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0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 23 0000. ref SDS 20 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - On 010906, Millie submitted an agenda to the medical team for the
040902 - meeting at UCSF on 090108 at 0830 to review progress recovering from
040903 - the 5th relapse of IBC, and to get a blood draw. ref SDS 20 NF70
040905 -  ..
040906 - Millie met with the medical team yesterday morning on 090108 at 0900,
040907 - as planned in the letter on 090108.
040909 -  ..
040910 - Yesterday afternoon on 090108, Millie received a letter from Glenna
040911 - confirming the work plan developed during the meeting with the medical
040912 - team at UCSF. ref SDS 23 LX7O  The work plan has several tasks for
040913 - Kaiser to perform.
040915 -  ..
040916 - Millie submitted the UCSF work plan to the primary care physician for
040917 - implementation at Kaiser...
040918 -
040919 -    1.  Subject: UCSF Work Plan from Meeting Today Jan 8th
040920 -        Date: Fri, 09 Jan 2009 00:00:32 -0800
040928 -         ..
040929 -    2.  Examination today at UCSF shows rise of IBC in the breastbone
040930 -        area of more intense ("angry") nodules [compared to examination
040931 -        on 081218 finding substantial progress recovering from IBC.
040932 -        ref SDS 7 VD4F].  Other sites seem stable, although Tara noted
040933 -        possible slight lump in IBC on upper left arm.  The CT test on
040934 -        081230 indicates improved to stable adenopathy, but does not
040935 -        recognize changes in IBC per se.  Rising IBC may relate to
040936 -        pausing treatments for a week [ordered by UCSF on 081218,
040937 -        ref SDS 7 QW48, following your examination on 081219 finding
040938 -        reduced IBC lesions and rash, ref SDS 9 3L9L, also reported at
040939 -        UCSF the day before on 081218. ref SDS 7 VD4F  The doctor
040940 -        decided today to continue sunitinib for another cycle with
040941 -        treatment reduced to maintain blood counts, explained below.
040942 -        ref SDS 0 UF3Q [Doctor Rugo noted during the meeting today
040943 -        planning follow on treatments at UCSF, discussed previously on
040944 -        081016. ref SDS 1 NW6M]
040945 -
040946 -            [On 090121 Glenna requested patient history on UCSF
040947 -            planning follow on treatments for Millie. ref SDS 34 Y67L
040949 -             ..
040950 -            [On 090122 Glenna advised that Doctor Rugo ended Millie's
040951 -            treatment with sunitinib a week early in order to remove
040952 -            toxicities so that Millie can start the next treatment on
040953 -            090129.
040955 -             ..
040956 -            [On on 090130 Millie's letter to the medical team reports
040957 -            that on 090129 Doctor Rugo prescribed treating Millie with
040958 -            hyperthermia in the Radiation Oncology Department at UCSF,
040959 -            and in order to establish local control of expanding IBC,
040960 -            following relapse during treatment with sunitinib study.
040961 -            ref SDS 40 AY9Q
040963 -         ..
040964 -    3.  Continuing sunitinib may reverse the rise of IBC observed
040965 -        today, as occurred previously in my patient history with
040966 -        sunitinib. [reported in Millie's letter on 081125, ref SDS 4
040967 -        XX4P; there was rise of IBC and then substantial recovery
040968 -        reported again on 081217, ref SDS 5 YJ4V; on 081230 Millie's
040969 -        letter reported on 081224 and 081225 rise of IBC, and then
040970 -        improvement on 081226, ref SDS 15 JV5M; most recently on 090106
040971 -        Millie cited again advance of IBC on 081224 and 081225, and now
040972 -        disease seems to be subsiding again. ref SDS 20 YO4V]
040974 -             ..
040975 -            [On 090113 Millie received letter from Arlette expressing
040976 -            regret on hearing in Millie's letter today on 090109 that
040977 -            findings from examination on 090108 indicate slow recovery
040978 -            from 5th relapse of IBC. ref SDS 28 LN6G
040980 -             ..
