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: December 19, 2008 11:40 AM Friday; Rod Welch

Millie meeting primary care physician Kaiser cancer progress review

1...Summary/Objective
2...Thinking Through Writing Advancing at Kaiser
3...Medical Chart Reports Examination Diagnosis Prescription Prognosis


..............
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CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 74 0000. ref SDS 51 XZ8W.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Regular 8 week visit, following up meeting at Kaiser on 081024.
040902 - ref SDS 50 0001, which was explained to the medical team in a letter
040903 - dated 081027. ref SDS 53 OS87  This meeting reviews progress reported
040904 - in the meeting yesterday at UCSF on 081218. ref SDS 72 5G5H
040906 -  ..
040907 - The doctor was sick today with a cold or the flu.  He described
040908 - illness as emotional reaction to buying a new house and moving.
040909 - Seemed to say the move is only down the street, so this would seem
040910 - like the smallest impact, compared to moving across town, to a new
040911 - town, or another state.  Moving in has been delayed while contractors
040912 - perform repairs and additions.  This remedial work has taken more time
040913 - than expected because more problems have been discovered that have to
040914 - be fixed.  Investigating and authorizing additional work, inspecting
040915 - performance, and resolving disputes takes a lot of time and effort
040916 - that cause delays and frustrations.  Managing contractors can be
040917 - complex, which increases emotional trauma, especially if the owner has
040918 - to move from the existing home before the new one is ready for
040919 - occupancy.  Since health care is very complex work with high anxiety
040920 - and stress, adding financial and logistics pressure of home
040921 - procurement, managing contractors, and moving creates stress that
040922 - overwhelm the body's natural immune system for many people.
040923 -
040924 -     [On 090121 Arlette was out sick and so had problems getting report
040925 -     on Millie's EKG test in the Cardiology Department. ref SDS 89 DM5J
040927 -  ..
040928 - The doctor had to leave the examination room several times in order to
040929 - sneeze without creating health risks for Millie who is a stage IV
040930 - cancer patient with very low blood counts that reduce immunity, and so
040931 - Millie is very high risk for infectious diseases.
040933 -  ..
040934 - The doctor received Millie's letter to the medical team on 081218
040935 - reporting Doctor Rugo prescribed blood tests at Kaiser on 081226 to
040936 - follow up the test yesterday on 081218 at UCSF, ref SDS 71 YN8O, and
040937 - to evaluate the treatment plan for Millie recovering from IBC.
040938 - ref SDS 74 GF5X, and further implementing planning during the meeting
040939 - at UCSF earlier in the day on 081218. ref SDS 72 BQ8F
040941 -  ..
040942 - The doctor used the computer in the examination room to order the
040943 - blood test on 081226.  Doctor Johnson asked for the time Millie is
040944 - scheduled to get Neupogen at Kaiser on 081226?  Since Millie was
040945 - already scheduled to get Neupogen on 081226 0930, reported earlier
040946 - today on 081219, ref SDS 76 HS5M, the doctor used the existing
040947 - schedule to include the blood draw as a predicate to assess
040948 - requirements for Neupogen.
040949 -
040950 -        [...below in this record on 081219 1140 Doctor Johnson explains
040951 -        rationale for ordering blood tests at Kaiser prescribed for
040952 -        Millie yesterday at UCSF to evaluate changing treatment levels
040953 -        that optimize recovery and minimize side effects. ref SDS 0
040954 -        545J
040956 -         ..
040957 -        [On 081223 2323 Millie's letter notifies medical team that
040958 -        blood test prescribed by Doctor Rugo at UCSF was ordered by
040959 -        Doctor Johnson at Kaiser. ref SDS 78 BV5P
040961 -  ..
040962 - The doctor included testing to cross-check findings for CA 15-3 95
040963 - reported for the labs at UCSF yesterday on 081218, ref SDS 71 A16M
040964 - The test on 081226 can be directly compared to the previous test at
040965 - Kaiser on 081210 that reported CA 15-3 197, ref SDS 65 PQTQ, which is
040966 - nearly double the previous high in Millie's 7 year history of cancer.
040968 -  ..
040969 - The doctor seemed to indicate today that sudden significant increase
040970 - in the cancer marker can result when drug treatment kills a lot of
040971 - cancer cells in a short time.  This releases all at once a lot of the
040972 - protien measured by the cancer marker.  Since Millie has experienced a
040973 - significant reduction of IBC inflammation, this might be why CA 15-3
040974 - 197 occurred for the lab at Kaiser on 081210. ref SDS 65 PQTQ
040976 -  ..
040977 - The primary care physician also added testing for lipid panel that
040978 - evaluates cholesterol for impacts on heart and circulatory systsms.
040980 -  ..
040981 - The doctor was very pleased with examination today finding substantial
040982 - progress for Millie recovering from IBC compared with examination at
040983 - Kaiser on 081024 that showed severe advancing cancer causing Millie's
040984 - 5th relapse of IBC, cited in Millie's letter to the medical team at
040985 - that time. ref SDS 51 XZ8W  Findings at Kaiser today align with the
040986 - examination at UCSF yesterday on 081218, ref SDS 72 QX44, including
040987 - reduced lyphm node in the left supraclavicular, ref SDS 72 QW6U, and
040988 - reported in Millie's letter to the medical team, also, on 081218.
040989 - ref SDS 74 4P7F
040990 -
040991 -        [...below in this record on 081219 medical chart reports
040992 -        examination finding reduced IBC rash, ref SDS 0 HT6Y, and no
040993 -        palpable LN in neck nor axillary. ref SDS 0 HT6V
040995 -         ..
040996 -        [On 081223 2323 Millie's letter to the medical team reported
040997 -        favorable and concurring opinion from Doctor Johnson with UCSF
040998 -        assessment the day before on 081218 that IBC has responded to
040999 -        treatment with the sunitinib clinical study. ref SDS 78 BV4T
041001 -         ..
041002 -        [On 090109 0027 Millie's letter to the medical team reports
041003 -        examination at UCSF the day before on 090108 found significant
041004 -        relapse of IBC. ref SDS 84 UE6R
041006 -         ..
041007 -        [On 090213 1140 Doctor Johnson examination at Kaiser finds
041008 -        severe progression of IBC, ref SDS A8 4W5I, complete reversal
041009 -        from favorable recovery observed today, per above. ref SDS 0
041010 -        3L9L
041012 -         ..
041013 -        [On 090325 0830 Doctor Johnson indicates examination
041014 -        finding reduced IBC symptoms and decline of cancer marker
041015 -        CA 15-3 251 for first time in over a year signal strong
041016 -        response to treatment with radiation and hyperthermia begun
041017 -        on 090219 and completed on 090317. ref SDS B3 P369
041019 -  ..
041020 - The doctor received Millie's letter to Kaiser sent this morning
041021 - requesting support, ref SDS 75 KY8Q, for planning at UCSF yesterday on
041022 - 081218 to end all treatments with Methotrexate, ref SDS 72 QW48, to
041023 - reduce sunitinib treatments and to maintain cyclophosphamide
041024 - chemotherapy at originally prescribed amounts, ref SDS 72 BQ8F, and as
041025 - further stated in Millie's letter to Kaiser this morning. ref SDS 75
041026 - SU9Q
041028 -             ..
041029 -            [...below, medical chart agrees on ending treatment with
041030 -            methotrexate. ref SDS 0 YH8O
041032 -  ..
041033 - The doctor printed Millie's letter.  During the meeting he read the
041034 - request for assistance evaluating changes to the amount (i.e., dose)
041035 - of drugs for treating's Millie's cancer, and which says in part...
041036 -
041037 -        1.  As you know, meetings with doctors are emotional.  I find
041038 -            it difficult to think clearly, especially on complex issues
041039 -            that affect how I feel.  What I wanted yesterday was
041040 -            consideration of alternate scenarios, but since there
041041 -            wasn't enough time, I simply agreed to what was proposed.
041042 -            ref SDS 75 SU8X
041044 -             ..
041045 -        2.  Yesterday, Doctor Rugo paused treatment for a week, and
041046 -            ended treatment entirely with Methotrexate.  This gives
041047 -            blood counts time to recover, along with Neupogen treatment
041048 -            approved for today and tomorrow. ref SDS 4 QW48
041050 -             ..
041051 -        3.  My concern is with dosage of sunitinib and cyclophosphamide
041052 -            starting up again next week on 081226.  There seem to be
041053 -            competing issues.  On the one hand, it seems that sunitinib
041054 -            has been the major contributor to my recovery.  Significant
041055 -            improvement occurred after the first 14 days of sunitinib
041056 -            alone, reported during examination at UCSF on 081126 [cited
041057 -            in the letter to the medical team on 081202. ref SDS 1 YJ3G
041059 -  ..
041060 - The doctor recalled today findings in the left supraclavicular during
041061 - examination at Kaiser on 080829 that indicated progression of cancer,
041062 - signalling Millie's 5th relapse of IBC. ref SDS 44 RP8T  Multiple
041063 - relapse of cancer presents a dilemma that cancer cells, which survived
041064 - 5 years of treatments at Kaiser, and 2 years at UCSF, have mutated
041065 - into a more aggressive, robust disease that is highly resistant to
041066 - chemotherapy drugs approved for use at Kaiser.  Therefore, on 080829
041067 - the doctor referred Millie's care to UCSF for innovation to prescribe
041068 - a "targeted" drug. ref SDS 44 RP9W  About 2 months later, UCSF
041069 - performed Kaiser's referral.  On 081016 UCSF prescribed the sunitinib
041070 - protocol with cyclophosphamide and Methotrexate. ref SDS 47 J38U
041072 -  ..
