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: March 2, 2010 08:30 AM Tuesday; Rod Welch

Millie meeting with Doctor Johnson treatment plan 10th relapse cancer.

1...Summary/Objective
2...Agenda Meeting Primary Care Physician Recover 10th Relapse Cancer
3...Advance Directive Declining Life-sustaining Treatment
4...Physician Orders Life-sustaining Treatment (POLST) Declined by Millie
5...Primary Care Physician Doctor Johnson
6...Breathing Improved CT Test Ground Glass Opacities Lungs Reduced
7...Radiation Injury Recovery Ground Glass Opacities Reduced CT Test
8...Skin Only Cancer Medical Problem CT Test Finds No Adenopathy
9...Distant Metastasis Not Found CT Test IBC in Skin Only Cancer Problem
10...Examination Finds IBC Spreads Near Untreated IBC Breastbone
11...IBC Spreads Right Side Chest Near Untreated IBC Breastbone
12...Stage V Cancer Unique Continuous Treatment 9 Years 10th Relapse
13...Unique Case Continuous Treatment 9 Years 10th Relapse Stage V Cancer
14...Pain Controlled Less Oxycodone IBC and Shingles Subsiding
15...Acyclovir (Zovirax) Treatment Ends Shingles Sufficient Recovery
16...Shingles Recoverd Sufficient End Treatment Acyclovir (Zovirax)
17...10th Relapse Abraxane Prescribed Navelbine End Treatment 9th Relapse
18...Abraxane Prescribed 10th Relapse Navelbine End Treatment 9th Relapse
19...Navelbine End Treatment 9th Relapse Abraxane Prescribed 10th Relapse
20...Side Effects Abraxane Tolerated Better than Navelbine
21...Trip 2-weeks May 15 Kaiser Committed Millie Quality of Life
22...Quality of Life Kaiser Committed Millie 2-weeks Trip May 15
23...Immune System Weakens Because Abraxane Lowers Blood Counts
24...Blood Counts Fall Risk Shingles Recurrence Pause Chemo Cancer Rises
25...Balance Treatment Shingles and Cancer Requires Targeted Drugs
26...Death Risk Increases Pause Treatment Cancer While Treating Shingles
27...Targeted Treatment Avoids Weakening Immune System
28...Bone Marrow Immune System Not Degraded with Targeted Cancer Agents
29...Cancer Shingles Concurrent Recovery Requires Targeted Cancer Treatment
30...Evidence-based Health Care Requires Trade-offs Balancing Risks
31...Due Process Life Threating Diseases Evidence-based Medical Practice
32...Targeted Treatment for Cancer Not Enough Time Present Trade-offs
33...Securemail Not Submitted for Patient Review
34...Authorization Blood Draws Power Port Primary Care Physician
35...Power Port Blood Draws Authorization Primary Care Physician
36...Blood Draws Power Port Authorization Primary Care Physician
37...Kaiser's Medical Chart Knowledge Management System
........History of Present Illness:
....2...Current medications:
....3...Review of systems:
........Physical Exam:
....4...Lab:
....5...Imaging:
....6...Assessment:
....7...Plan:


..............
Click here to comment!

CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 63 0000. ref SDS 61 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 100203, Millie resumed treatment after a 3-week pause ordered by
040902 - Doctor Johnson, on 100112 0830, ref SDS 51 G68H, while Millie was
040903 - treated to recover from a very severe case of shingles infection,
040904 - reported earlier on 100104 1115. ref SDS 47 0P9S
040906 -  ..
040907 - On 100217 0730 Millie got the 3rd treatment of the 3rd cycle with
040908 - Navelbine for Millie to recover from the 9th relaspe of cancer.
040910 -  ..
040911 - On 100218 1000 Millie got Neupogen treatment at Kaiser to maintain
040912 - blood counts essential for getting Navelbine chemotherapy treatment
040913 - for cancer. ref SDS 61 ER95
040915 -  ..
040916 - On 100218 1000 Millie had emergency meeting with Doctor Johnson,
040917 - primary care physician at Kaiser, after getting Neupogen treatment;
040918 - the doctor diagnosed relapse of shingles, and prescribed a 4th cycle
040919 - of treatment, but only with Acyclovir (Zovirax) 800 MG tablets,
040920 - ref SDS 61 0Y6O; the doctor also diagnosed Millie's 10 relapse of
040921 - cancer, and ordered switching treatment from Navelbine to Abraxane,
040922 - beginning on 100303. ref SDS 61 023N   The doctor further ordered a CT
040923 - test to evaluate rising pain. ref SDS 61 ES40
040925 -  ..
040926 - On 100218 1230 Millie had emergency CT test. ref SDS 61 PQ6R
040928 -  ..
040929 - On 100301 0005 letter to medical team reports improvement from CT test
040930 - on 100218, and increased energy may indicate Navelbine can continue
040931 - another cycle. ref SDS 63 ER95
040933 -  ..
040934 - On 100302 0830 meeting at Kaiser, ref SDS 0 ER95; Doctor Johnson
040935 - prescribed Abraxane for Millie starting treatment tomorrow for
040936 - recovering from 10th relapse of cancer. ref SDS 0 FB67  Blood counts
040937 - dropped significantly, ref SDS 0 IC4N; since Abraxane side effects
040938 - reduce blood counts this increases chances of shingles recurrence; the
040939 - doctor advised that treatment for cancer will be paused again, if
040940 - shingles recurs. ref SDS 0 FC68  Only way for Millie to get treatment
040941 - for shinges concurrent with cancer is to switch from Abraxane to a
040942 - "targeted" treatment for cancer that does not injure bone marrow
040943 - producing blood. ref SDS 0 IC85
040944 -
040945 -
040946 -
040948 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Agenda Meeting Primary Care Physician Recover 10th Relapse Cancer
041302 -
041303 - Doctor Johnson advised that he received and read Millie's letter dated
041304 - 100301 with the agenda for the meeting today at 0830. ref SDS 63 ER95
041305 - He commented extensively during the meeting on critical issues.
041306 -
041307 -    1.  Patient Directive.............................. ref SDS 0 P58M
041308 -    2.  Breathing improves recovery radiation
041309 -        injury......................................... ref SDS 0 FB85
041310 -    3.  Cancer skin only no distant metastasis
041311 -        CT test very favorable......................... ref SDS 0 FB90
041312 -    4.  Examination Cancer spreads on skin............. ref SDS 0 FB9Y
041313 -    5.  Pain subsides with shingles recovery........... ref SDS 0 FB55
041314 -    6.  Shingles improvement treatment stopped......... ref SDS 0 FU5F
041315 -    7.  Abraxane chemotherapy 10th relapse............. ref SDS 0 FB67
041316 -    8.  Blood counts fall high risk Abraxane........... ref SDS 0 IC4N
041317 -    9.  Balance treatment recover from cancer
041318 -        and shingles................................... ref SDS 0 FC68
041319 -   10.  Targeted cancer treatment needed for concurrent
041320 -        recovery from shingles......................... ref SDS 0 IC85
041321 -   11.  Trade-offs standard of care evidence-based
041322 -        health care requires "due process" for
041323 -        life-ending threats............................ ref SDS 0 ZV4N
041324 -   12.  Securemail from Kaiser dated 100208............ ref SDS 0 FC61
041325 -   13.  Authorization blood draws Power Port........... ref SDS 0 7M6H
041326 -
041327 -            [On 100304 2251 Millie notifies medical team on results
041328 -            meeting at Kaiser today with Doctor Johnson. ref SDS 65
041329 -            OP6R
041330 -
041331 -
041332 -
041333 -
0414 -