040981 -            [On 090116 Millie's letter to the medical team clarifies
040982 -            telecon call on condition following examination at UCSF on
040983 -            090108, reporting IBC in breastbone area looks stable to
040984 -            worse, and everywhere else looks improved to stable,
040985 -            indicating recovery has slowed ref SDS 32 IT8P relative to
040986 -            findings on 081218, ref SDS 7 VD4F, confirmed in Millie's
040987 -            letter later that day reporting significant recovery.
040988 -            ref SDS 8 GF8V,
040990 -  ..
040991 - Millie's letter to medical team continues...
040992 -
040993 -    4.  For some reason UCSF did not receive the fax Arlette sent on
040994 -        Tuesday [900106] for the CT test report. ref SDS 17 UT8M  On
040995 -        Tuesday, Arlette mentioned that your office was having
040996 -        equipment problems, ref SDS 17 JW6X, so evidently the glitch
040997 -        was not resolved still this morning.  Glenna tried to call for
040998 -        resubmission, but could not get through in time for the
040999 -        meeting.  Arlette's planning saved the day.  On Tuesday, she
041000 -        had me come by and pick up a copy. ref SDS 17 UT93  When Glenna
041001 -        said they didn't have the report, I remembered having a copy in
041002 -        the trunk of the car.   Problem solved.
041003 -
041004 -            [On 090109 Arlette reported that Kaiser got a return
041005 -            receipt showing the 2 reports for the CT test at Kaiser on
041006 -            081230 were received via FAX by UCSF on 090106. ref SDS 24
041007 -            HI6F
041009 -             ..
041010 -            [On 090311 1517 Kaiser reported more problems faxing blood
041011 -            test report to UCSF. ref SDS 42 QS3P
041013 -             ..
041014 -            [On 090409 2018 Doctor Davidson, Director fo Radiology of
041015 -            Kaiser Mt Diablo Service Area, advised that Kaiser CT
041016 -            Department Walnut Creek made a mistake issuing multiple
041017 -            reports for the CT test on 090413, ref SDS 43 WB6G, and
041018 -            advised that findings for future CT tests will consolidate
041019 -            findings into a single report for each test. ref SDS 43
041020 -            XZ6U
041022 -         ..
041023 -    5.  When time permits, please submit the 2 reports for the CT test
041024 -        with the electronic mail system.  That will save time typing it
041025 -        up.  [On 090106 Arlette planned to remind the doctor to submit
041026 -        the reports. ref SDS 17 B47I
041028 -  ..
041029 - During the meeting at UCSF yesterday, Tara complained that language in
041030 - the 2 reports present different findings for the supraclavicular and
041031 - axillary region.  She spent about 30 minutes reading one report and
041032 - transcribing text to the other report in order to develop a coherent
041033 - understanding of findings for trend analysis compared to prior tests.
041034 - She finally threw up her arms and said there isn't enough time to
041035 - figure out test results from Kaiser's new practice issuing multiple
041036 - reports for a single test.  The problem seems to be that scans for
041037 - axillary regions overlap scans performed from the neck down, and the
041038 - second pass of the CT equipment to scan the neck alone.  The analyst
041039 - described these findings, and evidently saw different things in the
041040 - different scans.
041041 -
041042 -            [On 090213 1140 primary care physician at Kaiser frustrated
041043 -            that having checked the computer and corrected the
041044 -            e-consult on 081219 to specify a consolidated report,
041045 -            Kaiser ignored the doctor's order and issued separate
041046 -            reports, ref SDS 0 UE6X, that caused delay and mistakes
041047 -            applying CT test data for paitent care. ref SDS 41 YG4F
041049 -             ..
041050 -            [On 090409 2018 Doctor Davidson, Director fo Radiology of
041051 -            Kaiser Mt Diablo Service Area, advised that Kaiser CT
041052 -            Department Walnut Creek made a mistake issuing multiple
041053 -            reports for the CT test on 090413, ref SDS 43 WB6G, and
041054 -            advised that findings for future CT tests will consolidate
041055 -            findings into a single report for each test. ref SDS 43
041056 -            XZ6U
041058 -             ..
041059 -            [On 090409 2347 letter thanks Doctor Davidson for
041060 -            correcting problems with CT test reporting, and explains
041061 -            problems for doctors caused by multiple reports on Kaiser
041062 -            CT tests. ref SDS 44 4R4K
041064 -  ..
