53 RV70, are not mentioned
740415 - in the report for the CT test on 080718.
740416 -
740417 -               [On 081112 CT test on 081107 reports few, shotty,
740418 -               nonenlarged pretracheal and prevascular lymph nodes are
740419 -               seen.  On image #20, there is suggestion of a 1.2 cm AP
740420 -               window node which appears enlarged compared with the
740421 -               prior examination.  Some of this appearance, however,
740422 -               may be volume averaging with the overlying pulmonary
740423 -               artery.  A 1-cm pretracheal lymph node is also
740424 -               identified. ref SDS 71 RV70
740425 -
740426 -
740428 -  ..
740429 - Thyroid Gland Findings Described Unchanged Not Presented in Prior Test
740430 -
740431 -
740432 -        g.  Thyroid gland...
740433 -
740434 -            Less than 1 cm low density lesions in the right lobe of the
740435 -            thyroid gland, unchanged from the 4/25/2008 exam.
740436 -            ref DRT 1 NB3L
740438 -  ..
740439 - There is no evident description of "thyroid" in the CT test report
740440 - received from Kaiser on 080428. ref SDS 53 RV70  Basis reporting
740441 - "unchanged" today is not clear.
740443 -  ..
740444 - CT test 080718 report continues...
740445 -
740446 -        h.  A few minimally enlarged lymph nodes in the mediastinum and
740447 -            no significant adenopathy in the mediastinum nor in the
740448 -            hila. ref DRT 1 S24F
740449 -
740451 -  ..
740452 - Findings describing "mediastinum" and "hila" may align with prior test
740453 - on 080425, reviewed on 080428 that discuss "hilar." ref SDS 53 CB95
740454 -
740456 -  ..
740457 - Heart Normal Change from 071210
740458 -
740459 - Follow up ref SDS 39 SR5I.
740460 -
740461 - CT test 080718 report continues...
740462 -
740463 -        i.  Heart size is normal. ref DRT 1 MG4J
740465 -  ..
740466 - This seems to show improvement from the test on 071210 reporting the
740467 - heart appeared slightly enlarged, shown in the record on 071213.
740468 - ref SDS 39 SR5I
740469 -
740471 -  ..
740472 - Lungs 4 Nodes Appear Smaller than Prior Studies
740473 - Pulmonary Embolism Findings CT Test 080718 Similar 080425
740474 -
740475 - Follow up ref SDS 53 RV78, ref SDS 48 RV78.
740477 -  ..
740478 - CT test 080718 report continues...
740479 -
740480 -        j.  2.1 mm nodular density in the right upper lobe on image
740481 -            #22. 2.1 mm nodular density close to the major fissure on
740482 -            image #36, vague 3.8 mm pleural-based nodular density in
740483 -            the right middle lobe on image #38.  Vague 2.8 mm
740484 -            pleural-based nodular density in the right lower lobe on
740485 -            image #45.  These are unchanged or even smaller than on the
740486 -            prior studies.  A decrease in size may be due to slice
740487 -            selection differences. ref DRT 1 H84M
740489 -  ..
740490 - Practice of citing test scan image number helps navigating Knowledge
740491 - Space, continuing practice on 080428. ref SDS 53 WX8J
740493 -  ..
740494 - The CT test this past Friday on 080718 finding nodes in the lungs are
740495 - unchanged or smaller than the test on 080425, seems similar to the
740496 - report for the test on 080425 reviewed a few days later on 080428.
740497 - ref SDS 53 RV78  This further aligns with the case study on patient
740498 - history listed in the record on 070117 that finds no support for
740499 - Kaiser's medical chart notation of "lung cancer." ref SDS 27 6T5I
740501 -  ..
740502 - On 080507 Millie reported spike in heart beat (pulse) while laying
740503 - down in bed; case study shows occassional spike in pulse reported by
740504 - heart monitor during exercise, evaluated previously as defective
740505 - equipment. ref SDS 58 CK4K
740507 -  ..
740508 - Pulmonary embolism was found in a CT test on 060930, reviewed on
740509 - 061012.  Findings in the prior CT test on 080425 seem similar to
740510 - language in the report finding PE on 061012. ref SDS 23 294Q
740512 -  ..