SUBJECTS
Default Null Subject Account for Blank Record

0503 -
050401 -  ..
050402 - Advance Directive Declining Life-sustaining Treatment
050403 - Physician Orders Life-sustaining Treatment (POLST) Declined by Millie
050404 -
050405 - Millie submitted signed EMSA #111B documentation on life-ending
050406 - directions, designating Pam with authority to decide medical issues
050407 - when Millie is medically unable to make her own decisions.  Doctor
050408 - Johnson filled out and signed his part of the form, as Millie's
050409 - primary care physician.  During the meeting Arlette came into the
050410 - examination room.  The doctor gave the signed documents to Arlette for
050411 - processing.
050413 -  ..
050414 - Millie also signed and received a copy of a pink document.  Doctor
050415 - Johnson said this is for efficient notice to care givers at home when
050416 - Millie suffers coma or dies.  It can be displayed on the refergerator
050417 - door for easy access.
050418 -
050419 -        [On 100309 1238 Millie requests documentation for approving
050420 -        communication, including confidential information, through the
050421 -        doctor's domestic email address at Kaiser, and in order to
050422 -        provide timely, accurate coordination among the doctors
050423 -        collaborating to provid Millie's health care. ref SDS 68 HL6R
050425 -         ..
050426 -        [On 100601 1531 Sharon asked Millie for Advance Directive on
050427 -        file at Kaiser, during call to start Hospice care. ref SDS 76
050428 -        NA6F
050430 -         ..
050431 -        [On 100602 0913 Liz asked again about Millie signing an Advance
050432 -        Directive on file at Kaiser. ref SDS 77 PE6G
050434 -         ..
050435 -        [On 100604 1350 Linda, Hospcie Case Manager, asked again for
050436 -        Millie's Advance Directive to avoid life-sustaining measures.
050437 -        ref SDS 78 MP4K
050439 -         ..
050440 -        [On 100607 1243 Judy reported that searching the records
050441 -        does not show Millie has an Advance Directive on file at
050442 -        Kaiser; Judy will investigate and let Millie know if this
050443 -        work needs to be done again. ref SDS 79 AO6J
050444 -
050445 -
050446 -
0505 -

SUBJECTS
Default Null Subject Account for Blank Record

0603 -
060401 -  ..
060402 - Primary Care Physician Doctor Johnson
060403 -
060404 - Milie was pleased that Doctor Johnson confirmed today his assignment
060405 - as her primary care physician.  Other documents from Kaiser the past
060406 - year have listed various other doctors, whom Millie never sees, as her
060407 - primary care physician.  Millie has consistently listed Doctor Johnson
060408 - as her primary care doctor, because he has performed this work since
060409 - the first meeting 9 years ago on 020321. ref SDS 1 MA3F
060411 -  ..
060412 - Millie noticed that Doctor Johnson has today a new badge replacing the
060413 - prior promotion for palliative care.  The new badge now promotes
060414 - comprehensive care, or something other than palliation.
060416 -  ..
060417 - The doctor explained that Palliative Care has not been well received
060418 - by Kaiser's customers.  Many patients evidently feel that "palliation"
060419 - implies a "Doctor Kervorkian" assisted suicide/euthanasia practice
060420 - that replaces care to extend quality of life, with medication to
060421 - provide a comfortable demise.
060422 -
060423 -        [On 100311 0930 Doctor Johnson's letter presents current
060424 -        position as Chief, Pallicative Care for Kaiser's Diablo Service
060425 -        Area. ref SDS 71 ER95
060426 -
060427 -
060428 -
060429 -
0605 -