041065 - Reporting should note conflicting data and explain why this occurs,
041066 - i.e., there were overlapping scan perhaps showing slightly different
041067 - angles; offer a professional opinion on most likely condition relative
041068 - to correlations with scans on prior tests, and alert the doctor to
041069 - examine the scans directly, if needed.
041070 -
041071 -           [On 090109 Millie received from the primary care physician
041072 -           using Kaiser's Knowledge Management system an electronic
041073 -           submission of the report for Millie's the CT test on
041074 -           081230; the doctor submitted only 1 of the 2 reports
041075 -           prepared by the CT Department, ref SDS 25 V53J; mistakes
041076 -           performing case management reflect confusion that increased
041077 -           cost and delayed work, reported on 081219, ref SDS 9 T59G,
041078 -           and caused by failing to consolidate findings into a single
041079 -           report for the CT test, which was ordered by the doctor on
041080 -           081219. ref SDS 9 WP30
041082 -         ..
041083 -    6.  My blood counts today dropped again - ANC 870 (NEUTS 0.87). [as
041084 -        shown in labs at UCSF on 090108, ref SDS 21 PU6K; reflecting
041085 -        increased side effects discussed during the meeting at UCSF on
041086 -        090108, and per agenda submitted on 090106, ref SDS 20 YO4S;
041087 -        extends concerns about cytopenia and Pancytopenia cited by
041088 -        Doctor Johnson at Kaiser on 081219. ref SDS 9 LS6K  Doctor Rugo
041089 -        ordered Neupogen for tomorrow and Saturday, as regularly
041090 -        scheduled at Kaiser. [On 081223 Glenna called and advised that
041091 -        the medical team orders Neupogen treatment, when blood counts
041092 -        fall below NEUTS 1.000 (ANC 1000), ref SDS 12 4P4K, and citing
041093 -        Glenna's letter from UCSF on 090108. ref SDS 23 UX4V
041094 -
041095 -            [On 090115 1522 Millie's letter reports continued side
041096 -            effects from chemotherapy that reflects continuing low
041097 -            blood counts that risk cytopenia. ref SDS 29 5J9Y
041099 -             ..
041100 -            [On 090116 1428 Millie's letter to medical team reports
041101 -            results of blood tests, and that difficulty tolerating side
041102 -            effects of chemotherapy increased. ref SDS 32 IT4S
041104 -         ..
041105 -    7.  Doctor Rugo paused cyclophosphamide, and continued sunitinib at
041106 -        the original prescribed dose, 37.5 mg per day. [requested in
041107 -        Millie's letter to the medical team on 090106, ref SDS 20 YO4Y,
041108 -        citing meeting with primary care physician at Kaiser on 081219,
041109 -        ref SDS 9 WN4J]
041110 -
041111 -            [On 090514 0830 Doctor Rugo prescribes MPA clinical trial
041112 -            for Millie to recover from the 8th relapse of cancer, and
041113 -            assigns Millie to get MPA only in order to avoid side
041114 -            effects of cyclophosphamide that caused severe side effects
041115 -            for Millie on the sunitinib protocol. ref SDS 45 265I
041117 -         ..
041118 -    8.  Doctor Rugo prescribes another blood test next week.  If ANC
041119 -        rises to 1000, I will resume cyclophosphamide and reduce the
041120 -        dose to 5 days per week [per Glenna's letter earlier today on
041121 -        090109. ref SDS 23 UX4V]  If not, I will need another Neupogen
041122 -        treatment, and cyclophosphamide will not be resumed.
041124 -         ..
041125 -    9.  Accordingly, please order another lab for 090116 coordinated to
041126 -        precede my Neupogen treatment currently scheduled in the
041127 -        Infusion Clinic for 1030.
041128 -
041129 -            [On 090109 Arlette ordered blood test for Millie at Kaiser
041130 -            to accomplish care prescribed by UCSF. ref SDS 24 BF5N
041132 -             ..
041133 -            [On 090110 Bella will add lab for blood test when Millie
041134 -            comes to Kaiser on 090116 1030 for Neupogen. ref SDS 26
041135 -            6U9I
041137 -         ..