041073 - Millie thanked Doctor Johnson today for working hard collaborating to
041074 - implement the UCSF work plan, also, listed on 081016. ref SDS 47 J36R,
041075 - Kaiser performed a wide variety of tests that required hundreds of
041076 - tasks to manage the work.  For example, the biopsy to evaluate status
041077 - change required 50 tasks, listed on 081016. ref SDS 47 W26G  This
041078 - explains why doctors and other hospital staff suffer a high rate of
041079 - illness coping with stress performing complex health care procedures,
041080 - illustrated by the doctor's case today, per above. ref SDS 0 QW5J
041082 -  ..
041083 - The doctor was disappointed today that timely diagnosis of Millie's
041084 - cancer getting worse (progression), and planning for referral to UCSF
041085 - in the meeting at Kaiser on 080829 was frustrated by delays starting
041086 - sunitinib treatment at UCSF 70 days later on 081114. ref SDS 61 505G
041087 - Millie was fortunate that examination today finding favorable
041088 - response, per above, ref SDS 0 3L9L, indicates that despite delays,
041089 - treatment started in time to be effective.
041091 -  ..
041092 - The doctor explained again that Millie's cancer has now mutated
041093 - through multiple relapses into a much more aggressive disease.  He
041094 - feels that treatment for the next relapse of IBC must be started
041095 - quickly in order to be effective controlling rapidly expanding cancer
041096 - cells.  This was discussed previously on 081024. ref SDS 50 BO9F
041097 -
041098 -        [On 090122 2314 message from Glenna advises Doctor Rugo
041099 -        diagnoses Millie has suffered 6th relapse of IBC and requires
041100 -        starting new treatment next week on 090129. ref SDS 91 J47F
041102 -         ..
041103 -        [On 090123 1326 Doctor Johnson calls and concurs Millie has
041104 -        suffered IBC relapse with cancer marker CA 15-3 303 in blood
041105 -        test on 090116 at Kaiser; confirms Millie's cancer has mutated
041106 -        to resist treatments available at Kaiser, authorizes UCSF to
041107 -        prescribe next treatment. ref SDS 92 RK6O
041109 -         ..
041110 -        [On 090204 0219 Millie's letter asks Doctor Rugo to submit
041111 -        proactive planning for follow on treatment after hyperthermia
041112 -        and Doxil for Millie's 6th relapse of IBC. ref SDS 99 278T
041114 -         ..
041115 -        [On 090213 1140 doctor attributes sudden rapid advance of IBC
041116 -        after significant recovery signals mutated cancer into much
041117 -        more aggressive disease that requires getting treeatment in
041118 -        time to be effective. ref SDS A8 GC6N
041120 -         ..
041121 -        [On 090213 1140 Doctor Johnson authorizes Kaiser support for
041122 -        proactive planning at UCSF to treat Millie's next relapse of
041123 -        IBC as a chronic disease, ref SDS A8 GD3I, and approved meeting
041124 -        with Doctor Rugo at UCSF to start research so that treatment
041125 -        can begin in time to be effective. ref SDS A8 WZ6K
041127 -         ..
041128 -        [On 090218 1205 Millie's letter notifies medical team that
041129 -        Doctor Johnson has ordered Millie's continued care at UCSF,
041130 -        citing prior instructions on 080829, 081026, 081219, and on
041131 -        090123, all authorizing UCSF to begin planning for Millie's
041132 -        next treatment, so that past delays are avoided, because
041133 -        Millie's cancer has mutated through multiple relapses (total of
041134 -        7 so far) into a very aggressive disease which requires
041135 -        treatment quickly in order to be effective. ref SDS A9 TH6U
041137 -  ..
041138 - The doctor asked when Millie is scheduled to meet with Doctor Rugo at
041139 - UCSF?  He is disappointed, but not surprised that UCSF has not sent a
041140 - list of follow on treatments requested on 080829, ref SDS 43 PX5V, and
041141 - again during the meeting at Kaiser on 081024. ref SDS 50 BO9F
041142 - Millie's letter to the medical team on 080829 confirmed that Kaiser
041143 - asked UCSF for a list of treatments for Millie's future relapses.
041144 - ref SDS 44 RP9R  On 081016, Doctor Rugo seemed to say that she has
041145 - prepared a list of many treatments for Millie. ref SDS 47 NW6M
041147 -  ..
041148 - Millie said today that the next meeting is in 3 weeks on 090108, shown
041149 - in the UCSF schedule reported in the record on 081218. ref SDS 71 PN6F
041151 -  ..
041152 - Doctor Johnson said Millie should ask Doctor Rugo to start planning
041153 - immediatlely for the next treatment.  He feels work should begin now
041154 - while things are going well with sunitinib treatment, as seen today,
041155 - per above. ref SDS 0 3L9L  Proactive planning provides enough time to
041156 - innovate prescribing multi-agent, "targeted" treatment at UCSF that
041157 - will be effective for Millie's next IBC relapse, as discussed during
041158 - the meeting at Kaiser on 081024.  At that time, the doctor explained
041159 - Kaiser does not have treatments for Millie to recover because her
041160 - cancer has mutated through 5 relapses to become a much more aggressive
041161 - disease that resists treatments available at Kaiser. ref SDS 50 BO9F
041163 -  ..
041164 - The doctor wants a letter from Doctor Rugo recommending Millie's next
041165 - treatment, so that he can expedite the process at Kaiser authorizing
041166 - referral.  The doctor feels that getting a letter from UCSF at this
041167 - time will help avoid delays that occurred starting Millie's treatment
041168 - at UCSF in January 2007, shown by case study on 070130. ref SDS 27
041169 - RM4G  The same thing happened transitioning to sunitinib treatment,
041170 - shown on 081029. ref SDS 54 NQ7L  Doctor Johnson explained that
041171 - treating cancer as a "chronic disease" to extend survival and quality
041172 - of life requires planning now for treating Millie's 6th relapse of IBC
041173 - to go smoothly, rather than be delayed again with mind numbing stress
041174 - and trauma that occurred on 081112, when everybody was scrambling at
041175 - Kaiser and UCSF one (1) day before Millie needed to start treatment,
041176 - which had already been delayed a month. ref SDS 56 FJ5J
041178 -         ..
041179 -        [On 090121 1017 Glenna called and advised that Doctor Rugo
041180 -        wants a list from the patient of UCSF treatment plans for
041181 -        Millie's future relapses. ref SDS 88 Y67L
041183 -         ..
041184 -        [On 090123 1326 Doctor Johnson complimented Doctor Rugo
041185 -        for proactive case management getting a list for
041186 -        treating Millie's cancer as a chronic disease.
041187 -        ref SDS 92 VK6O
041189 -         ..
041190 -        [On 090129 0800 Doctor Rugo wrote a letter to Kaiser explaining
041191 -        next treatment with hyperthermia and Doxil for Millie to
041192 -        recover from 6th relapse of IBC, cited in Millie's letter to
041193 -        the medical team on 090130.
041195 -         ..
041196 -        [On 090205 1318 Doctor Johnson wants better communication for
041197 -        coordinating treatment at UCSF of Millie's 6th IBC relapse,
041198 -        so that critical details do "fall through the cracks."
041199 -        ref SDS A5 256K
041201 -         ..
041202 -        [On 090213 1140 Doctor Johnson authorizes Kaiser support for
041203 -        proactive planning at UCSF to treat Millie's next relapse of
041204 -        IBC as a chronic disease, ref SDS A8 GD3I, and approved meeting
041205 -        with Doctor Rugo at UCSF to start research so that treatment
041206 -        can begin in time to be effective. ref SDS A8 WZ6K
041208 -  ..
041209 - Millie proposed that instead of the patient sending a letter to UCSF
041210 - on behalf of Kaiser, that Doctor Johnson, Millie's primary care
041211 - physician, make arrangements notifying Doctor Rugo directly of
041212 - Kaiser's referral authorization, and request planning so that the next
041213 - treatment can start in time to be effective.  Millie cited the record
041214 - of patient history on 061230.  At that time on 061230, Doctor Johnson
041215 - and Doctor Rugo corresponded directly to make the original
041216 - arranagements for UCSF to treat Millie on referral from Kaiser.
041217 - ref SDS 26 086H
041219 -  ..
041220 - Why can't the doctor at Kaiser correspond directly with the doctor at
041221 - UCSF again this time?
041223 -  ..
041224 - Doctor Johnson recalled that despite initial direct correspondence
041225 - with Doctor Rugo at UCSF on 061230, there were delays at Kaiser
041226 - finalizing authorization for Millie's treatment at UCSF in January
041227 - 2007, shown by case study on 070130. ref SDS 27 2W58  Delayed
041228 - treatment allowed Millie's cancer to worsen, which caused Doctor Rugo
041229 - to feel the medical team nearly lost control of Millie's cancer,
041230 - reported on 070301. ref SDS 29 LB5L
041232 -  ..
041233 - The doctor feels that any delay starting Millie's next treatment for a
041234 - 6th relapse would be very serious.  Planning today for proactive steps
041235 - that avoid delay starting treatment for the next relapse, are prudent
041236 - because Millie's cancer has mutated into a much more aggressive
041237 - disease that now makes delay the same as denial of care.
041239 -             ..