SUBJECTS
Default Null Subject Account for Blank Record

0703 -
070401 -  ..
070402 - Breathing Improved CT Test Ground Glass Opacities Lungs Reduced
070403 - Radiation Injury Recovery Ground Glass Opacities Reduced CT Test
070404 -
070405 - The doctor was very pleased that Millie's breathing has finally
070406 - recovered enough to resume hiking, reported in her letter yesterday on
070407 - 100301. ref SDS 63 ON6Y
070409 -  ..
070410 - Doctor Johnson advised that increased energy and breathing capacity
070411 - for hiking, reported in Millie's letter yesterday, aligns with the CT
070412 - test at Kaiser on 100218 reporting findings that ground glass opacity
070413 - nodules in Millie's lungs appear reduced for the first time since the
070414 - test on 090413, that found increased ground glass opacities, presented
070415 - in the record on 090415. ref SDS 30 RV78  On 090514 Doctor Rugo
070416 - diagnosed Millie's breathing problems were caused by ground glass
070417 - opacities from radiation injury to the lungs. ref SDS 31 NL9I
070418 -
070419 -
0705 -

SUBJECTS
Default Null Subject Account for Blank Record

0803 -
080401 -  ..
080402 - Skin Only Cancer Medical Problem CT Test Finds No Adenopathy
080403 - Distant Metastasis Not Found CT Test IBC in Skin Only Cancer Problem
080404 -
080405 - This morning, Doctor Johnson confirmed comment in his letter from
080406 - Kaiser dated 100225, and received on 100228, ref SDS 62 565G,
080407 - transmitting the report on Millie's CT test on 100218, ref SDS 61
080408 - PQ6R, and showing test findings of no adenopathy, see 100228 2216,
080409 - ref SDS 62 KL5X, as further related in Millie's letter to the medical
080410 - team on 100301, ref SDS 63 ER95, indicate that Millie's only medical
080411 - issues now are pulmonary embolism, IBC in the skin, and shingles,
080412 - noted in Millie's letter to the medical team yesterday. ref SDS 63
080413 - OO5U, and reflecting Doctor Johnson's letter dated 100225, received in
080414 - the record on 100228 2216. ref SDS 62 4Q54
080416 -  ..
080417 - Discussion today of results for CT test on 100218, and received on
080418 - 100228, per above, ref SDS 0 FB90, are reflected in Kaiser's Medical
080419 - Chart today listing test summary in the Impression section (see below,
080420 - ref SDS 0 9D4Y).
080421 -
080422 -
080423 -
080424 -
0805 -

SUBJECTS
Default Null Subject Account for Blank Record

0903 -
090401 -  ..
090402 - Examination Finds IBC Spreads Near Untreated IBC Breastbone
090403 - IBC Spreads Right Side Chest Near Untreated IBC Breastbone
090404 -
090405 - Doctor Johnson examined Millie and found expanding IBC rash, since his
090406 - emergency examination on 100218 that found Millie's cancer has
090407 - relapsed for the 10th time, and so requires changing treatment,
090408 - beginning tomorrow, ref SDS 61 023N, and confirmed today, discussed
090409 - below. ref SDS 0 FB67
090411 -  ..
090412 - The doctor carefully palpated left and right axilla, and left and
090413 - right supraclavicular, where lymph nodes swelled from cancer have
090414 - always occurred in Millie's patient history of many relapse episodes.
090415 - Today, Doctor Johnson reported finding no evidence of LNs.  This
090416 - aligns with the CT test on 100218 which reported finding no
090417 - adenopathy in axilla nor supraclavicular lymph nodes.
090419 -  ..
090420 - Today, Millie is concerned about new nodules on the right breast and
090421 - on the upper left chest.
090423 -  ..
090424 - The doctor concurred that IBC enveloping the right breast is a
090425 - significant increase in cancer well above any prior condition in
090426 - Millie's 9-year patient history, as related in Millie's letter to the
090427 - team yesterday on 100301 0005. ref SDS 63 ON6V
090428 -
090429 -            [On 100303 0730 Millie begins 1st treatment of 1st cycle
090430 -            with Abraxane, ref SDS 64 625I; CA 15-3 426 reported for
090431 -            blood test yesterday on 100301; cancer marker more than
090432 -            doubling to rise over 200 in the past 4 weeks, signals
090433 -            Millie's cancer has mutated and is now progressing
090434 -            rapidly, which requires ending Navelbine, and starting
090435 -            another drug for Millie to recover from 10th relapse.
090436 -            ref SDS 64 EG9I
090438 -             ..
090439 -            [On 100304 2251 Millie notifies medical team that Doctor
090440 -            Johnson's prescription today on 100302 to start Abraxane
090441 -            treatment tomorrow, rather than try another cycle of
090442 -            Navelbine, was very effective because Millie's cancer
090443 -            marker, CA 15-3 426 increased to the highest level in
090444 -            patient history, and more than 200 points in the past
090445 -            month, following a 3 week pause in treatment to recover
090446 -            from shingles. ref SDS 65 OQ4T
090448 -             ..
090449 -            [On 100319 0843 cancer marker CA 15-3 360 dropped about 60
090450 -            points - aligns with evident reduction in IBC rash that
090451 -            signals some recovery achieved with first 2 treatments
090452 -            using Abraxane. ref SDS 72 1T4R
090454 -             ..
090455 -            [On 100330 0830 examination at Kaiser by Doctor Johnson,
090456 -            primary care physician, and starting 2nd cycle of
090457 -            Abraxane chemotherapy, Millie shows response to 1st
090458 -            cycle of treatment, ref SDS 74 FB9Y, including "drying
090459 -            up" of IBC nodules. ref SDS 74 HR9K
090461 -  ..
090462 - IBC first occurred in a small part of the inner right breast near the
090463 - breastbone originally reported at Kaiser during examination on 061208
090464 - 1200, ref SDS 6 AX6G, and confirming notice from Millie to the
090465 - medical team on 061204 0851. ref SDS 5 AE5I
090467 -  ..
090468 - IBC remained contained for 3 years until after UCSF made mistakes
090469 - failing to treat Millie's cancer in the breastbone for 6 months.
090470 - Untreated IBC has now spread to the entire right breast.
090472 -  ..
090473 - Doctor Johnson was pleased that in the past week or so intensity of
090474 - IBC seems to have subsided, and several bleeding lesions on Millie's
090475 - chest and left arm have improved by drying up, signaling some recovery
090476 - from responding to treatment with Navelbine, as related in Millie's
090477 - letter to the medical team on 100301 0005. ref SDS 63 ON6V
090478 -
090479 -
090480 -
0905 -