740513 - On 080226 letter to Kaiser with copy to UCSF requests comment from
740514 - medical team, including notice to coagulation control case management.
740515 - ref SDS 51 S14Y
740516 -
740518 -  ..
740519 - Cetuximab Side Effects Interstitial Disease CT Test Finding
740520 - Interstitial Disease Lungs Mostly Reduced Right Lower Lobe Increased
740521 -
740522 -
740523 - CT test 080718 report continues...
740524 -
740525 -        k.  There is a focal area of interstitial disease in the left
740526 -            upper lobe and a focal area of interstitial disease in the
740527 -            mid right lung.  There is also a focus of interstitial
740528 -            disease in the medial aspect of the right lower lobe.
740529 -            Since the two prior studies, the interstitial disease in
740530 -            the left upper lobe is unchanged and the interstitial
740531 -            disease in the mid right lung is definitely less
740532 -            pronounced.  The interstitial disease in the medial aspect
740533 -            of the right lower lobe appears more pronounced than on the
740534 -            prior studies. ref DRT 1 W85L
740536 -  ..
740537 - Findings today of lung "interstitial disease" unchanged, more, and
740538 - less pronounced in various areas of the lungs conflicts with patient
740539 - history, shown in case study today (see below. ref SDS 0 7W6F).  The
740540 - most recent prior test on 080425 made no evident findings of
740541 - "interstitial disease," see 080428. ref SDS 53 RV78  The test on
740542 - 080212 made no findings, reviewed on 080215. ref SDS 48 RV78  The test
740543 - on 070520 found "no interstitial disease" reviewed at UCSF on 070524.
740544 - ref SDS 32 SP3F  Same for the test on 070326 reviewed at UCSF on
740545 - 070329. ref SDS 31 5S6L
740547 -                ..
740548 -               [On 080804 Millie's letter to Doctor Rugo with copy to
740549 -               primary care physician at Kaiser notifying of plans on
740550 -               returning to work, cites CT test findings of
740551 -               Interstitioal lung disease. ref SDS 65 GU6P
740553 -  ..
740554 - How do findings today of "interstitial disease" correlate with
740555 - clinical study documents received from UCSF on 070116 and describe a
740556 - serious lung condition that occurs for less than 1% of patients
740557 - treated with cetuximab? ref SDS 26 0256  On 080717, the day before the
740558 - CT test on 080718, since starting treatments on 070201, Millie
740559 - received 83 treatments of cetuximab. ref SDS 60 V94O
740561 -                ..
740562 -               [On 080821 meeting with medical team, there was no
740563 -               discssion of CT test performed 080718 finding
740564 -               Interstitial lung disease. ref SDS 66 056G
740566 -                ..
740567 -               [On 080829 during a meeting at Kaiser the primary care
740568 -               physician used the computer in the Examination room to
740569 -               open files for the CT test on 080718; after examination
740570 -               CT scan files the doctor commented that Interstitional
740571 -               lung disease reported on 080723, ref SDS 0 TS4J, appears
740572 -               very mild and not a significant side effect of cetuximab
740573 -               treatment for Millie's cancer. ref SDS 67 RP4X
740575 -                ..
740576 -               [On 080912 report on follow up CT test the day before on
740577 -               080911 makes no findings of "Interstitional lung
740578 -               disease," but may be reported with different language.
740579 -               ref SDS 68 TS4J
740580 -
740582 -  ..
740583 - Questions on CT test findings...
740584 -
740585 -            1.  Has Millie now been diagnosed with "interstitial lung
740586 -                disease"? ref SDS 0 TS4J
740587 -
740588 -            2.  If the condition is "unchanged" and "more pronounced,"
740589 -                when was the diagnosis made?  The test on 071210 says
740590 -                interstitial prominence has increased, ref SDS 39 SR66,
740591 -                but does not say from when?  Is "prominence" the same
740592 -                as "disease"?
740593 -
740594 -                   [On 080821 meeting with medical team none of the
740595 -                   questions today, ref SDS 0 6A4J, were addressed
740596 -                   during the meeting at UCSF. ref SDS 66 056G
740598 -                 ..
740599 -            3.  Is this manageable to continue receiving cetuximab
740600 -                safely given that Millie has been exposed with weekly
740601 -                treatments for 18 months to a low risk disease, per
740602 -                above. ref SDS 0 6A3N
740604 -                 ..