041240 -            [On 090130 1453 UCSF called Millie to schedule hyperthermia
041241 -            treatment in the Radiation Oncology Department, and said
041242 -            that UCSF has not received referral authorization from
041243 -            Kaiser. ref SDS 93 NM5H
041245 -             ..
041246 -            [On 090130 1722 Millie's letter to primary care physician
041247 -            advises UCSF reported communication delay prevented getting
041248 -            referral from Kaiser, which then delayed starting
041249 -            hyperthermia treatment on 090129 in time to be effective.
041250 -            ref SDS 94 AY8Q
041252 -             ..
041253 -            [On 090201 1852 Millie letter reports to medical team 6th
041254 -            relapse IBC getting worse by the hour requires immediate
041255 -            treatment to prevent cancer from getting out of control.
041256 -            Rising pain from IBC makes sleeping difficult. ref SDS 95
041257 -            KN9T
041259 -             ..
041260 -            [On 090202 0920 UCSF called in the morning, and said Kaiser
041261 -            has not submitted authorization for Millie's treatment by
041262 -            Doctor Hsu. ref SDS 97 9Y5I  Michelle asked the patient to
041263 -            coordinate with the primary care physician at Kaiser to
041264 -            file Authorization, ref SDS 97 9Y6Y, reported in Millie's
041265 -            letter to the medical team later on 090202 1028.
041266 -            ref SDS 98 GV4M
041268 -             ..
041269 -            [On 090202 1437 IBC disease has advanced significantly
041270 -            since examination at UCSF on 090129, and pain on chest is
041271 -            rising.  Since Doctor Rugo has much more experience with
041272 -            IBC, if this just "looks bad," but delaying treatment to
041273 -            090219 presents no risk of losing control, then I am fine
041274 -            with waiting until the 19th. ref SDS A0 R23S
041276 -             ..
041277 -            [On 090202 1732 Doctor Rugo notifies medical team that
041278 -            Millie needs urgent treatment quickly to be effective.
041279 -            ref SDS A1 Y15J
041281 -             ..
041282 -            [On 090203 1417 Millie asks medical team whether treatment
041283 -            at UCSF can be advanced from 090219.  If not, is the
041284 -            medical condition urgent enough to require another
041285 -            provider, and, if so, is VCI a good choice under the
041286 -            circumstances?  Is there another way to get this work done
041287 -            in time to be effective? ref SDS A2 IS5V
041289 -             ..
041290 -            [On 090203 1438 Jennette with UCSF Radiation Oncology
041291 -            Department called back and advised that Doctor Hsu advanced
041292 -            Millie's hypertermia treatment by 3 weeks to begin on
041293 -            090205 in time to be effective recovering from 6th relapse
041294 -            of IBC, ref SDS A3 XX5I, rather than risk waiting until
041295 -            090219, as UCSF initially proposed on 090202 1357.
041296 -            ref SDS 99 XO7G
041298 -             ..
041299 -            [On 090312 during examination at UCSF Tara advised that
041300 -            Millie's response to the sunitinib treatment changed
041301 -            quickly from strong recovery, reported today, per above,
041302 -            ref SDS 0 3L9L, to significant spread of disease, because
041303 -            her cancer has mutated into a much more aggressive disease.
041304 -            ref SDS B2 XJ4I,
041306 -  ..
041307 - Doctor Johnson explained that Millie's letter on 080829 was effective
041308 - coordinating the medical team at Kaiser about requirements for Millie
041309 - to change treatment on referral to UCSF. ref SDS 44 RP9R  He recalled
041310 - that his oncology referral in July, went smoothly because Millie
041311 - provided patient hisory that helped the Surgery Department understand
041312 - what was needed, reported on 080605. ref SDS 36 635W  Later, on 081024,
041313 - the doctor asked Millie to coordinate complications doing the test in
041314 - the CT Department on 081107 using Millie's Power Port. ref SDS 52 V58K
041316 -  ..
041317 - The doctor feels that Millie's record of patient history for two (2)
041318 - years at UCSF supports the doctor/patient partnership that enables
041319 - timely, effective communication, and that good business relations
041320 - between Kaiser and UCSF will help the extended medical team work
041321 - smoothly together so that Millie's next treatment is not delayed.  The
041322 - doctor said that delays moving into his new home are frustrating,
041323 - discussed earlier, per above, ref SDS 0 QW5J, but delay starting
041324 - Millie's next treatment could be fatal.
041326 -  ..
041327 - The doctor asked Millie again to coordinate getting a letter from
041328 - Doctor Rugo recommending Millie's next treatment, so that care can
041329 - start in time to be effective.  The doctor indicated that a letter
041330 - from Doctor Rugo at UCSF will support the referral process at Kaiser.
041331 - He recalled today the letter from Doctor Rugo's associate, Doctor
041332 - Benz, reporting to Kaiser on Millie's 2nd opinion consultation at UCSF
041333 - on 060821. ref SDS 22 0001  Millie later received a copy of UCSF 2nd
041334 - opinion treatment proposals from Doctor Johnson during a meeting at
041335 - Kaiser on 060929, ref SDS 23 6L9O, Several months later on 061208,
041336 - Millie needed to change treatments.  By that time, Kaiser had
041337 - misplaced the UCSF report, so Doctor Johnson asked Millie for a copy
041338 - of the Benz 2nd opinion to support his referral for Kaiser to
041339 - authorize Millie's care at UCSF in 2007. ref SDS 25 P270  He wants
041340 - another letter from Doctor Rugo to support the next treatment
041341 - referral.
041343 -             ..
041344 -            [On 090122 Doctor Rugo orders ending Millie's treatment
041345 -            with sunitinib, because cancer is progressing rapidly, and
041346 -            side effects have become difficult to tolerate. ref SDS 91
041347 -            AT6N
041349 -             ..
041350 -            [On 090130 Millie's letter to medical team reports Doctor
041351 -            Rugo's letter on 090129 sent to Kaiser, ref SDS 94 AY9Q,
041352 -            with diagnosis of Millie's 6th relapse of IBC suffering
041353 -            rising pain, ref SDS 94 TZ6H; prescribes treatment with
041354 -            hyperthermia and doxil to implement Kaiser's referral
041355 -            strategy for continuing treatment at UCSF. ref SDS 94 TZ6H
041357 -             ..
041358 -            [On 090220 case study shows 103 tasks required to start
041359 -            Millie's treatment for the 6th relapse of IBC. ref SDS B0
041360 -            4V5M
041362 -  ..
041363 - Millie asked about immediate issues surrounding changing treatment
041364 - levels by ending Methotrexate, pausing all treatments for a week,
041365 - lowering the dose of sunitinib, and continuing original dose of
041366 - cyclophosphaide.  How will this proposed change effect optimizing
041367 - recovery, as shown in her letter to Kaiser this morning, per above.
041368 - ref SDS 0 5E4K
041369 -
041370 -            [...below, medical chart cites discussion of changing
041371 -            treatment levels for IBC. ref SDS 0 465J
041373 -  ..
041374 - The doctor noted the record meeting at UCSF yesterday on 081218, which
041375 - discussed changing the treatment plan to maintain recovery and reduce
041376 - side effects from the sunitinib protocol. ref SDS 72 R65H   The doctor
041377 - recalled poor results at Kaiser reducing the dose of capecitabine in
041378 - 2006, after getting very good results the year before using the full
041379 - dose, cited in the record yesterday at UCSF on 081218. ref SDS 72 EL6I
041380 - The primary care physician also recalled that Millie responded well to
041381 - the full dose of Carboplatin prescribed with cetuximab on referral to
041382 - UCSF earlier this year in March, April, and May, and that progression
041383 - of disease occurred when the dose was reduced on 080519, also,
041384 - reported in the record meeting at UCSF yesterday on 081218.
041385 - ref SDS 72 R667
041387 -  ..
041388 - Doctor Johnson concurred with Doctor Rugo's order during the meeting
041389 - yesterday at UCSF on 081218 1000 to pause Millie's treatment with all
041390 - chemotherapy on the sunitinib protocol, including cyclophosphamide,
041391 - and Methotrexate. ref SDS 72 QW48  He agrees that a week of rest from
041392 - daily chemotherapy will enable blood counts to recover from cellular
041393 - elements that have been persistently low the past few weeks, shown by
041394 - the lab at UCSF yesterday on 081218 0800. ref SDS 71 075H
041395 -
041396 -            [...below in the record today on 081219 1140 medical chart
041397 -            explains chemotherapy paused for a week and reduced in
041398 -            response to expansing low blood counts because cytopenia
041399 -            risks fatal infection. ref SDS 0 465J
041401 -     ..
041402 -    Log#:                   081218 08:30
041403 -    <----------------------- U C S F -----------------------> <-------------  Kaiser -------------->
041404 -    Type                 Results   Units        Normal        ACRO   Type            Units        Normal
041405 -    WBC COUNT      L        2.2    x10E9/L     3.4  -   10     WBC   WBC x10-3        K/uL     3.4  -  10.0
041406 -    RBC COUNT      L        2.79   x10E12/L      4  -   5.2    RBC   RBC x10-6        M/uL    3.60  -  5.70
041407 -    HEMOGLOBIN     L       10.2    g/dL         12  -   15.5   HGB   Hemoglobin       g/dL    11.5  -  15.0
041408 -    HEMATOCRIT     L       27.7    PERCENT      36  -   46     HCT   Hematocrit       %       34.0  -  46.0
041409 -    PLATELETS      L       67      x10E9/L     140  -  450     PLT   Plt x10-3        K/uL     140  -  400
041410 -    NEUTS          L        0.74   x10E9/L     1.8  -  6.8     N-A   ANC                      1500
041411 -    MONOS          L        0.07   x10E9/L     0.2  -  0.8     M-A   Monocyte          %         0  -  11
041412 -    CARBON DIOX TL L       21      mmol/L       23  -  32      CO2
041413 -    CALCIUM        L        8.3    mg/dL       8.7  - 10.1     CA    Calcium           mg/dL   8.4  - 10.2
041415 -  ..