SUBJECTS
Default Null Subject Account for Blank Record

1003 -
100401 -  ..
100402 - Stage V Cancer Unique Continuous Treatment 9 Years 10th Relapse
100403 - Unique Case Continuous Treatment 9 Years 10th Relapse Stage V Cancer
100404 -
100405 - Doctor Johnson commented that Millie's case is unique getting
100406 - continuous treatment for 9 years, and with 10 changes of modality,
100407 - noted in Millie's letter to the medical team on 100301 0005.
100408 - ref SDS 63 PRYQ
100410 -  ..
100411 - On 090213, the doctor cited comprehensive case management by Kaiser
100412 - and UCSF, ref SDS 25 JL5I, had extended Millie's survival and quality
100413 - of life by orders of magnituge compared to other patients with similar
100414 - disease prognosis, reported on 090213 1140. ref SDS 25 4W72
100416 -  ..
100417 - At the next meeting a month later on 090325 0830, Doctor Johnson drew
100418 - a similar graph, but added a mark indicating Millie is near the end of
100419 - sustainable quality of life, and would soon suffer rapid decline.
100420 - ref SDS 26 P39M
100422 -  ..
100423 - On 090725, Millie's letter to the medical team cited Doctor Johnson
100424 - explained to Millie's daughter Pam, that surviving aggressive cancer
100425 - longer than expected takes "yoeman's work" performing comprehensive
100426 - case management in time to be effective. ref SDS 37 T58R
100427 -
100428 -
100429 -
100430 -
100431 -
1005 -

SUBJECTS
Default Null Subject Account for Blank Record

1103 -
110401 -  ..
110402 - Pain Controlled Less Oxycodone IBC and Shingles Subsiding
110403 -
110404 - Doctor Johnson asked Millie about pain she reported during the
110405 - emergency meeting on 100218, ref SDS 61 ES3U, and cited in her letter
110406 - to the team yesterday on 100301 0005. ref SDS 63 OP5U
110408 -  ..
110409 - Millie reported today now having less pain from shingles, and also
110410 - from cancer on her left arm and chest.  She indicated that pain is
110411 - controlled now with less oxycodone (Percocet), since ending treatment
110412 - a few days ago with Acyclovir (Zovirax) to recover from recurrent
110413 - shingles, and prescribed by the doctor during the meeting on 100218.
110414 - ref SDS 61 0Z33
110415 -
110416 -
110417 -
1105 -

SUBJECTS
Default Null Subject Account for Blank Record

1203 -
120401 -  ..
120402 - Acyclovir (Zovirax) Treatment Ends Shingles Sufficient Recovery
120403 - Shingles Recoverd Sufficient End Treatment Acyclovir (Zovirax)
120404 -
120405 - This morning the doctor described Millie's forehead shows slight
120406 - coloration, and the shingles "bump" swelling, which he observed on
120407 - 100218, ref SDS 61 PP5Y, has subsided.  Doctor Johnson decided that
120408 - examination shows shingles has recovered sufficiently to end treatment
120409 - with Acyclovir (Zovirax), so that Millie can start treatment tomorrow
120410 - with Abraxane to recover from the 10th relapse of cancer.  Balancing
120411 - tratment for shingles and cancer is discussed further below.
120412 - ref SDS 0 FC68
120414 -             ..
120415 -            [On 100304 2251 Millie reports to medical team that
120416 -            shingles coloration on forehead seems more intense, and
120417 -            there is increased pain; Millie reports no new "bumps"
120418 -            appear on her forehead. ref SDS 65 OP6W
120420 -             ..
120421 -            [On 100305 0822 Millie reports shingles seems well
120422 -            controlled, so there is hope of getting the 2nd treatment
120423 -            of the 1st cycle with Abraxane next Wednesday, and to
120424 -            recover from the 10th relapse of cancer ref SDS 66 0V6U
120426 -  ..
120427 - Doctor Johnson seemed to recommend during the meeting today shingles
120428 - vaccination because shingles is contagious for Millie's care givers.
120429 - He cited virulent affect on Millie with shingles lasting now over 2
120430 - months.  Recommendation for shingles vaccination aligns with research
120431 - on 100104 1115. ref SDS 47 5D3J
120432 -
120433 -        [On 100305 1000 VA was notified that Millie diagnosed with
120434 -        shingles, and her doctor reported this is a contagious disease;
120435 -        as a result, Doctor Lee ordered shingles vaccination.
120436 -        ref SDS 67 4O4O; and vaccination was performed later that same
120437 -        day. ref SDS 67 GT5G
120438 -
120439 -
120440 -
120441 -
120442 -
120443 -
1205 -