740605 -            4.  What is the cetuximab protocol for responding to
740606 -                findings of interstitional lung disease?
740608 -                 ..
740609 -            5.  Does increased exercise, like hiking that stresses the
740610 -                cardio pulmonary system present increased risk with
740611 -                pulse normally below 130, but sometimes increasing to
740612 -                150+ for periods of several minutes, and in rare cases
740613 -                to over 200 for 10 seconds or so?
740615 -                 ..
740616 -            6.  Does increased exercise help reduce "interstitial lung
740617 -                disease" in light of findings today that some disease
740618 -                is difinitely less pronounced? ref SDS 0 TS4J
740619 -
740620 -
740622 -  ..
740623 - Case Study Interstitial Disease Patient History CT Tests
740624 -
740625 - Background on "interstitial" issues in Millie's patient history
740626 - shows...
740627 -
740628 -            1.  CT test
740629 -
740630 -                Lung windows show stable, parenchymal
740631 -                interstitial opacities at the left
740632 -                apex and ventral, subpleural
740633 -                lingula........................ 030710, ref SDS 4 WS4K
740635 -                 ..
740636 -            2.  CT test
740637 -
740638 -                ...stable left apical interstitial
740639 -                septal change. The lungs are
740640 -                otherwise clear, free of infiltrates
740641 -                or masses.  There are no pleural
740642 -                effusions.  There are no hilar
740643 -                or mediastinal masses
740644 -                seen........................... 040416, ref SDS 7 EH50
740646 -                 ..
740647 -            3.  CT test
740648 -
740649 -                ...increased interstitial markings
740650 -                in the left upper lobe and lingui
740651 -                which may be due to therapeutic
740652 -                changes........................ 041104, ref SDS 12 QP7X
740654 -                 ..
740655 -            4.  CT test
740656 -
740657 -                Left apical interstitial fibrotic
740658 -                like densities unchanged. mediastinal
740659 -                (right anterior paratrachael) nodes
740660 -                measuring up to 9.4 mm seen
740661 -                unchanged. No new nodules
740662 -                seen in either lung............ 041230, ref SDS 13 PV6L
740664 -                 ..
740665 -            5.  Lymphedema research...
740666 -
740667 -                ...accumulation of interstitial
740668 -                fluid containing high molecular
740669 -                weight proteins. ...lymphatic
740670 -                system returns proteins, lipids,
740671 -                and accompanying water from the
740672 -                interstitium to the venous
740673 -                circulation near the subclavian
740674 -                vein-internal jugular
740675 -                vein junction,
740676 -                bilaterally.................... 060106, ref SDS 17 ST6O
740678 -                 ..
740679 -            6.  Cetuximab side effects lung disease..
740680 -
740681 -                Interstitial lung disease (ILD)
740682 -                results in inflammation, scarring
740683 -                and hardening of
740684 -                lungs.......................... 070116, ref SDS 26 0256
740686 -                 ..
740687 -            7.  Lung cancer case study CT tests
740688 -
740689 -                Lung cancer report in Kaiser medical
740690 -                chart not supported by patient
740691 -                history of tests............... 070117, ref SDS 27 6T5I
740692 -                and cites Interstitial lung
740693 -                disease (ILD).................. 070117, ref SDS 27 2K8L
740695 -                 ..
740696 -            8.  Meeting UCSF clinical study
740697 -
740698 -                Interstitial lung disease (ILD)
740699 -                side effect cetuximab CT tests
740700 -                strategy distinguish from symptoms
740701 -                similar to Pulmonary
740702 -                Embolism....................... 070130, ref SDS 28 MO7K
740704 -                 ..
740705 -            9.  CT test 070326, reviewed at UCSF...
740706 -
740707 -                Lungs no interstitial
740708 -                disease........................ 070329, ref SDS 31 5S6L
740709 -                shows this side effect of
740710 -                cetuximab that compounds
740711 -                pulmonary embolism has
740712 -                not occurred................... 070329, ref SDS 31 H84K
740714 -                 ..
740715 -           10.  CT test 070520, reviewed at UCSF...
740716 -
740717 -                Lungs no interstitial
740718 -                disease........................ 070524, ref SDS 32 SP3F
740720 -                 ..
