CONTACTS 

SUBJECTS
Neupogen Side Effects Bone Pain Fatigue No Headache Suffered Today A

1503 -
1503 -    ..
1504 - Summary/Objective
1505 -
150501 - Follow up ref SDS C3 0000. ref SDS C0 0000.
150502 -
150503 -
150504 -
150505 -
150506 -
150508 -  ..
1506 -
1507 -
1508 - Progress
1509 -
150901 - Neupogen Treatment at Kaiser Prescribed at UCSF for Clinical Trial
150902 -
150903 - Follow up ref SDS C3 9W9I, ref SDS C0 9W9I.
150904 -
150905 - Background on missing treatment at UCSF due to low blood counts, and
150906 - requirements for Neupogen are reported in the record on 081016.
150907 - ref SDS A1 OK67
150909 -  ..
150910 - Case study on 060809 shows Millie has often received chemotherapy when
150911 - blood counts are below the standard for safe treatments, and on some
150912 - occassions has received Neupogen to increase blood counts. ref SDS 9
150913 - HV45
150915 -  ..
150916 - Research on neutropenia was reported on 070301, ref SDS 11 O59H, when
150917 - Doctor Rugo was concerned about holding blood counts with weekly
150918 - Carboplatin treatments. ref SDS 11 VF6O
150920 -  ..
150921 - Background on getting Neupogen treatment is reported in the record on
150922 - 081107. ref SDS C0 1M9O
150924 -  ..
150925 - Bonnie was Millie's nurse again today.
150927 -  ..
150928 - Bonnie asked Millie why she has missed Neupogen treatments since
150929 - 081108. ref SDS C3 UZ7K
150931 -  ..
150932 - Millie explained that on 080829 Doctor Johnson ordered a change in
150933 - treatment that was implemented at UCSF on 081016.  Millie was then off
150934 - treatment from 081023 until 081114.  On 081126 NEUTS had dropped to
150935 - 1.50 despite being off treatment for several weeks, and then starting
150936 - daily treatments with cyclophosphamide 50 mg on 081114. ref SDS C4
150937 - 505G   At that time, UCSF advised on 081126 that Neupogen would not be
150938 - needed until the next lab was done at UCSF scheduled for 081218, cited
150939 - in Millie's letter to the medical team on 081202. ref SDS C6 AT8U
150941 -  ..
150942 - Bonnie asked about the new treatment?
150944 -  ..
150945 - Bonnie indicated that 50 mg of cyclophosphamide is not a lot.  She
150946 - also seemed to indicate that methotrexate would not be expected to
150947 - decrease blood counts.  Bonnie was not familiar with sunitinib.
150949 -  ..
150950 - Millie explained the letter sent to the medical team this morning
150951 - reporting evident low blood counts. ref SDS C9 YF5I  She explained
150952 - that Kaiser's report to patients in the online system does not show
150953 - NEUTS (ANC at Kaiser).
150955 -  ..
150956 - Bonnie checked Kaiser's computer for results of the blood test at
150957 - Kaiser on 081203. ref SDS C7 7N82,
150959 -  ..
150960 - She said that WBC 2.4 reported in the record on 081205, ref SDS C8
150961 - OT8J), and neutrophils 26 are both very low.  Bonnie used a small
150962 - calculator to compute ANC 624, shown on 081205, ref SDS C8 QY6H, which
150963 - translates to NEUTS 0.624 at UCSF.
150965 -  ..
150966 - Background on 060810 shows formula for calculating ANC. ref SDS 9 GL4M
150967 - Formula was clarified on 060814. ref SDS 10 C56L
150968 -
150969 -                ANC = WBC x 1000 x (Neutrophils + Bands)
150971 -  ..
150972 - Bands are not reported in the test on 081203, as shown in the record
150973 - on 081205. ref SDS C8 M85G
150974 -
150975 -                ANC = 2.4 x 1000 x .26
150976 -
150977 -                ANC = 624
150979 -  ..
150980 - Bonnie advised that ANC 624 shows neutrophils are very low. indicating
150981 - Millie's immune system is weakened by neutropenia.  Weak immune system
150982 - causes fatigue and high risk for infection and disease, shown by
150983 - research on 070301, ref SDS 11 516G, that describes severe neutropenia
150984 - occurs with ANC below 500. ref SDS 11 R13I
150985 -
150986 -        [On 081205 UCSF notifies that Neupogen is needed with low
150987 -        neutrophils. ref SDS D0 JE5I
150989 -  ..
150990 - Bonnie asked Millie to wait while she consults with the doctor.
150992 -  ..
150993 - After about 15 minutes, Bonnie returned and reported that Millie's
150994 - primary care physician, Doctor Johnson, is out of the office until
150995 - 081208.  Bonnie asked for the doctor's backup, but evidently everyone
150996 - is at lunch, or possibly the backup is with a patient, or out of the
150997 - office also.  She said things are very hectic today.
150999 -  ..
151000 - Bonnie took Millie's vitals and observed very high blood pressure with
151001 - low pulse.  She feels this is not a good combination to give Neupogen,
151002 - and commented that Neupogen can cause high blood pressure, per below.
151003 - ref SDS 0 4C4F
151005 -  ..
151006 - She asked Millie to just relax and rest for a few minutes.  During
151007 - this time, Bonnie tended to other patients.