SUBJECTS
Default Null Subject Account for Blank Record

1303 -
130401 -  ..
130402 - 10th Relapse Abraxane Prescribed Navelbine End Treatment 9th Relapse
130403 - Abraxane Prescribed 10th Relapse Navelbine End Treatment 9th Relapse
130404 - Navelbine End Treatment 9th Relapse Abraxane Prescribed 10th Relapse
130405 -
130406 - Doctor Johnson did not have time yesterday nor this morning to contact
130407 - the lab for expediting the report on the cancer marker, as requested
130408 - in Millie's letter on 100301 0005. ref SDS 63 OO3R  After the meeting,
130409 - Arlette said she would get results on CA 15-3, and report to Millie
130410 - and the doctor for last minute consideration on changing treatments.
130412 -  ..
130413 - During the meeting, Doctor Johnson advised that regardless of results
130414 - from the CT test on 100218, and for the cancer marker from the lab on
130415 - 100301, examination today establishs that Millie has suffered her 10th
130416 - relapse of cancer, per above, ref SDS 0 FB9Y, and therefore the best
130417 - course of care is to end treatment with Navelbine and start Millie on
130418 - Abraxane tomorrow, as planned during the meeting on 100218.
130419 - ref SDS 61 023N
130420 -
130421 -            [On 100303 0730 Millie begins 1st treatment of 1st cycle
130422 -            with Abraxane, ref SDS 64 625I; CA 15-3 426 reported for
130423 -            blood test yesterday on 100301; cancer marker more than
130424 -            doubling to rise over 200 in the past 4 weeks, signals
130425 -            Millie's cancer has mutated and is now progressing
130426 -            rapidly, which requires ending Navelbine, and starting
130427 -            another drug for Millie to recover from 10th relapse.
130428 -            ref SDS 64 EG9I
130430 -             ..
130431 -            [On 100304 2251 Millie notifies medical team that Doctor
130432 -            Johnson's prescription today on 100302 to start Abraxane
130433 -            treatment tomorrow, rather than try another cycle of
130434 -            Navelbine, was very effective because Millie's cancer
130435 -            marker, CA 15-3 426 increased to the highest level in
130436 -            patient history, and more than 200 points in the past
130437 -            month, following a 3 week pause in treatment to recover
130438 -            from shingles. ref SDS 65 OQ4T
130440 -             ..
130441 -            [On 100319 0843 cancer marker CA 15-3 360 dropped about 60
130442 -            points - aligns with evident reduction in IBC rash that
130443 -            signals some recovery achieved with first 2 treatments
130444 -            using Abraxane. ref SDS 72 1T4R
130446 -             ..
130447 -            [On 100330 0830 examination at Kaiser by Doctor Johnson,
130448 -            primary care physician, and starting 2nd cycle of
130449 -            Abraxane chemotherapy, Millie shows response to 1st
130450 -            cycle of treatment, ref SDS 74 FB9Y, including "drying
130451 -            up" of IBC nodules. ref SDS 74 HR9K
130452 -
130453 -
130454 -
130455 -
130456 -
1305 -

SUBJECTS
Default Null Subject Account for Blank Record

1403 -
140401 -  ..
140402 - Side Effects Abraxane Tolerated Better than Navelbine
140403 -
140404 - Doctor Johnson discussed concerns about side effects of Abraxane,
140405 - reported in Millie's letter to the medical team on 100301 0005.
140406 - ref SDS 63 OO4Y
140408 -  ..
140409 - Millie was pleased hearing Doctor Johnson comment that Abraxane side
140410 - effects are tolerated by most patients better than Navelbine.
140411 -
140412 -            [On 100303 0730 Millie at Kaiser for 1st treatment of 1st
140413 -            cycle with Abraxane to recover from 10th relapse of cancer.
140414 -            ref SDS 64 625I
140416 -             ..
140417 -            [On 100305 0810 Millie reports tolerating Abraxane well
140418 -            2-days after the 1st treatment. ref SDS 66 0V6X
140419 -
140420 -
140421 -
1405 -

SUBJECTS
Default Null Subject Account for Blank Record

1503 -
150401 -  ..
150402 - Trip 2-weeks May 15 Kaiser Committed Millie Quality of Life
150403 - Quality of Life Kaiser Committed Millie 2-weeks Trip May 15
150404 -
150405 - Millie was further very pleased hearing the doctor's commitment today
150406 - on helping Millie recover from cancer with enough energy to make the
150407 - 2-week trip planned with her daughter, Pam, and daughter-in-law, Kim,
150408 - for May 10th.  Doctor Johnson mentioned the May 10th trip several
150409 - times during the meeting as a goal guiding the medical team.
150410 -
150411 -
150412 -
150413 -
1505 -