740721 -           11.  CT test 070723 reviewed at UCSF...
740722 -
740723 -                Lungs show no new pulmonary nodules
740724 -                Left apical groundglass opacities
740725 -                with associated septal thickening is
740726 -                stable in appearance and is likely
740727 -                due to post inflammatory
740728 -                scarring....................... 070802 ref SDS 33 OX4O
740730 -                 ..
740731 -           12.  CT test on 070930 reviewed at UCSF
740733 -                 ..
740734 -                Made no findings of interstitial
740735 -                disease in the
740736 -                lungs.......................... 071018, ref SDS 36 KK6J
740738 -                 ..
740739 -           13.  CT test 071210 reviewed at UCSF...
740740 -
740741 -                There is some interstitial prominence
740742 -                and ground-glass opacity within the
740743 -                right lower lobe medially, which is
740744 -                slightly increased.  This may be
740745 -                partially due to atelectasis.
740746 -                Pneumonia cannot be
740747 -                excluded....................... 071213, ref SDS 39 SR66
740749 -                 ..
740750 -           14.  CT test 080212 reviewed
740751 -
740752 -                Interstitial disease is not described;
740753 -                The report says...
740754 -                New ill defined areas of increased
740755 -                density are seen in the right middle
740756 -                lobe along the fissure.  This may
740757 -                merely be volume averaging with
740758 -                the fissure, but developing
740759 -                infiltrate within the lung cannot
740760 -                entirely be excluded. Patchy ill
740761 -                defined areas of increased
740762 -                density are seen in the right
740763 -                lower lobe, unchanged from
740764 -                previous exam.  No pleural
740765 -                effusions are
740766 -                noted.......................... 080215, ref SDS 48 RV78
740767 -
740768 -                    [...below CT test on 0811107 reviewed
740769 -                    on 081112 finds Interstitional disease
740770 -                    at similar levels shown by CT test
740771 -                    on 080212. ref SDS 0 4I4N
740773 -                 ..
740774 -           15.  CT test 080425 reviewed
740775 -
740776 -                Interstitial disease is not described;
740777 -                The report says...
740778 -                Ill-defined areas of reticular opacity
740779 -                are again noted in the left lung apex
740780 -                and lateral, posterior aspect of the
740781 -                right middle lobe.  Patchy areas of
740782 -                increased opacity also noted in right
740783 -                lower lobe.  Pleural, approximately
740784 -                4 mm and 5 mm pulmonary densities
740785 -                in the right middle lobe are without
740786 -                significant change. Approximately
740787 -                3 mm nodular density in the
740788 -                lateral aspect of the right
740789 -                middle lobe (image 36) also
740790 -                is similar to the prior study.
740791 -                No new pulmonary nodules are
740792 -                seen........................... 080425, ref SDS 53 RV78
740794 -                 ..
740795 -           16.  CT test 080718
740796 -
740797 -                There is a focal area of interstitial
740798 -                disease in the left upper lobe and
740799 -                a focal area of interstitial disease
740800 -                in the mid right lung.  There is
740801 -                also a focus of interstitial disease
740802 -                in the medial aspect of the right
740803 -                lower lobe.  Since the two prior
740804 -                studies, the interstitial disease
740805 -                in the left upper lobe is
740806 -                unchanged and the interstitial
740807 -                disease in the mid right lung
740808 -                is definitely less pronounced.
740809 -                The interstitial disease in
740810 -                the medial aspect of the right
740811 -                lower lobe appears more pronounced
740812 -                than on the prior
740813 -                studies........................ 080723, ref SDS 0 TS4J
740814 -
740815 -                    [...below CT test on 0811107 reviewed
740816 -                    on 081112 finds Interstitional disease
740817 -                    at higher levels than shown by CT test
740818 -                    on 080718. ref SDS 0 4I4N
740820 -                 ..
740821 -           17.  6 questions presented by CT test
740822 -                findings Interstitional lung
740823 -                disease that is a rare side
740824 -                effect of cetuximab, and in
740825 -                relation to Millie's patient
740826 -                history getting cetuximab
740827 -                treatments for the past
740828 -                80 weeks....................... 080723, ref SDS 0 6A4J
740830 -                 ..