151009 -  ..
151010 - Bonnie left the area again to consult with a doctor.  She returned in
151011 - about 10 minutes and seemed to have authority to give Millie treatment
151012 - today. ref SDS 0 4C50
151014 -  ..
151015 - Bonnie took Millie's vitals again.  This time she indicated vitals are
151016 - within a safe range for Neupogen. ref SDS 0 KW95
151018 -  ..
151019 - After verifying Millie's vitals had settled to a safe level, per
151020 - review of side effects below, ref SDS 0 4C4F, Bonnie gave Millie 2
151021 - injections required for the 1st Neupogen treatment this week...
151022 -
151023 -            Neupogen 480 mcg SQ
151024 -
151025 - ...as shown in UCSF Chemotherapy Order on 080918, ref SDS 84 PWSY, and
151026 - ordered by primary care physician at Kaiser on 080609. ref SDS 39 L16I
151028 -  ..
151029 - Prior instructions describe Kaiser protocol for 480 mcg be given with
151030 - 2 injections, discussed on 080801 ref SDS 59 9W9I, and originally
151031 - presented by Laura on 080628. ref SDS 44 Q74G
151033 -  ..
151034 - Bonnie suggested asking UCSF for new guidance on Neupogen treatments,
151035 - since the prior protocol was related to weekly treatments on Thursday,
151036 - and now Millie is getting daily treatments with cyclophosmaide.  She
151037 - feels Millie's patient history of ANC 624 (NEUTS 0.624 at UCSF),
151038 - requires review for maintaining blood counts, based on treatments that
151039 - have reduced blood counts, shown in another record today. ref SDS C8
151040 - OE6K
151042 -         ..
151043 -        [On 081205 UCSF notifies that Neupogen should not be
151044 -        self-medicated and is needed with low neutrophils. ref SDS D0
151045 -        JE5I
151047 -  ..
151048 - Bonnie further recommended that Millie ask UCSF about adding a 3rd
151049 - Neupogen treatment next week to supplement the treatment today, and
151050 - treatment scheduled for tomorrow.
151052 -  ..
151053 - Bonnie suggested another blood test next week in advance of labs
151054 - scheduled at UCSF to start the next cycle on 081218, and in order to
151055 - assess requirements for increasing Neupogen again the following week
151056 - and further in order to increase blood counts to a safe level for
151057 - daily chemotherapy.
151059 -         ..
151060 -        [On 081205 Millie notifies UCSF that NEUTS 0.625 on blood test
151061 -        performed at Kaiser on 081203, and further asked UCSF about
151062 -        adding a 3rd Neupogen treatment next, and doing another blood
151063 -        test next week. ref SDS D1 NN6P
151065 -         ..
151066 -        [On 081205 UCSF responds to the letter on 081202, ref SDS C6
151067 -        AT8U, and the follow up today on 081205, ref SDS C9 YF5I - the
151068 -        doctor notified Millie not to self-medicate, and that Neupogen
151069 -        is needed when neutrophils are low. ref SDS D0 JE5I
151071 -         ..
151072 -        [On 081206 Millie submitted Kaiser's report for the blood
151073 -        test on 081203, and asked UCSF again about doing a 3rd
151074 -        Neupogen treatment with another lab test to verify recovery
151075 -        from low blood counts. ref SDS D2 2K6P
151077 -         ..
151078 -        [On 081209 Millie letter asks medical team about recommendation
151079 -        today on 081205 for another blood test during week of 081208 -
151080 -        081212 to evaluate further Neupogen treatments in advance of
151081 -        meeting at UCSF the following week on 081218. ref SDS D3 RL6W
151083 -         ..
151084 -        [On 081210 Arlette ordered follow up blood test. ref SDS D4
151085 -        616R
151087 -         ..
151088 -        [On 081210 Millie went to Kaiser and got laboratory work for
151089 -        a blood test. ref SDS D5 L84V
151091 -         ..
151092 -        [On 081210 blood test results show ANC 1085, below the target
151093 -        of 1500; letter to Kaiser asks primary care physician about
151094 -        getting 3rd Neupogent treatment on 081210, and 2 more regularly
151095 -        scheduled on 081212 and 081213? ref SDS D6 0Y4V
151097 -         ..
151098 -        [On 081210 primary care physician called Millie and advised
151099 -        that ANC 1085 in blood test on 081210 does not require
151100 -        Neupogen under Kaiser standards and practices until ANC
151101 -        falls below 1000, ref SDS D7 J43V; doctor ordered follow up
151102 -        blood test on 081212 to evaluate ANC below 1000 based on
151103 -        patient history indicating ANC falling 120+ points per day
151104 -        on sunitinib treatment protocol, which would cause ANC to
151105 -        drop below 500 without Neupogen until Millie's next
151106 -        scheduled lab at UCSF on 081218. ref SDS D7 H44M
151107 -
151108 -
151109 -
151110 -
151111 -
1512 -