SUBJECTS
Default Null Subject Account for Blank Record

1603 -
160401 -  ..
160402 - Immune System Weakens Because Abraxane Lowers Blood Counts
160403 - Blood Counts Fall Risk Shingles Recurrence Pause Chemo Cancer Rises
160404 -
160405 - Doctor Johnson was concerned today about the sudden and significant
160406 - decline in Millie's blood counts reported for the lab on Monday,
160407 - 100301.  NEUTS 1.2 is well below Kaiser's standard of care for safe
160408 - chemotherapy treatment.  The doctor confirmed Zan's letter from the
160409 - Kaiser Oncology Pharmacy on 100219 disclosing that Abraxane lower's
160410 - immunity to infection by lowering blood counts, reported in Millie's
160411 - letter to the medical team on 100301 0005. ref SDS 63 4R3P  The doctor
160412 - cited Millie's patient history of Kaiser and UCSF waiving policy to
160413 - withhold chemotherapy when NEUTS fall below 1.5.  Doctor Johnson
160414 - explained that since Millie has consistently tolerated chemotherapy
160415 - with NEUTS above 1.0, reported in case study on 060810, ref SDS 3
160416 - HV45, he feels comfortable today approving her to start treatment with
160417 - Abraxane tomorrow with NEUTS at 1.2
160419 -             ..
160420 -            [On 100304 2251 Millie notifies medical team that Doctor
160421 -            Johnson is concerned starting Abraxane with blood counts
160422 -            already below published guidance for safe chemotherapy,
160423 -            since Abraxane will further reduce blood counts, which will
160424 -            increase risk of shingles recurring. ref SDS 65 OQ3V
160426 -  ..
160427 - More recent study on 081023 reports that Millie required 2 Neupogen
160428 - treatments per week to maintain blood counts for getting chemotherapy
160429 - with Carboplatin. ref SDS 12 QQ8H
160431 -  ..
160432 - The doctor decided to continue Neupogen with only 1 treatment, rather
160433 - than increase this to 2 treatments, despite side effects of Abraxane
160434 - chemotherapy reducing blood counts, reported by Zan in a letter from
160435 - Kaiser on 100219, as reported in Millie's letter to the medical team
160436 - on 100301 0005. ref SDS 63 4R3P  Millie's risk of further infection
160437 - from shingles due to treatment with Abraxane is therefore compounded
160438 - by the recent record of Millie's blood counts starting below the safe
160439 - level for chemotherapy getting both 1 Neupogen treatment, and having a
160440 - week of rest with no chemotherapy following the end of the 3rd cycle
160441 - of Navelbine on 100217.
160442 -
160443 -        [On 100304 2251 Millie's letter to Kaiser confirms that the
160444 -        medical team will approve the 2nd treatment for Millie next
160445 -        Wednesday on 100310, even if blood counts fall further below
160446 -        safe levels and increase Neupogen to increase blood counts.
160447 -        ref SDS 65 OQ4Q
160449 -         ..
160450 -        [On 100309 1643 Millie letter to medical team commends Doctor
160451 -        Johnson for case management because blood counts recover
160452 -        substantially, reversing sudden decline the past 2 weeks;
160453 -        justifies prescription on 100302 for 1 Neupogne teatment,
160454 -        ref SDS 0 FC5U, following the 1st reatment of the 1st cycle for
160455 -        Abraxane chemotherapy. ref SDS 69 2O9P
160457 -  ..
160458 - Doctor Johnson indicated that he will approve Millie for treatment
160459 - again next week, even if her NEUTS falls below 1.0, and in that case
160460 - he would prescribe increasing support from 1 to 2 Neupogen treatments.
160461 -
160462 -
160463 -
1605 -