740831 -           18.  Examination UCSF
740832 -
740833 -                There was no review of CT test
740834 -                on 080718 reporting findings
740835 -                of Interstitional lung disease;
740836 -                UCSF obtaining report
740837 -                for review..................... 080724, ref SDS 64 GG6J
740839 -                 ..
740840 -           19.  Examination UCSF
740841 -
740842 -                Millie reported heaviness in chest
740843 -                during exercise on one occassion,
740844 -                and this was not repeated with
740845 -                further exercise; Interstitional
740846 -                lung disease reported in CT test
740847 -                on 080718, and a rare side effect
740848 -                of cetuximab, which Millie has
740849 -                received for 80 weeks, was not
740850 -                discussed with medical
740851 -                team........................... 080821, ref SDS 66 R37H
740853 -                 ..
740854 -           20.  CT test 080911
740855 -
740856 -                Interstitional lung disease is not
740857 -                discussed in the CT test report; but
740858 -                may be presented using other
740859 -                terminology.................... 080912, ref SDS 68 TS4J
740861 -                 ..
740862 -           21.  Examination UCSF
740863 -
740864 -                There was no review of CT test on
740865 -                080718 finding Interstitional lung
740866 -                disease, which is a rare side effect
740867 -                of cetuximab, which Millie has
740868 -                received for 85 weeks; no
740869 -                discussion of 6 questions
740870 -                on Millie's care............... 080918, ref SDS 69 056G ,
740872 -                 ..
740873 -           22.  Sunitinib protocol scheduled to
740874 -                start 081114
740876 -                 ..
740877 -                Millie changing treatment to
740878 -                sunitinib protocol includes
740879 -                cyclophosphamide (Cytoxan)
740880 -                which has rare, serious side
740881 -                effect of Interstitial
740882 -                pneumonitis.................... 081017, ref SDS 70 AR3W
740884 -                 ..
740885 -           23.  CT test 081107
740886 -
740887 -                What appears to be interstitial
740888 -                disease is seen in the right lower
740889 -                lobe.  This does appear to have
740890 -                progressed from the prior exam
740891 -                in July of 2008, ref SDS 0 KG6K,
740892 -                and it appears more similar to those
740893 -                studies of February of 2008.
740894 -                ref SDS 0 L25G  No new parenchymal
740895 -                nodules are seen.  No pleural
740896 -                effusions are
740897 -                noted.......................... 081112, ref SDS 71 TS4J
740898 -
740900 -  ..
740901 - CT test 080718 report continues...
740902 -
740903 -        l.  No pleural disease. ref DRT 1 OG6M
740904 -
740905 -        m.  Gallbladder, biliary tree and pancreas appear normal.
740906 -            ref DRT 1 EH7F
740908 -  ..
740909 - This aligns with the test on 080425 reviewed on 080428, ref SDS 53
740910 - YY6N, and extends favorable findings for the prior test on 080212
740911 - reviewed on 080215. ref SDS 48 A27K
740913 -  ..
740914 - CT test 080718 report continues...
740915 -
740916 -        n.  1.7 x 1.4 cm ______ is in the dome of the liver, unchanged
740917 -            from the prior. ref DRT 1 0S7I
740919 -  ..
740920 - This aligns with the test on 080425 reviewed on 080428, ref SDS 53
740921 - RV91, and extends favorable findings for the prior test on 080212
740922 - reviewed on 080215. ref SDS 48 RV91
740924 -  ..
740925 - CT test 080718 report continues...
740927 -  ..
740928 - Spleen Calcifications Granulamatous Disease
740929 - Granulamatous Disease Spleen Calcifications
740930 -
740931 - Follow up ref SDS 53 R96N, ref SDS 48 N96N.
740932 -
740933 -        o.  Spleen shows numerous calcifications, consistent with old
740934 -            granulomatous disease.  Adrenal glands appear normal.
740935 -            ref DRT 1 S57M
740937 -  ..
740938 - The previous test on 080425 found calcifications in the region of the
740939 - splenic hilum which may represent splenic artery aneurysms similar in
740940 - appearance as are the likely calcified splenic granulomas, reviewed
740941 - 080428. ref SDS 53 R96N  The prior test on 080212 described coarse
740942 - calcifications in the spleen consistent with prior granulomatous
740943 - infection.  Large coarse calcifications are seen near the splenic
740944 - hilum.  These have been unchanged from multiple prior exams and are
740945 - most consistent with calcified splenic artery aneurysms.  They could,
740946 - however, represent densely calcified lymph nodes, possibly from prior
740947 - infection. ref SDS 48 N96N
740949 -  ..