041416 - The doctor explained that Millie's low blood cell counts present
041417 - diagnosis of "cytopenia" which risks infection of fatal disease.
041418 - Symptoms in recent weeks of chronic fatigue, muscle weakness, and
041419 - severe loss of vitality and vigor caused by chemotherapy found during
041420 - examination at UCSF yesterday on 081218, ref SDS 72 QW7H, including
041421 - nose bleed, ref SDS 72 WS8O, demonstrate rising symptoms of low blood
041422 - counts, as set out in Millie's letter to the medical team on findings
041423 - during the meeting with UCSF yesterday. ref SDS 74 KT6J
041425 -             ..
041426 -            [On 090106 1136 Millie's letter to the medical team
041427 -            submitting agenda for meeting at UCSF reports continuing
041428 -            fatigue, muscle weakness, loss of vitality and vigor
041429 -            associated with chemotherapy, ref SDS 83 YO4S, due to
041430 -            expanding low blood counts that cause cytopenia.
041431 -            ref SDS 83 YO4Y
041433 -             ..
041434 -            [On 090109 Millie letter to medical team reports blood
041435 -            counts very low again, NEUTS 0.87, confirms UCSF treatment
041436 -            plan on 090108 continues sunitinib at full strenth, and
041437 -            pauses cyclophosphamice until blood counts rise to NEUTS
041438 -            1.00. ref SDS 84 UF3Q
041440 -             ..
041441 -            [On 090115 1522 Millie's letter reports continued side
041442 -            effects from chemotherapy that reflects continuing low
041443 -            blood counts that risk cytopenia. ref SDS 86 5J9Y
041445 -             ..
041446 -            [On 090122 0925 Millie suffers fall during aerobics
041447 -            exercise at the gym due to fatigue and muscle weankess
041448 -            caused by low blood counts, ref SDS 90 CW6J; suffered
041449 -            severe pain, ref SDS 90 WS7T, and treated for dislocated
041450 -            shoulder at Emergency Room Department, ref SDS 90 W05P
041452 -             ..
041453 -            [On 090122 2312 Glenna calls leaves message while Millie
041454 -            being treated in ER Department for separated shoulder that
041455 -            Doctor Rugo ended chemotherapy with sunitinib protocol due
041456 -            to progression of disease; should begin to relieve side
041457 -            effects of rising fatigue and low counts. ref SDS 91 AT6N
041459 -             ..
041460 -            [On 090212 0017 Millie's letter to medical team reports
041461 -            rising fatigue, ref SDS A7 1N3U, even after ending
041462 -            chemotherapy on 090122, ref SDS 91 AT6N, and hoping does
041463 -            not signal cancer cascading out of control with CA 15-3 303
041464 -            at Kaiser on 090116, ref SDS 87 PQTQ, cited by primary care
041465 -            physician at Kaiser on 090123. ref SDS 92 RK6O
041467 -             ..
041468 -            [On 090213 1140 Doctor Johnson explains risks of cytopenia
041469 -            and pancytopenia that reduce energy, fitness, and muscle
041470 -            strength, which contributed to Millie's fall and dislocated
041471 -            shoulder. ref SDS A8 HG8O
041473 -             ..
041474 -            [On 090213 1140 the medical chart Assessment reports anemia
041475 -            due to chemotherapy. ref SDS A8 IH88
041477 -             ..
041478 -            [On 090309 1500 blood test at Kaiser shows some blood
041479 -            counts have begun to improve about 45 days after ending
041480 -            chemotherapy. ref SDS B1 OT8J
041482 -             ..
041483 -            [On 090609 1427 Kaiser plans blood transfusions to enable
041484 -            Millie to cope with severe effects reducing blood counts
041485 -            that expose risks of infection, and cause pain and
041486 -            suffering getting Gemzar treatments. ref SDS B5 WU3N
041487 -
041489 -  ..
041490 - Research on the Internet describes....
041491 -
041492 -        Cytopenia is a reduction in the number of blood cells. It
041493 -        takes a number of forms:
041494 -
041495 -              http://en.wikipedia.org/wiki/Cytopenia
041496 -
041497 -        1.  Low red blood cell count: anemia.
041499 -             ..
041500 -        2.  Low white blood cell count: leukopenia or
041501 -            neutropenia (because neutrophils make up at least half
041502 -            of all white cells, they are almost always low in
041503 -            leukopenia).
041505 -             ..
041506 -        3.  Low platelet count: thrombocytopenia.
041507 -        4.  Low granulocyte count: granulocytopenia
041509 -             ..
041510 -        5.  Low red blood cell, white blood cell, and platelet counts:
041511 -            pancytopenia.
041513 -  ..
041514 - The doctor also mentioned concern about "pancytopenia," which seems to
041515 - be part of Cytopenia (see item 5 above, ref SDS 0 LS7P)...
041516 -
041517 -        Pancytopenia is a medical condition in which there is a
041518 -        reduction in the number of red and white blood cells, as well
041519 -        as platelets.
041520 -
041521 -              http://en.wikipedia.org/wiki/Pancytopenia#Causes
041523 -             ..
041524 -            [...below medical chart Assessment lists Pancytopenia due
041525 -            to chemotherapy, ref SDS 0 NE6M, which is part of cytopenia
041526 -            shown by research above - see item 5, ref SDS 0 LS7P, and
041527 -            cited in the medical chart History section, ref SDS 0 465J,
041528 -            and in the work plan concurs with UCSF prescription.
041529 -            ref SDS 0 UN8M
041531 -  ..
041532 - Another website says...
041533 -
041534 -        AIDS & Infectious Disease Science Center
041535 -        3550 General Atomics Ct. Suite 2-108
041536 -        San Diego, CA 92121
041537 -        800) 877-9541
041538 -
041539 -              http://www.infection-research.org/research.html
041541 -         ..
041542 -        HIV
041544 -         ..
041545 -        Cytopenias (loss of blood cells) are a major risk factor in HIV
041546 -        infection, heart disease, and cancer. Cytopenias that arise
041547 -        from abnormal hematopoiesis such as its inhibition leads to, or
041548 -        cause, multiple cytopenias in HIV infected individuals with
041549 -        thrombocytopenia emerging as a major risk factor for morbidity
041550 -        and mortality and even more so in patients also suffering from
041551 -        heart conditions.  Thrombocytopenia is also a major risk factor
041552 -        in cancer patients undergoing chemotherapy.
041554 -  ..
041555 - Millie's letter to the medical team on 081211 requested comment on low
041556 - plateletts. ref SDS 68 S28P   Millie's letter letter on 081217 then
041557 - cited a series of recent blood tests with expanding elements below
041558 - required ranges. ref SDS 70 YJ4S  Millie's letter on 081218 reported
041559 - continuing findings from lab at UCSF yesterday of low blood counts.
041560 - ref SDS 74 GF9X, with symptoms of fatigue, muscle weakness, loss of
041561 - vitality associated with chemotherapy, and now nosebleed. ref SDS 74
041562 - KT6J  Millie's letter earlier this morning on 081219 1023 asked for
041563 - discussion today on alternatives for changing treatment to reduce side
041564 - effects, including low blood counts. ref SDS 75 SU9Q
041566 -             ..
041567 -            [...below medical chart Assessment lists Pancytopenia due
041568 -            to chemotherapy, ref SDS 0 NE6M, which is part of
041569 -            cytopenia, per above, ref SDS 0 019H, cited in the History
041570 -            section, ref SDS 0 465J, and work plan concurs with UCSF
041571 -            prescription to pause treatment with sunitinib protocol for
041572 -            a week. ref SDS 0 UN8M
041574 -  ..
041575 - Doctor Johnson concurred with UCSF planning to test blood counts at
041576 - Kaiser on 081226, per order today, shown above, ref SDS 0 3L7J, in
041577 - order to evaluate continuing the high dose of sunitinib beginning on
041578 - 081226, and in order to optimize potential for recovery based on
041579 - patient history showing prior progression of disease with lower dose
041580 - levels, and recovery with high dose, as prescribed yesterday on
041581 - 081218. ref SDS 72 BQ8F
041582 -
041583 -            [...below in the record today on 081219 1140 medical chart
041584 -            explains chemotherapy paused for a week and reduced in
041585 -            response to expansing low blood counts because cytopenia
041586 -            risks fatal infection. ref SDS 0 465J
041588 -             ..
041589 -            [On 090106 1136 Millie's letter to the medical team
041590 -            submitting agenda for meeting at UCSF reports continuing
041591 -            fatigue, muscle weakness, loss of vitality and vigor
041592 -            associated with chemotherapy, ref SDS 83 YO4S, due to
041593 -            expanding low blood counts that cause cytopenia.
041594 -            ref SDS 83 YO4Y
041596 -             ..
041597 -            [On 090109 Millie letter to medical team reports blood
041598 -            counts very low again, NEUTS 0.87, confirms UCSF treatment
041599 -            plan on 090108 continues sunitinib at full strenth, and
041600 -            pauses cyclophosphamice until blood counts rise to NEUTS
041601 -            1.00. ref SDS 84 UF3Q
041603 -             ..