SUBJECTS
Default Null Subject Account for Blank Record

1703 -
170401 -  ..
170402 - Balance Treatment Shingles and Cancer Requires Targeted Drugs
170403 - Death Risk Increases Pause Treatment Cancer While Treating Shingles
170404 -
170405 - Millie asked about balancing treatment for shingles and cancer, as
170406 - related in her letter yesterday on 100301 0005. ref SDS 63 OP6Q
170408 -  ..
170409 - Doctor Johnson confirmed this morning that treating Millie's cancer
170410 - with Abraxane chemotherapy risks fatal infection from  recurrent
170411 - shingles, because chemotherapy lowers blood counts, which then weaken
170412 - the immune system, as reported in Kaiser's letter dated 100219, on
170413 - side effects, and cited in Millie's letter to the medical team on
170414 - 100301. ref SDS 63 OO6Q
170416 -  ..
170417 - Doctor Johnson advised today that, if shingles recurs again, as
170418 - occurred recently on 100218, Millie will need treatment to recover
170419 - from shingles, which the doctor further noted today will require
170420 - pausing Millie's treatment again to recover for cancer, as was done
170421 - for 4 weeks, beginning on 100112, reported in Millie's letter to the
170422 - team on 100120 0217. ref SDS 52 HL3X
170424 -  ..
170425 - Since Millie has already suffered recurrence of shingles while getting
170426 - chemotherapy Navelbine, the chances another recurrence increase while
170427 - getting another cycle of chemotherapy, based on the sudden drop in
170428 - Millie's blood counts this week, discussed above. ref SDS 0 IC4N
170430 -             ..
170431 -            [On 100304 2251 Millie notifies medical team that Doctor
170432 -            Johnson plans to pause treatment with Abraxane essential
170433 -            for Millie to recover from the 10th relpase of cancer, of
170434 -            Millie suffers recurrence of shingles, and which will
170435 -            require immediediate treatment and recovery before resuming
170436 -            treatment for cancer. ref SDS 65 OQ4T
170437 -
170439 -  ..
170440 - Since Millie's cancer spread rapidly, with CA 15-3 426 more than
170441 - doubling to the highest level in patient history, during the 3-week
170442 - pause for treating shingles, any additional pause at this time
170443 - treating Millie's advancing cancer risks rapid decline to death from
170444 - losing control of her cancer.
170446 -  ..
170447 - This presents a dilemma like the team faced during treatment with
170448 - sunitinib, reported on 081230. ref SDS 18 I87N  At that time, rather
170449 - than increase Neupogen to strengthen the immune system, the team
170450 - paused treatment for cancer.  Pausing treatment, however, lost control
170451 - of cancer, forcing the team into emergency mode, when the cancer
170452 - marker doubled to CA 15-3 303 on 090116, at Kaiser. ref SDS 19 PQTQ
170454 -             ..
170455 -            [On 100305 0822 Millie reports shingles seems better
170456 -            controlled, ref SDS 66 ER95; she is more hopeful about
170457 -            getting through the 1st cycle without needing treatment for
170458 -            shingles, and so able to get 2nd treatment with Abraxane
170459 -            for recovering from 10th relapse of cancer. ref SDS 66 0W3Q
170460 -            Millie asks about prescription for treating shingles to
170461 -            have medication on hand to ensure timely recovery so that
170462 -            treatment for cancer is not interrupted. ref SDS 66 0W3T
170464 -             ..
170465 -            [On 100310 0730 Doctor Johnson visited with Millie in the
170466 -            Oncology Chemotherapy Infusion Clinic and made an
170467 -            examination.  The doctor concurred that shingles subsided,
170468 -            and that blood counts recovered to support getting Millie's
170469 -            2nd treatment with Abraxane, ref SDS 70 OR3H; the doctor
170470 -            did not prescribe treatment for shingles to maintain
170471 -            continuity of treatment for cancer. ref SDS 70 KE9I
170473 -             ..
170474 -            [On 100330 0830 Doctor Johnson examination at Kaiser finds
170475 -            no evidence of shingles recurrence, makes no assessment of
170476 -            the cause for increased pain on the forehead, head, neck,
170477 -            and across the upper back, ref SDS 74 FU5F; and, which was
170478 -            reported to the medical team the day before on 100329,
170479 -            ref SDS 73 WA8Y; the doctor does not extend prescription
170480 -            for Acyclovir (Zovirax) medication to be prepared for
170481 -            recovering from shingles recurrence, ref SDS 74 4E48, which
170482 -            Millie requested on 100305, ref SDS 66 0W3T, and in order
170483 -            to recover from shingles with enough time to maintain
170484 -            continuity of treatment to avoid death by recovering from
170485 -            cancer; instead, additional pain medication was prescribed
170486 -            with morphine. ref SDS 74 FB55
170488 -  ..
170489 - On 090202 Doctor Rugo notified the team to expedite treatment because
170490 - Millie's rapidly declining condition required "urgent" care "quickly."
170491 - ref SDS 22 Y15J  Kaiser immediately made a referral on 090202, for
170492 - UCSF to treat Millie with Hyperthermia and Doxil, reported in the
170493 - record on 090205. ref SDS 24 278T  Three (3) days after Doctor Rugo's
170494 - notice for "urgent" care, on 090205 delay getting treatment caused
170495 - cancer to worsen, most notably in the breastbone area. ref SDS 23 PR5K
170496 - Rapidly advancing cancer required Doctor Hsu to change the UCSF
170497 - treatment plan to radiation with hyperthermia. ref SDS 23 EY5F
170499 -  ..
170500 - Months after completing radiation and hyperthermia on 090317, Doctor
170501 - Hsu reported on 090609 that UCSF made two mistakes that injured
170502 - Millie...
170503 -
170504 -        1.  Cancer in the beastbone with the greatest concentration of
170505 -            IBC nodules, and which therefore required the most
170506 -            treatment, was not treated because radiation zones were
170507 -            layed out incorrectly. ref SDS 34 W65W
170509 -             ..
170510 -        2.  Radiation caused severe pain breathing from injury to the
170511 -            lungs, ref SDS 34 R24G, which was discovered from CT
170512 -            testing on 090413, finding ground glass opacities, and
170513 -            noted by Doctor Rugo on 090514. ref SDS 31 NL9I
170515 -  ..
170516 - As noted, after 8 months and two trips to the Emergency Department for
170517 - treatment of painful breathing, Millie's breathing has finally
170518 - improved the past few months.
170519 -
170520 -
170521 -
170522 -
170523 -
1706 -