SUBJECTS
Default Null Subject Account for Blank Record

1603 -
160401 -  ..
160402 - Schedule Neupogen Treatments Extended through August
160403 -
160404 - Follow up ref SDS C3 WJ4O, ref SDS C0 WJ4O.
160405 -
160406 - Millie's schedule for Neupogen treatments was last updated on 081018.
160407 - ref SDS A4 WJ4O
160409 -  ..
160410 - Treatment today and tomorrow are shown in the schedule. ref SDS A4
160411 - YU4H
160413 -  ..
160414 - During the meeting today, Bonnie scheduled Millie for Neupogen through
160415 - 090109.
160417 -  ..
160418 - Bonnie indicated she will extend this schedule through February after
160419 - the meeting today...
160420 -
160421 -                                    UCSF Treatment Prescription
160422 -                                              Cyclophos  Metho
160423 -                         Neupogen  Sunitinib   phamide   trexate
160424 -    #   Date    Time NEUTS   MCG    #    MG    #    MG    #   MG
160425 -   ================================================================
160426 -    1.  081205  1300 0.624   480   22  826.0   8    400   3   15 .. ref SDS C8 PY5I
160427 -    2.  081206  0900         960
160428 -    3.  081212  1300        1540
160429 -    4.  081213  0900        2020
160430 -    5.  081219  1300        2500
160431 -    6.  081220  0900        2980
160432 -    7.  081226  0930        3460
160433 -    8.  081227  0930        3940
160434 -    9.  090102  0800        4420
160435 -   10.  090103  0930        4900
160436 -   11.  090109  0830        5380
160437 -
160438 -
160439 -
1605 -

SUBJECTS
Default Null Subject Account for Blank Record

1703 -
170401 -  ..
170402 - Side Effects Neupogen Treatments Increase May Be Chemotherapy
170403 -
170404 - Follow up ref SDS C3 SB8I, ref SDS C0 SB8I.
170405 -
170406 - Research on Neupogen side effects was reported on 080629. ref SDS 44
170407 - RQ9I
170409 -  ..
170410 - Millie last reported side effects on 081018 experiencing bone pain,
170411 - headache, and fatigue associated with Neupogen and chemotherapy.
170412 - ref SDS A4 Y17L
170414 -  ..
170415 - Bonnie reported vitals today...
170416 -
170417 -               BP  167 93   Pulse  46  Temp  96.7
170419 -  ..
170420 - Bonnie was concerned that this diagnostic event presents "high"
170421 - vitals.  She seemed to indicate that that giving Millie Neupogen today
170422 - would further increase blood pressure.  Bonnie asked Millie to sit
170423 - back and relax for a few minutes.  During this time, she treated other
170424 - chemotherapy patients.
170426 -  ..
170427 - Millie explained blood pressure was much lower taken this morning at
170428 - home On 081205. ref SDS C8 5X6K
170430 -  ..
170431 - Bonnie left the area to get advice from a doctor.  She returned in
170432 - about 10 minutes, and indicated Millie's Neupogen treatment today was
170433 - approved, based on low blood counts.
170435 -  ..
170436 - Bonnie took Millie's vitals again and got...
170437 -
170438 -               BP  158 79   Pulse  49  Temp  96.9
170440 -  ..
170441 - She decided this was a safe level for Neupogen based on discussions
170442 - with the doctor.
170444 -  ..
170445 - Side effects of Neupogen may be increasing, reported on...
170446 -
170447 -               081205................, ref SDS 0 Y17L
170448 -               081018................, ref SDS A4 Y17L
170449 -               081011................, ref SDS 97 FL4H
170450 -               081010................, ref SDS 96 SB8I
170451 -               081006................, ref SDS 94 3E4K
170452 -               081004................, ref SDS 93 Y17L
170453 -               081002................, ref SDS 91 Y17L
170454 -               080930................, ref SDS 90 Y17L
170455 -               080923................, ref SDS 86 K16F
170456 -               080915................, ref SDS 82 9W9I
170457 -               080810................, ref SDS 64 9W9I
170458 -               080803................, ref SDS 60 9W9I
170459 -               080726................, ref SDS 57 9W9I
170460 -               080721................, ref SDS 55 9W9I
170461 -               080713................, ref SDS 49 RM94
170462 -               080629................, ref SDS 44 6Q5J
170463 -               080628................, ref SDS 42 6Q5J
170464 -
170465 -
170466 -
170467 -
170468 -
170469 -
1705 -