041604 -            [On 090115 1522 Millie's letter reports continued side
041605 -            effects from chemotherapy that reflects continuing low
041606 -            blood counts that risk cytopenia. ref SDS 86 5J9Y
041608 -  ..
041609 - The doctor recalled previously prescribing 6 treatments with AC that
041610 - included cyclophosphamide chemotherapy, ending on 050329. ref SDS 16
041611 - E87M  Progression of cancer while using these prior drugs, reported on
041612 - 060711, ref SDS 20 025H, indicates Millie's cancer may now, as well,
041613 - resist treatment with cyclophosphamide.  Additionally, chemotherapy
041614 - with cyclophosphamide may be causing more severe side effects, shown
041615 - by chronic low blood counts reported in Millie's letter to the medical
041616 - team on 081217, ref SDS 70 YJ6R, and which required pausing all
041617 - treatments for a week, ordered by UCSF yesterday on 081218.
041618 - ref SDS 74 GF4V
041619 -
041620 -        [On 081220 Millie's letter to Doctor Stritter keeping her
041621 -        informed, ref SDS 77 I69Q, to support 2nd opinion process,
041622 -        cites review at Kaiser of UCSF treatment planning. ref SDS 77
041623 -        9G6Q
041625 -         ..
041626 -        [On 081230 case study dilemma cancer treatments cause low blood
041627 -        counts, which prevents getting treatment; not getting treatment
041628 -        incerases cancer; UCSF paused treatment for a week and
041629 -        prescribed Neupogen to increase blood counts. ref SDS 80 I87N
041631 -  ..
041632 - The doctor explained there may be resistance at UCSF to reduce or
041633 - eliminate cyclophosphamide in order to reduce ineffective treatment
041634 - that causes severe side effects, and instead reduce sunitinib
041635 - "targeted" treatment that has been effective against Millie's cancer
041636 - with minimal side effects, because the treatment protocol specifies
041637 - the purpose of treatment to test effectiveness of sunitinib,
041638 - ref SDS 48 RZ5M, in combination with cyclophosphamide and
041639 - Methotrexate, reviewed on 081017. ref SDS 48 004O  Since Millie's
041640 - treatment at UCSF is testing for advantages of combining sunitinib
041641 - with cyclophosphamide and Methotrexate to reduce recurrence of cancer,
041642 - reviewed on 081017, ref SDS 48 006S, the UCSF team may prefer to
041643 - reduce sunitinib that helps Millie in order to get more results for
041644 - testing the study theory.
041646 -  ..
041647 - Understandably, Millie's top priority is to recover from cancer as
041648 - much as possible and to minimize side effects in order to optimize
041649 - quality of life.
041651 -  ..
041652 - The doctor pointed to results observed today.  Substantial recovery
041653 - from IBC, per above, ref SDS 0 3L9L, indicates treatment decisions are
041654 - producing good results.
041656 -  ..
041657 - Millie noted these results were achieved with full dose of sunitinib,
041658 - which has now been paused for a week, and has been ordered to be
041659 - reduced.  Will good results continue with less treatment?
041661 -  ..
041662 - The doctor feels that a constructive letter to UCSF can address this
041663 - question.
041665 -         ..
041666 -        [On 081223 Millie's letter to medical team commends Doctor Rugo
041667 -        for engineering recovery from 5th relapse of Inflammatory
041668 -        Breast Cancer (IBC) with sunitinib, ref SDS 78 BV4T; Millie
041669 -        cited discussion with Doctor Johnson at Kaiser today on 081219
041670 -        explaining competing values of patient health and getting test
041671 -        data, ref SDS 78 BV6R; Millie advised the medical team of
041672 -        willingness to optimize recovery by maintaining sunitinib dose
041673 -        amount that has been effective, and to reduce dose or eliminate
041674 -        treatment with cyclophosphamide that may not be effective, and
041675 -        which may be causing severe adverse chemotherapy side effects.
041676 -        that prevent Millie from getting sufficient treatment with
041677 -        sunitinib to continue recovery. ref SDS 78 BW3V
041679 -         ..
041680 -        [On 090106 Millie's letter to medical team submitting
041681 -        agenda for meeting on 090106 discusses reducing
041682 -        cyclophosphamide in order to maintain treatment with
041683 -        sunitinib. ref SDS 83 YO4Y
041685 -         ..
041686 -        [On 090109 Millie letter to medical team reports blood
041687 -        counts very low again, NEUTS 0.87, confirms UCSF treatment
041688 -        plan on 090108 continues sunitinib at full strenth, and
041689 -        pauses cyclophosphamice until blood counts rise to NEUTS
041690 -        1.00. ref SDS 84 UF3Q
041692 -  ..
041693 - On 081210, the doctor called and scheduled Millie's next CT test on
041694 - 081230 1020, ref SDS 66 SX9O, and based on Millie's letter to Kaiser
041695 - presenting the scope of work using the Power Port for injecting
041696 - contrast medium (also ordered on 081230, ref SDS 66 VZ9K), and
041697 - included the neck, which was submitted on 081209. ref SDS 64 RL5X  The
041698 - doctor planned for Arlette to notify Interventional Services (IS) in
041699 - the Radiology Department to schedule qualified staff for assisting
041700 - with Millie's CT test on 081230 1020.
041702 -  ..
041703 - The next day on 081211, Millie received a telephone message from
041704 - Arlette, the doctor's assistant, advising that the Infusion Clinic is
041705 - scheduled to access Millie's Power Port for injecting contrast medium
041706 - needed for the CT test on 081230 1000, so there is 20 minutes to do
041707 - the work, and for Millie to walk to the CT Department about .25 miles
041708 - in time for the test at 1020.  After the call with the doctor on
041709 - 081210, later in the afternoon, Millie received a letter from the
041710 - doctor confirming Kaiser scheduled the CT test for 081230 1020.
041711 - ref SDS 67 GJ39
041713 -  ..
041714 - Today, the doctor recalled getting Millie's letter on 081211
041715 - confirming plans and coordination for Millie's CT test on 081230 1020.
041717 -  ..
041718 - Since this work was scheduled on 081210, ref SDS 66 H48N, the doctor
041719 - asked why check the referral again today?
041721 -  ..
041722 - Discussed difficulties with prior referral for a biopsy on the neck,
041723 - reported on 081021. ref SDS 49 4Q4C  Case study of patient history
041724 - listed on 081016 showed the neck biopsy referral suffered many errors
041725 - that delayed work and increased costs. ref SDS 47 W26G  Verification
041726 - today can help prevent problems with the CT test on 081230.
041728 -  ..
041729 - Millie asked the doctor to verify the scope for the CT test scheduled
041730 - on 081230 1030, following up placing the order for the referral during
041731 - the call on 081210. ref SDS 66 H48N
041733 -  ..
041734 - Doctor Johnson objected, because he clearly recalled entering
041735 - everything for the CT test referral in the computer during the call on
041736 - 081210.
041738 -  ..
041739 - Millie cited patient history showing work often conflicts with the
041740 - doctor's order entered in the computer weeks earlier.  She recalled
041741 - that things "fell through the cracks" in the CT Department previosuly
041742 - on...
041743 -
041744 -             080711............................ ref SDS 40 PP7O
041745 -             080718............................ ref SDS 41 FM74
041746 -             081107............................ ref SDS 55 7S8K
041748 -  ..
041749 - The doctor used the computer in the examination room to verify
041750 - arrangements for Millie's CT test on 081230, ref SDS 66 H49K,
041751 - including Barium Sulfate suspension for oral contrast medium.
041752 - ref SDS 66 VZ9K
041753 -
041754 -        [On 081219 1140 Barrium Sulfate Suspension not in Kaiser's
041755 -        medical chart listing patient medications. ref SDS 0 UF6L
041757 -  ..
041758 - The doctor advised that somebody must have have changed his referral
041759 - because the order in the computer today for the CT test on 081230
041760 - conflicts with what he entered during the call on 081210.  Doctor
041761 - Johnson advised that the order as shown today does not specify using
041762 - Millie's Power Port, and does not specify including the neck, nor show
041763 - consolidated findings are requested, contrary to discussions on
041764 - 081210. ref SDS 66 H44N
041766 -  ..
041767 - The doctor was disappointed by difficulties maintaining a well ordered
041768 - record.  He recalled problems with Millie's prior test on 081107, when
041769 - communication failures caused delay, extra cost, and frustration in
041770 - the CT Department, ref SDS 55 2D60, and which increased emotional
041771 - trauma to the patient. ref SDS 55 Z14M
041772 -
041773 -        [On 090205 1318 Doctor Johnson wants better communication for
041774 -        coordinating treatment at UCSF of Millie's 6th IBC relapse,
041775 -        so that critical details do "fall through the cracks."
041776 -        ref SDS A5 256K
041778 -         ..
041779 -        [On 090213 1140 Doctor Johnson explains a well ordered record
041780 -        for case management takes a lot of will power, especially for
041781 -        referrals, citing difficulty tracking lab work between UCSF and
041782 -        Kaiser. ref SDS A8 JL5I
041784 -  ..
041785 - As a result, the doctor changed the referral order in the computer for
041786 - the CT test on 081230 1020, to include the neck, and to specify using
041787 - Millie's Power Port, which requires coordination with IS, so that the
041788 - CT Department is alerted about requirements in time to perform the
041789 - work on 081230 1020.