740950 - CT test 080718 report continues...
740952 -  ..
740953 - Kidneys Appear Unchanged
740954 -
740955 - Follow up ref SDS 53 653N.
740956 -
740957 -        p.  The kidneys demonstrate a few tiny low density lesions
740958 -            which are too small to accurately characterize as being
740959 -            solid or cystic.  Prompt excretion of contrast by both
740960 -            kidneys.  There is slight prominence of both renal pelves,
740961 -            but this does not appear to be obstructed.  No hydroureter.
740962 -            ref DRT 1 GI8G
740964 -             ..
740965 -        q.  The urinary bladder appears normal. ref DRT 1 F18N
740967 -             ..
740968 -        r.  The uterus is absent, apparently due to hysterectomy.
740969 -            ref DRT 1 F192
740971 -  ..
740972 - This report seems to align with the test on 080425 reviewed on 080428,
740973 - ref SDS 53 653N, and extends favorable findings for the prior test on
740974 - 080212 reviewed on 080215. ref SDS 48 347O
740976 -  ..
740977 - CT test 080718 report continues...
740979 -  ..
740980 - Colon Bowel Hiatal Hernia Diverticulitis No evidence
740981 - Bowel Colon Hiatal Hernia Diverticulitis No evidence
740982 - Diverticulitis No evidence Colon Bowel Hiatal Hernia
740983 - Hiatal Hernia Diverticulitis No evidence Colon Bowel
740984 -
740985 - Follow up ref SDS 53 256J, ref SDS 48 RV51.
740986 -
740987 -        s.  There is a small sliding hiatal hernia.  Moderate
740988 -            diverticulosis of the sigmoid colon and mild diverticulosis
740989 -            of the rest of the colon.  No evidence for diverticulitis.
740990 -            ref DRT 1 MH8O
740992 -  ..
740993 - The test on 080425 found no evidence of bowel obstruction, similar to
740994 - prior study, reviewed on 080428. ref SDS 53 256J  The prior study
740995 - 080212 reported the small bowel and colon appear unremarkable,
740996 - reviewed on 080215. ref SDS 48 RV51
740998 -  ..
740999 - Did hiatal hernia and diverticulosis develop within the past 12 weeks?
741001 -  ..
741002 - Hiatal Hernia Patient History....
741003 -
741004 -               1.  Small hiatal hernia noted without comment in CT test
741005 -                   on 041103, reported on 041104. ref SDS 12 QP6S
741006 -
741007 -               2.  Hiatal hernia cited without comment in CT test on
741008 -                   070131, reviewed on 070202. ref SDS 29 0156
741010 -  ..
741011 - Diverticulosis Patient History....
741012 -
741013 -               1.  Diverticulosis of the sigmoid colon noted without
741014 -                   comment in the CT test on 040410 and reviewed on
741015 -                   040416. ref SDS 7 7V4H
741016 -
741017 -               2.  Diverticulitis is an uncomfortable condition of
741018 -                   aging, that affects about 10% of the population.
741019 -                   Small pouches in the colon bulge outward through
741020 -                   weak spots, like an inner tube that pokes through
741021 -                   weak places in a tire.  When the pouches become
741022 -                   infected or inflamed, the condition is called
741023 -                   diverticulitis.  This happens in 10 to 25 percent of
741024 -                   people with diverticulosis.  Diverticulosis and
741025 -                   diverticulitis are also called diverticular disease,
741026 -                   reported in research on 070307. ref SDS 30 XG8H
741028 -                    ..
741029 -               3.  CT test 070326 finds bowel normal.  Diverticuli in
741030 -                   the sigmoid colon, reported on 070329. ref SDS 31
741031 -                   AP83
741033 -                    ..
741034 -               4.  CT test 070520 finds bowel normal.  Diverticuli in
741035 -                   the sigmoid colon, reported on 070524. ref SDS 32
741036 -                   SP65
741038 -                    ..