041138 -   10.  INR 3.1 was slightly high in the lab today at UCSF. ref SDS 21
041139 -        K66J  This may be related to pausing cancer treatments for 1
041140 -        week on 081219, and ending treatment with Methotrexate.  During
041141 -        the meeting today, I recalled taking Coumadin out of order by 5
041142 -        or 6 hours on 1 or 2 days.  Tara thought this change in routine
041143 -        may account for the slight rise of INR today.  By copy advise
041144 -        Gloria in the Coagulation Control Clinic of change in treatment
041145 -        plan with cyclophosphamide, and of slight rise in INR.  Will
041146 -        continue with current prescription of Coumadin [shown in
041147 -        Kaiser's letter on 081219, ref SDS 10 EW3G], unless I hear
041148 -        differently from Gloria.
041149 -
041150 -            [On 090116 INR 3.1 again for labs at Kaiser; may reflect
041151 -            pausing cyclophosphamide the previous week. ref SDS 31 PU7Y
041153 -             ..
041154 -            [On 090116 Millie letter notified Gloria in Coagulation
041155 -            Control Clinic that INR 3.1 and context with plans to
041156 -            continue current dose. ref SDS 32 IT8X
041158 -             ..
041159 -            [On 090122 INR 3.7 for lab at Kaiser treating Millie in
041160 -            Emergency Department for separated shoulder; Doctor orders
041161 -            Coumadin paused for 2 days, and to contact Coagulation
041162 -            Control Clinic for instructions. ref SDS 36 F56L
041164 -             ..
041165 -            [On 090123 Millie letter to medical team notified Gloria in
041166 -            Kaiser Coagulation Control Clinic of Doctor Lillenstein's
041167 -            prescription to recover from INR 3.7 in lab today on
041168 -            090122. ref SDS 38 KR5V
041170 -             ..
041171 -            [On 090123 Gloria called responding to Millie's letter
041172 -            earlier on 090123; Gloria concurred with Doctor
041173 -            Lillenstein's order for Millie to hold Coumadin for 2 days;
041174 -            Gloria prescribed continuing with current treatment plan
041175 -            issued on 081219, and to get another INR blood test at UCSF
041176 -            on 090129. ref SDS 39 MG5L
041178 -         ..
041179 -   11.  Doctor Rugo requests an EKG to evaluate my heart based on
041180 -        persistent pulse below 50 in recent weeks during treatment with
041181 -        sunitinib.  [see record on 090108 showing research indicates
041182 -        heart issues can result from sunitinib. ref SDS 22 SX4H]  This
041183 -        was first reported to the medical team in my letter on 081121.
041184 -        ref SDS 3 5T9R
041185 -
041186 -            [On 090109 Arlette ordered EKG for Millie which can be done
041187 -            anytime next week. ref SDS 24 IF58
041189 -             ..
041190 -            [On 090112 Millie got the CT test at Kaiser. ref SDS 27
041191 -            DB5I
041193 -             ..
041194 -            [On 090116 Glenna called and requested submission of
041195 -            results for the EKG test to UCSF. ref SDS 30 JY9G
041197 -             ..
041198 -            [On 090116 letter to medical team asks Kaiser to submit
041199 -            report on EKG performed 090112. ref SDS 32 IT8U
041201 -             ..
041202 -            [On 090120 Millie letter to Kaiesr requesting report on EKG
041203 -            test performed at Kaiser on 090112. ref SDS 33 2P3P
041205 -             ..
041206 -            [On 090121 Millie went to Kaiser to get a printed copy of
041207 -            the report and discovered the report for the EKG test on
041208 -            090112 has not been prepared due to a hectic schedule in
041209 -            the Cardiology Department. ref SDS 35 4R7J
041211 -             ..
041212 -            [On 090122 Millie received report on EKG test, and results
041213 -            of cancer marker for blood test on 090116, from primary
041214 -            care physician ref SDS 37 FJ6G
041216 -             ..
041217 -            [On 090123 report for Millie's EKG test on 090112 was
041218 -            submitted to UCSF. ref SDS 38 KR8V
041220 -         ..
041221 -   12.  These understandings were confirmed by Glenna's letter today
041222 -        after meeting with the medical team at UCSF this morning (see
041223 -        below). ref SDS 23 LX7O
041224 -
041231 -
041232 -
041233 -
041234 -
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041236 -
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041238 -
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0413 -