041791 -  ..
041792 - The doctor recalled during the meeting today that he expressly ordered
041793 - consolidated findings for the CT test, ref SDS 66 PU3L, yet the
041794 - referral order today does not show this was ordered.  Changing the
041795 - doctor's order without notice presents a big challenge for effective
041796 - care.
041798 -  ..
041799 - Doctor Johnson remembered the CT Department issued a separate report
041800 - for the second pass on CT test performed at Kaiser in Walnut Creek on
041801 - 081107. ref SDS 55 FW6L  On 081112 Millie received the main report
041802 - from the primary care physician on CT test performed on 081107.
041803 - ref SDS 57 6V5I  This was reviewed the next day on 081113 with the
041804 - medical team at UCSF.  After meeting at UCSF, on 081113 the primary
041805 - care physician at Kaiser sent a second report on the neck only.
041806 - ref SDS 59 TP8L  Sending two reports, and sending them separately days
041807 - apart, with the second report received after examination at UCSF,
041808 - caused confusion about test findings of cancer in the left and right
041809 - supraclavicular, which disrupted consideration and application by UCSF
041810 - for Millie's care, reported in a letter to the medical team also on
041811 - 081113. ref SDS 60 D13H
041813 -  ..
041814 - Today, the doctor changed the referral for the CT test on 081230 to
041815 - again specify consolidating all findings into a single report in order
041816 - to avoid further confusion in patient care, reported yesterday at UCSF
041817 - on 081218, ref SDS 72 LM4I, and cited in Millie's letter to Kaiser
041818 - also yesterday on 081218. ref SDS 73 UY3T
041819 -
041820 -            [On 081230 Jennifer, CT Technologist at Kaiser CT
041821 -            Department in Walnut Creek CA added comments to the work
041822 -            order for the CT test to consolidate findings in a single
041823 -            report, ref SDS 81 FF8M, and to correct the test last month
041824 -            on 081107 by comparing with the previous test on 080911,
041825 -            rather than with the test on 080718. ref SDS 81 F34K
041827 -             ..
041828 -            [On 090106 Chris in Radiology Department reported that the
041829 -            order for the referral by Millie's primary care physician
041830 -            specified a consolidated report for Millie's CT test on
041831 -            081230. ref SDS 82 OO82
041833 -             ..
041834 -            [On 090109 Millie received from the primary care physician
041835 -            using Kaiser's Knowledge Management system an electronic
041836 -            submission of the report for Millie's the CT test on
041837 -            081230; the doctor submitted only 1 of the 2 reports
041838 -            prepared by the CT Department, ref SDS 85 V53J; mistakes
041839 -            performing case management reflect confusion that increased
041840 -            cost and delayed work, reported on 081219, ref SDS 0 T59G,
041841 -            and caused by failing to consolidate findings into a single
041842 -            report for the CT test, which was ordered by the doctor on
041843 -            081219. ref SDS 0 WP30
041845 -             ..
041846 -            [On 090409 2018 Doctor Davidson, Director fo Radiology of
041847 -            Kaiser Mt Diablo Service Area, advised that Kaiser CT
041848 -            Department Walnut Creek made a mistake issuing multiple
041849 -            reports for the CT test on 090413, ref SDS B4 WB6G, and
041850 -            advised that findings for future CT tests will consolidate
041851 -            findings into a single report for each test. ref SDS B4
041852 -            XZ6U
041854 -  ..
041855 - There was discussion today of Doctor Rugo's request during the meeting
041856 - on 081113 at UCSF for the report on the CT test performed at Kaiser on
041857 - 081107 to compare results with the previous test on 080911, rather
041858 - than with an earlier test on 080718, as related in Millie's letter to
041859 - the medical team on 081113. ref SDS 60 8Q8V
041861 -  ..
041862 - The doctor entered this additional clarification in the computer for
041863 - the referral ordering the CT test on 081230.
041865 -  ..
041866 - The doctor also added clarification in the medical chart on the scope
041867 - of the blood test scheduled today for 081212, per above. ref SDS 0
041868 - 3L6L  There was discussion about also clarifying the scope of the CT
041869 - test referral, per above. ref SDS 0 PU4H  The doctor asked for the
041870 - purpose of entering the reasons work is ordered, since this is well
041871 - understood today?
041873 -  ..
041874 - There was brief discussion about quality care posting the medical
041875 - chart that avoids mistakes caused by reacting on impulse from cursory
041876 - analysis, when people are pressed for time, explained in NWO.
041877 - ref OF 14 JZ5N  Doctor Johnson feels that Kaiser's new online
041878 - Knowledge Management system, which was first instituted in late 2005,
041879 - now makes editing fast and easy to refine referrals, illustrated by
041880 - work today, per above. ref SDS 0 WP30  This helps makes communication
041881 - among doctors, staff, and departments clear, concise, and complete for
041882 - comprehensive patient care.
041883 -
041884 -        [On 090205 1318 Doctor Johnson wants better communication for
041885 -        coordinating treatment at UCSF of Millie's 6th IBC relapse,
041886 -        so that critical details do "fall through the cracks."
041887 -        ref SDS A5 256K
041889 -  ..
041890 - Doctor Johnson commented that Millie's patient assstant would not make
041891 - a good doctor, because medical practice requires recognizing important
041892 - issues, rather than comprehensive reporting "writig every little thing
041893 - down" in the medical chart.  This perspective aligns with the
041894 - surgeon's comments on 080708. ref SDS 39 OK8M
041896 -  ..
041897 - Worry about unnecessary overkill writing everything down was cited at
041898 - SRI on 010411. ref SDS 2 X34F  Earlier on 890809 Ross worried that
041899 - writing everything down was unnecessary. ref SDS 1 3S6H
041901 -  ..
041902 - On 921127 Morris Jones, executive and founder at Chips and
041903 - Technologies noted Knowledge Management dilemma that small
041904 - inconsequential issues seem annoying when presented at the time, but
041905 - later explode into major problems that require all of everybody's the
041906 - attention, and this prevents correcting little deviations from
041907 - objectives, requirements, and commitments at a time when corrections
041908 - take very little time and expense.
041909 -
041910 -
041911 -
0420 -

SUBJECTS
Default Null Subject Account for Blank Record

2303 -
230401 -  ..
230402 - Thinking Through Writing Advancing at Kaiser
230403 - Medical Chart Reports Examination Diagnosis Prescription Prognosis
230404 -
230405 - Follow up ref SDS 50 YT5N. ref SDS 43 YT5N.
230406 -
230407 - Rather than submit the record electronically using Kaiser's Knowledge
230408 - Management email system for the meeting today to the patient at the
230409 - end of the meeting, as done previously, the doctor plans to submit the
230410 - medical chart later today after doing more editing using the "thinking
230411 - through writing" model set out in POIMS, ref OF 7 3742, that helps
230412 - "debug" communication to avoid mistakes, also, explained in POIMS.
230413 - ref OF 6 1108
230415 -  ..
230416 - Later on 081231 2156 Millie received a letter from Doctor Johnson
230417 - using Kaiser's Knowledge Management system that transmitted the
230418 - doctor's medical chart for Mil's visit on 081219 1140...
230419 -
230420 -    1.  Received:  12/31/08 9:56 PM
230421 -
230422 -    2.  Subject:  Office visit 081219 1140
230424 -         ..
230425 -    3.  Patient presents with:  recheck - 8 wk
230427 -         ..
230428 -    4.  History of Present Illness:
230429 -
230430 -        The patient is a 72 Y female with a history of [secondary] IBC
230431 -        of left breast who was initially diagnosed 03/04/02 [with
230432 -        biopsy reported in the record on 020306, ref SDS 3 5K9F -
230433 -        pathology findings "left breast infiltrating carcinoma"
230434 -        presented to patient on 020321, ref SDS 5 YE5N; surgery left
230435 -        breast sentinel node procedure with left axillary disection and
230436 -        left breast lumpectomy performed 020312, ref SDS 4 Q78M, and
230437 -        pathology reported on 020321. ref SDS 4 Q78M  Phase I adjuvant
230438 -        treatment started with AC on 020423, ref SDS 6 0001; after 2
230439 -        cycles cancer marker CA 15-3 rising and PET scan test indicated
230440 -        cancer spreading, so on 020610 switched to Taxotere for last 2
230441 -        cycles of Phase I; ref SDS 7 MR5I; radiation was completed on
230442 -        020910 with 2 weeks of additional treatment, reported on
230443 -        020924. ref SDS 8 0J7H  Phase II with 4 cycles of Taxotere
230444 -        completed adjuvant treatment on 021204. ref SDS 9 F5Z5]  She
230445 -        had recurrent disease noted in the cervical LN's 03/03/04. [as
230446 -        shown in patient history, ref SDS 10 Y171, and results reported
230447 -        to patient on 040309, ref SDS 11 0001.  Pathology findings for
230448 -        biopsy on 040419 diagnosed IBC, reported to the patient on
230449 -        040517, ref SDS 13 RH5V].  On E2100 Study with Avastin
230450 -        ([beginning on 040420, ref SDS 12 9Z5J], but she had a PE noted
230451 -        on CT 11/03/2004 [reported 041104, ref SDS 14 RZ4I; treatment
230452 -        was resumed with 4 cycles of AC on 050104, ref SDS 15 407N].