741039 -               5.  CT test 070726 finds sigmoid predominant
741040 -                   diverticular disease, reported on 070802.
741041 -                   ref SDS 33 813K
741043 -                    ..
741044 -               6.  CT test 071210 finds sigmoid diverticular are again
741045 -                   noted. reported on 071213. ref SDS 39 SS35
741046 -
741048 -  ..
741049 - Abdominal Aorta No Aneurysm
741050 - Splenic Artery Calcification Aneurysms
741051 -
741052 - Follow up ref SDS 53 R96N, ref SDS 48 N96N.
741054 -  ..
741055 - CT test 080718 report continues...
741056 -
741057 -        t.  No aneurysm of the abdominal aorta. Extensive calcification
741058 -            of the splenic artery with perhaps slight dilatation.
741059 -            ref DRT 1 F99J
741061 -             ..
741062 -            No significant lymphadenopathy and no ascites. ref DRT 1
741063 -            G49N
741064 -
741066 -  ..
741067 - The test on 080425 found calcification within normal caliber abdominal
741068 - aorta, reviewed on 080428. ref SDS 53 256J
741070 -  ..
741071 - Does calcification of splenic artery with dilatation align with the
741072 - test on 080425 that reported splenic artery aneurysms and infection,
741073 - reviewed on 080428? ref SDS 53 654O, citing alignment with findings
741074 - for the prior test on 080212 reviewed on 080215. ref SDS 48 N96N
741076 -  ..
741077 - What is the signficance of artery aneurysms and infection in the
741078 - spleen found on 080212, ref SDS 48 N96N, and reported again on 080425,
741079 - ref SDS 53 R96N, and not noted in the recent test on 080718, per
741080 - above. ref SDS 0 NC8N
741082 -  ..
741083 - Spine Lower Lumbar Degenertive Changes in Disks Facet Joints
741084 -
741086 -  ..
741087 - CT test 080718 report continues...
741088 -
741089 -        u.  There are also degenerative changes in the disks and facet
741090 -            joints of the lower lumbar spine. ref DRT 1 NC4L
741091 -
741093 -  ..
741094 - CT test 080718 report concludes...
741096 -  ..
741097 - May be Increased Lymph Nodes Right Axilla Interstitial Disease
741098 -
741099 -
741100 -    7.  IMPRESSION
741101 -
741102 -        Since 4/25/2008 and 2/12/2008 CT scans, I suspect there might
741103 -        be slight enlargement of the lymph nodes in the right axilla
741104 -        but the differences are slight and might even be explained by
741105 -        differences in slice selection.  There appears to be less
741106 -        prominence of the focus of interstitial disease in the mid
741107 -        right lung.  There might be slight worsening of a focus of
741108 -        interstitial disease in the medial aspect of the right lower
741109 -        lobe.  Since the prior studies, a different type of central
741110 -        catheter is now in place.  It was difficult in canulating this
741111 -        catheter.  There is contrast extravasation into the right chest
741112 -        wall before today's study. ref DRT 1 4L4O
741114 -  ..
741115 - Difficulties with using the Power Port are cited in Findings,
741116 - ref SDS 0 EO8F, and aligns with the report on performing the test
741117 - 080718. ref SDS 61 LK3R
741119 -  ..
741120 - Impression of possible slight enlargement of lymph nodes shows no
741121 - significant evidence that cancer is expanding, which aligns with
741122 - visible observations of IBC rash areas stable to subsiding, cited in
741123 - examination at UCSF on 080626. ref SDS 59 FH7M  Comparison of measured
741124 - nodes today, per above, shows 6 months stable condition since
741125 - February. ref SDS 0 4K5H
741126 -
741127 -        [On 080724 examination at UCSF finds stable to improving IBC
741128 -        disease based on rash conditions. ref SDS 64 FH7M
741130 -  ..
741131 - Interstitional lung disease seems stable, i.e., less and slightly
741132 - worse, may align with Millie's improved fitness from significantly
741133 - increased exercise the past 3 months.  This past week she hiked 40
741134 - miles.  Hopefully, Interstitional lung disease will continue to
741135 - recover, so that Millie can continue to benefit from Cetuximab.
741136 - ref SDS 0 TS4J
741137 -
741138 -
741139 -
741140 -
741141 -
741142 -
741143 -
741144 -
7412 -