230453 -        Progression of disease required changing treatment to Taxotere
230454 -        and Xeloda started on 4/15/05. ref SDS 17 407N  She had a total
230455 -        of 8 cycles ending 9/16/05. ref SDS 18 407N  [IBC symptoms
230456 -        fully subsided, and cancer marker declined].  She had a
230457 -        palliative left mastectomy performed 10/21/05. ref SDS 19 EG5L
230458 -        Then her left chest lesions began expanding again.  The patient
230459 -        started Taxotere and Xeloda again 07/21/06 for 7 cycles.
230460 -        ref SDS 21 407N  She was started on [weekly treatments in ] a
230461 -        Clinical Trial 02/01/07 at UCSF and was randomized to the
230462 -        Erbitux only (no Carbo) Arm. ref SDS 28 XR3M  She had weekly
230463 -        Carboplatin added 03/13/08 because of progression of disease.
230464 -        ref SDS 33 TZ8I  Her disease has progressed again [for the 5th
230465 -        time] and she is being considered for Phase I/II Study of
230466 -        Sunitinib (SU11248) at UCSF [shown by patient's letter to the
230467 -        medical team on 081016, ref SDS 47 J38U, and listing UCSF work
230468 -        plan. ref SDS 47 J36R]
230470 -         ..
230471 -        Lengthy discussion about current status and response to
230472 -        therapy. ref SDS 0 NS6G  Because of cytopenia, MTX to be D/C'd
230473 -        [Methotrexate to be discontinued] and Sutent and CTX held and
230474 -        then dose reduced. ref SDS 0 NS6G
230476 -  ..
230477 - During the meeting, the doctor explained Doctor Rugo's prescription to
230478 - pause chemotherapy for a week will help Millie recover from expanding
230479 - low blood counts, ref SDS 0 JK7H, cytopenia reflects expanding low
230480 - blood counts risk fatal infection. ref SDS 0 LS6K
230481 -
230482 -            [...below medical chart Assessment lists Pancytopenia due
230483 -            to chemotherapy, ref SDS 0 NE6M, which is part of cytopenia
230484 -            cited in the History section, ref SDS 0 465J, and work plan
230485 -            concurs with UCSF prescription. ref SDS 0 UN8M
230487 -             ..
230488 -            [On 090106 1136 Millie's letter to the medical team
230489 -            submitting agenda for meeting at UCSF reports continuing
230490 -            fatigue, muscle weakness, loss of vitality and vigor
230491 -            associated with chemotherapy, ref SDS 83 YO4S, due to
230492 -            expanding low blood counts that cause cytopenia.
230493 -            ref SDS 83 YO4Y
230495 -             ..
230496 -            [On 090115 1522 Millie's letter reports continued side
230497 -            effects from chemotherapy that reflects continuing low
230498 -            blood counts that risk cytopenia. ref SDS 86 5J9Y
230500 -             ..
230501 -            [On 090122 0925 Millie suffers fall during aerobics
230502 -            exercise at the gym due to fatigue and muscle weankess
230503 -            caused by low blood counts, ref SDS 90 CW6J; suffered
230504 -            severe pain, ref SDS 90 WS7T, and treated for dislocated
230505 -            shoulder at Emergency Room Department, ref SDS 90 W05P
230507 -             ..
230508 -            [On 090213 1140 Doctor Johnson explains risks of cytopenia
230509 -            and pancytopenia that reduce energy, fitness, and muscle
230510 -            strength that contribute to Millie's fall and dislocated
230511 -            shoulder. ref SDS A8 PQTX
230513 -             ..
230514 -            [On 090213 1140 the medical chart Assessment reports anemia
230515 -            due to chemotherapy. ref SDS A8 IH88
230517 -             ..
230518 -            [On 090309 1500 blood test at Kaiser shows some blood
230519 -            counts have begun to improve about 45 days after ending
230520 -            chemotherapy. ref SDS B1 OT8J
230522 -             ..
230523 -            [On 090609 1427 Kaiser plans blood transfusions to enable
230524 -            Millie to cope with severe effects reducing blood counts
230525 -            that expose risks of infection, and cause pain and
230526 -            suffering getting Gemzar treatments. ref SDS B5 WU3N
230528 -  ..
230529 - Medical Chart continues...
230530 -
230531 -    5.  Current Medications
230532 -
230533 -        SUNITINIB.............................. 081113, ref SDS 58 T446
230534 -        CYHCLOPHOSPHAMIDE........... Cytoxan... 081127, ref SDS 62 VR5F
230535 -        METHOTREXATE...............ended....... 081218, ref SDS 72 TG6L
230536 -        HYDROCODONE/ACETAMINOPHEN 5 5
230537 -        combined in tablets of...... Vicodin/Lortab 080708, ref SDS 39 BT8C
230538 -        PROCHLORPERAZINE 10MG....... Compazine. 080313, ref SDS 32 FA4H
230539 -        ONDANSETRON 8 MG TABLETS.... Zofran.... 080313, ref SDS 32 FA4H
230540 -        CEPHALEXIN 500 MG CAPSULES.. Keflex.... 080409, ref SDS 34 F142
230541 -        FLUOXETINE 20 MG CAPSULES... Prozac.... 080305, ref SDS 31 5L5M
230542 -        NEUPOGEN 480MCG/1.6ML.................. 080502, ref SDS 35 NL4M  ,
230543 -        WARFARIN 4 MG TABLETS....... Coumadin.. 061002, ref SDS 24 MI5I
230544 -        TIMOLOL MALEATE 0.5% EYE.... Eye drops
230545 -        ACYCLOVIR 800MG............. Zoviraxe.. 070614 (no record prescribed by Doctor Rugo to treat cold sore on lip)
230546 -        LORAZEPAM 1 MG.............. Ativan.... 070921, ref SDS 30 3N8J
230548 -  ..
230549 - Methotrexate was prescribed on 081126 as part of sunitinib protocol,
230550 - but was later discontinued on 081218 to reduce side effects, per
230551 - above, ref SDS 0 NS6G, including low blood counts ("cytopenia"), noted
230552 - in the medical chart, per above. ref SDS 0 465J
230554 -  ..
230555 - The medical chart does not include contrast medium solution treatment
230556 - for CT test on 081230 ordered by Kaiser for Millie on 091210, and
230557 - checked today, 081219, per above. ref SDS 0 WP30
230558 -
230559 -        Barrium Sulfate Suspension............. 081210, ref SDS 66 VZ9K
230561 -  ..
230562 - Continues omission of contrast medium for the prior CT test on 081107
230563 - ordered on 081024 1150, ref SDS 50 A54L, and for the previous test on
230564 - 080911, ref SDS 45 X56N, which was ordered on 080829, and omitted from
230565 - the medical chart at that time. ref SDS 43 554I
230567 -  ..
230568 - Medical Chart continues...
230570 -  ..
230571 - This list for "Review of systems" is a little different from the the
230572 - medical chart on 081024. ref SDS 50 1Z6O.
230573 -
230574 -    6.  Review of systems:
230575 -
230576 -        a.  Constitutional: Appetite and energy level are good.  No
230577 -            recent fevers.
230579 -             ..
230580 -        b.  Eyes: Vision is OK.
230582 -             ..
230583 -        c.  ENT: No mucositis or nose bleeds.
230585 -             ..
230586 -        d.  Cardiovascular: No SOB, palpitations or chest pain
230588 -             ..
230589 -        e.  Respiratory: No hemoptysis or cough
230591 -             ..
230592 -        f.  GI: No nausea, vomiting, diarrhea or abdominal pain
230594 -             ..
230595 -        g.  GU: No hematuria or dysuria
230597 -             ..
230598 -        h.  Musculoskeletal: No edema or bone pain
230600 -             ..
230601 -        i.  Skin: No rash or petechiae
230603 -  ..
230604 - Not sure why "skin" would not report IBC rash, as reported in medical
230605 - chart for the meeting on 081024. ref SDS 50 CU4W
230607 -  ..
230608 - Medical Chart Review of Systems continued...
230609 -
230610 -        j.  Neurological: No confusion, sensory changes or motor
230611 -            weakness
230612 -
230613 -        k.  Psychiatric: No indication of anxiety or depression
230615 -         ..
230616 -    7.  Physical Exam:
230617 -
230618 -        Follow up prior examination on 081024. ref SDS 50 OP5L
230619 -
230620 -        a.  ECOG Performance Score 0
230621 -
230622 -               [On 090205 1600 ECOG performance score 0 used to assess
230623 -               oncology patients ability to benefit from aggressive
230624 -               cancer treatment. ref SDS A6 JG5I
230626 -                ..
230627 -               ECOG is a 5 criteria assessment, explained in Wikipedia,
230628 -               reviewed on 090205, ref SDS A6 356K, and is similar to
230629 -               Karnofsky scale, also discussed at that time.
230630 -               ref SDS A6 LH3O
230632 -             ..
230633 -        b.  BP 156/80
230634 -            Pulse 53
230635 -            Temp (Src) 97.3 F (36.3 C) (Oral)
230636 -            Ht 5' 3"
230637 -            Wt 139 lb (63.05 kg)
230638 -            SpO2 99%
230640 -             ..
230641 -        c.  Head: normocephalic
230643 -             ..
230644 -        d.  Eyes: normal conjunctiva
230646 -             ..
230647 -        e.  Lymph: no nodes palpable in neck, axillae or groin
230649 -  ..
230650 - Shows improvement from examination on 081024, ref SDS 50 TN6H, aligns
230651 - with findings reported during examination today, per above.
230652 - ref SDS 0 3L9L
230654 -  ..
230655 - Medical Chart Physical Exam continues...
230656 -
230657 -        f.  Breasts: marked improvement in erythema on chest wall
230659 -             ..
230660 -        g.  Lungs: clear to percussion and auscultation
230662 -             ..
230663 -        h.  Heart: regular without murmur or gallop
230665 -             ..
230666 -        i.  Abd: soft with normal bowel sounds. No masses or
230667 -            organomegaly
230669 -             ..
230670 -        j.  Ext: no edema
230672 -             ..
230673 -        k.  Bones: no tenderness
230675 -             ..
230676 -        l.  Neuro: awake, alert, and oriented. Moves all extremities
230677 -            well. Normal gait.
230678 -
230680 -         ..
230681 -    8.  Lab:
230682 -
230683 -        Follow up ref SDS 50 NL3K.
230684 -
230685 - Medical Chart shows no document source identification.  Valuations are
230686 - consistent with laboratory report on blood tests performed at Kaiser
230687 - on 081212, ref SDS 69 075H, but excludes about 50% of the report.  The
230688 - basis for listing some and not all of the test results is not
230689 - indicated in the medical chart...
230690 -
230691 -            WBC L 3.1 K/uL
230692 -            RBC L 2.90 M/uL
230693 -            Hemoglobin L 9.6 g/dL
230694 -            Hematocrit L 29.0 %
230695 -            MCV 100 fL
230696 -            RDW H 15.9 %
230697 -            Plt L 64 K/uL
230699 -             ..
230700 -            CA 15-3 H 197 U/mL
230702 -  ..
230703 - CA 15-3 197 was reported for the lab on 081210, ref SDS 65 PQTQ,
230704 - rather than the test on 081212, which seems be the source for the
230705 - other diagnostics.
230707 -  ..
230708 - Medical Chart Lab continues...
230709 -
230710 -            Albumin 4.4 g/dL
230711 -            Magnesium 1.9 mg/dL
230712 -            Bili, Tot Adult 0.6 mg/dL
230713 -            Calcium 9.0 mg/dL
230714 -            Creatinine 0.66 mg/dL
230716 -  ..
230717 - The above values appear to come from the lab at Kaiser on 081210.
230718 - ref SDS 65 GT9I
230720 -  ..
230721 - The Bili, Tot Adult 0.6 mg/dL test value correlates with the test at
230722 - Kaiser on 081203, and reported on 081205. ref SDS 63 SE9J
230724 -  ..
230725 - Medical Chart Lab continues...
230726 -
230727 -            03/03/06
230728 -            Cholesterol H 268 mg/dL
230729 -            Triglycerides 97 mg/dL
230730 -            HDL Cholesterol 58 mg/dL
230731 -            LDL Calculated H 191 mg/dL
230733 -  ..
230734 - These values do not correspond to any recent labs.  Blood test a week
230735 - later on 081226 evaluated cholesterol. ref SDS 79 XE8K
230737 -  ..
230738 - The 03/03/06 seems to be a date, possibly 060303, not sure.
230740 -  ..
230741 - Medical Chart Lab continues...
230742 -
230743 -    9.  Imaging:
230744 -
230745 -        09/11/08 CT THORAX, ABDOMEN, PELVIS W CONTRAST - Status post
230746 -        left mastectomy.  There has been little interval change.
230747 -        Prominent right axillary lymph nodes are again noted, little
230748 -        changed in size, which could be accounted for by sampling
230749 -        variability. Reticular densities and tiny punctate densities in
230750 -        the lungs are not significantly changed, and there are no new
230751 -        identifiable lesions.  No new adenopathy or ascites.
230753 -  ..
230754 - This appears to duplicate content from medical chart on 081024.
230755 - ref SDS 50 339K
230757 -  ..
230758 - This changes the format listing imaging patient history in the medical
230759 - chart for prior tests, shown in the record on 080829. ref SDS 43 Q89J
230761 -  ..
230762 - Complete history of imaging tests shows no evidence distant metastsis,
230763 - listed on 081112. ref SDS 57 GM3N
230765 -  ..
230766 - Medical Chart Lab continues...
230767 -
230768 -   10.  Assessment:
230769 -
230770 -        Follow up ref SDS 50 336O.
230771 -
230772 -        1.  Metastatic breast cancer (IBC) lung, lymph node and chest
230773 -            wall; left supraclavicular LN progression on Phase I/II
230774 -            Study of Sunitinib (SU11248) Trial
230776 -  ..
230777 - This assessment appears similar to content of medical chart for
230778 - meeting on 081024, ref SDS 50 336O; and it seems conflicting with
230779 - findings from examination today of significant recovery from IBC,
230780 - including reduction of LN in left supraclavicular, per above.
230781 - ref SDS 0 3L9L  Physicial examination in the medical chart reports no
230782 - nodes palpable in the neck, ref SDS 0 HT6V,
230784 -  ..
230785 - Medical Chart Lab continues...
230786 -
230787 -        2.  Pancytopenia due to chemotherapy
230789 -  ..
230790 - During the meeting, the doctor explained Doctor Rugo's prescription to
230791 - pause chemotherapy for a week will help Millie recover from expanding
230792 - low blood counts, ref SDS 0 JK7H; cytopenia reflects expanding low
230793 - blood counts risk fatal infection, ref SDS 0 LS6K, cited in the
230794 - medical Chart History section, per above, ref SDS 0 465J, Research
230795 - found that pancytopenia is part of cytopenia, per above. ref SDS 0
230796 - LS8T
230798 -                ..
230799 -               [On 090106 1136 Millie's letter to the medical team
230800 -               submitting agenda for meeting at UCSF reports continuing
230801 -               fatigue, muscle weakness, loss of vitality and vigor
230802 -               associated with chemotherapy, ref SDS 83 YO4S, due to
230803 -               expanding low blood counts that cause cytopenia.
230804 -               ref SDS 83 YO4Y
230806 -                ..
230807 -               [On 090109 Millie letter to medical team reports blood
230808 -               counts very low again, NEUTS 0.87, confirms UCSF
230809 -               treatment plan on 090108 continues sunitinib at full
230810 -               strenth, and pauses cyclophosphamice until blood counts
230811 -               rise to NEUTS 1.00. ref SDS 84 UF3Q
230813 -                ..
230814 -               [On 090115 1522 Millie's letter reports continued side
230815 -               effects from chemotherapy that reflects continuing low
230816 -               blood counts that risk cytopenia. ref SDS 86 5J9Y
230818 -                ..
230819 -               [On 090122 0925 Millie suffers fall during aerobics
230820 -               exercise at the gym due to fatigue and muscle weankess
230821 -               caused by low blood counts, ref SDS 90 CW6J; suffered
230822 -               severe pain, ref SDS 90 WS7T, and treated for dislocated
230823 -               shoulder at Emergency Room Department, ref SDS 90 W05P
230825 -                ..
230826 -               [On 090213 1140 Doctor Johnson explains risks of
230827 -               cytopenia and pancytopenia that reduce energy, fitness,
230828 -               and muscle strength that contribute to Millie's fall and
230829 -               dislocated shoulder. ref SDS A8 PQTX
230831 -                ..
230832 -               [On 090213 1140 the medical chart Assessment reports
230833 -               anemia due to chemotherapy. ref SDS A8 IH88
230835 -                ..
230836 -               [On 090309 1500 blood test at Kaiser shows some blood
230837 -               counts have begun to improve about 45 days after ending
230838 -               chemotherapy. ref SDS B1 OT8J
230840 -                ..
230841 -               [On 090609 1427 Kaiser plans blood transfusions to
230842 -               enable Millie to cope with severe effects reducing blood
230843 -               counts that expose risks of infection, and cause pain
230844 -               and suffering getting Gemzar treatments. ref SDS B5 WU3N
230846 -  ..
230847 - Medical Chart Lab continues...
230848 -
230849 -        3.  Hyperlipidemia; currently off statins
230851 -         ..
230852 -   11.  Plan:
230853 -
230854 -        1.  Continue Phase I/II Study of Sunitinib (SU11248) after one
230855 -            week to resume 12/26/08 because of positive response,
230856 -            ref SDS 0 545J
230858 -             ..
230859 -        2.  Agree with D/C of MTX.......... ref SDS 0 NS6G
230861 -             ..
230862 -        3.  CBC and CA 15-3 on 12/26/08......... ref SDS 0 3L6L
230863 -
230864 -               [On 090106 1136 Millie's letter to the medical team
230865 -               submitting agenda for meeting at UCSF reports continuing
230866 -               fatigue, muscle weakness, loss of vitality and vigor
230867 -               associated with chemotherapy, ref SDS 83 YO4S, due to
230868 -               expanding low blood counts that cause cytopenia.
230869 -               ref SDS 83 YO4Y
230871 -                ..
230872 -               [On 090109 Millie letter to medical team reports blood
230873 -               counts very low again, NEUTS 0.87, confirms UCSF
230874 -               treatment plan on 090108 continues sunitinib at full
230875 -               strenth, and pauses cyclophosphamice until blood counts
230876 -               rise to NEUTS 1.00. ref SDS 84 UF3Q
230878 -             ..
230879 -        4.  CT neck, chest, abdomen and pelvis 12/30/08... ref SDS 0 PU4H
230881 -             ..
230882 -        5.  Check lipids off statins........... ref SDS 0 3L9H
230884 -             ..
230885 -        6.  RTC 8 weeks
230887 -         ..
230890 -
230891 -
230892 -
230893 -
230894 -
230895 -
230896 -
230897 -
2309 -