SUBJECTS
Default Null Subject Account for Blank Record

1803 -
180401 -  ..
180402 - Targeted Treatment Avoids Weakening Immune System
180403 - Bone Marrow Immune System Not Degraded with Targeted Cancer Agents
180404 - Cancer Shingles Concurrent Recovery Requires Targeted Cancer Treatment
180405 -
180406 - Doctor Johnson said the only way for Millie to get treatment for both
180407 - cancer and shingles concurrently to maintain continunity of cancer
180408 - treatments and avoid exposure to fatal infection is to switch from
180409 - chemotherapy to prescribe agents, like PARP, targeted to the genetic
180410 - profile of cancer, because "targeted" cancer treatments, like
180411 - cetuximab and sunitinib, do not reduce bone marrow production that
180412 - replenishes blood counts.
180414 -  ..
180415 - PARP was cited by Doctor Rugo on 090616, as having been agreed with
180416 - Kaiser for Millie's next "targeted" treatment for Millie at UCSF after
180417 - starting with MPA to recover from cancer spreading due to UCSF medical
180418 - mistakes providing radiation services on referral from Kaiser.
180419 - ref SDS 35 KD6L  On 090716, UCSF ended MPA on 090716, and said PARP
180420 - would not be ready until September. ref SDS 36 EE6P  In September,
180421 - Doctor Johnson said UCSF had not contacted him about Millie starting
180422 - PARP.  On 090909, Doctor Johnson planned to invest time prescribing
180423 - "targeted" treatment for Millie to recover from UCSF medical mistakes.
180424 - ref SDS 38 3P4G
180426 -  ..
180427 - On 100108, Doctor Johnson submitted a letter he received from Doctor
180428 - Rugo's office worrying that treating Millie with PARP at UCSF was
180429 - complicated by Millie's prior treatment with Carboplatin. ref SDS 49
180430 - FM5I  Review showed that Doctor Rugo has doctor discretion for medical
180431 - necessity to resolve complications and provide essential care in time
180432 - to be effective.  UCSF can therefore provide PARP as necessary and
180433 - reasonable care for Millie to recover from cancer spreading due to
180434 - UCSF medical mistakes. ref SDS 49 WO9J  Millie's letter to the medical
180435 - team on 100112, requests medical services with PARP or equal to
180436 - recover from UCSF medical mistakes. ref SDS 50 IS5V
180438 -  ..
180439 - During the meeting at Kaiser on 100112, Doctor Johnson reviewed PARP,
180440 - and expressed high hopes that PARP will be effective for Millie,
180441 - because PARP is targeted to Millie's triple negative patient profile.
180442 - At that time, on 100112, Doctor Johnson called for Doctor Rugo at UCSF
180443 - to start Millie on PARP; he reported that Millie's treatment for
180444 - cancer with chemotherapy had to be paused to avoid risk of fatal
180445 - infection from shingles, because Doctor Rugo did not have time to
180446 - return his call on scheduling treatment with PARP that does not cause
180447 - any risk of fatal infections. ref SDS 51 OJ8G
180449 -  ..
180450 - Doctor Johnson's review on 100112, indicates PARP treatment targeted
180451 - to cancer, can be equal or better than results achieved for Millie
180452 - with cetuximab.  Millie confirmed these understanings in a letter to
180453 - the medical team requesting treatment with PARP to extend benefits of
180454 - prior treatment with cetuximab, reported on 100120 0217. ref SDS 52
180455 - HL7Y ref SDS 52 HL7Y
180457 -  ..
180458 - Doctor Johnson advised this morning that Doctor Rugo has still not had
180459 - time to return his calls on Millie starting treatment with PARP at
180460 - UCSF in order to recover from cancer spreading due to UCSF medical
180461 - mistakes.
180463 -  ..
180464 - Experience treating Millie for nearly 2 years with cetuximab shows
180465 - that targeted therapies control cancer without oncerous side effects.
180466 - This reduces pain in two (2) ways:  (1) preventing spread of cancer
180467 - prevents pain from rising cancer; and (2) treatment "targeted" to
180468 - cancer does not destroy blood cells, and so avoids pain from Neupogen
180469 - treatments to maintain the immune system, essential for survival, by
180470 - recovering from low blood counts caused by general chemotherapy agents
180471 - like Abraxane (see discussion above.
180472 -
180473 -            [On 100330 0830 doctor worried about Millie's rising pain
180474 -            from cancer spreading for 6 months during treatments with
180475 -            chemotherapy, and requiring Neupogen treatment needed to
180476 -            replenish blood cells destroyed by chemotherapy, and which
180477 -            causes additional pain, ref SDS 74 SM3L; prescribes more
180478 -            chemotherapy, ref SDS 74 FB67, adds morphine medication to
180479 -            mask pain, rather than prescribe therapy "targeted" to
180480 -            Millie's patient profile to eliminate pain by destroying
180481 -            cancer cells, and eliminating need for Neupogen.
180482 -            ref SDS 74 QX3K
180484 -             ..
180485 -            [On 100427 0830 Doctor Johnson reported Millie's cancer has
180486 -            mutated to resist chemotherapy, and so she needs a new
180487 -            strategy to treat her cancer as a chronic disease with
180488 -            therapy targeted to her patient profile. ref SDS 75 SJ6N
180489 -            Aligns with Doctor Johnson's review today of PARP targeted
180490 -            to Millie's triple negative status, reported on 100112
180491 -            0830, ref SDS 51 N586
180493 -  ..
180494 - Case study on Millie's patient history shows that treatments with
180495 - cetuximab and sunitinib were never paused due to low blood counts,
180496 - reported on 081205. ref SDS 15 EC5N
180497 -
180498 -            [On 100304 2251 Millie asks the medical team again to
180499 -            submit analysis of trade-offs for treatments "targeted" to
180500 -            Millie's patient profile which do not injure the bone
180501 -            marrow, and so reduce recurrence of shingles, and permit
180502 -            concurrent treatment with cancer and shingles, in the event
180503 -            that shingles does recur. ref SDS 65 OQ4Y
180505 -  ..
180506 - Accordingly, Kaiser and UCSF play "Russian Roulette" giving treatment
180507 - that is known to weaken the immune system, and thereby cause fatal
180508 - infection with shingles, diagnosed on 100104, ref SDS 47 PS49, and
180509 - which in turn can only be treated by stopping treatment for cancer at
180510 - a time when the cancer marker has exploded to the highest level in 9
180511 - years, reflecting the doctor's determination today that Millie's
180512 - cancer is spreading at record levels for her patient history.
180513 - ref SDS 0 FB9Y
180515 -             ..
180516 -            [On 100319 0843 Millie's letter to medical team reports
180517 -            initial recovery from 10th relapse after 2 treatments with
180518 -            Abraxane gives time to complete review and compare
180519 -            trade-offs for alternative oncology treatments in time for
180520 -            Millie to recover from the 11th relapse by treating
180521 -            Millie's cancer as a chronic disease. ref SDS 72 1T5V
180522 -
180523 -
1806 -

SUBJECTS
Default Null Subject Account for Blank Record

1903 -
190401 -  ..
190402 - Evidence-based Health Care Requires Trade-offs Balancing Risks
190403 - Due Process Life Threating Diseases Evidence-based Medical Practice
190404 - Targeted Treatment for Cancer Not Enough Time Present Trade-offs
190405 -
190406 - The doctor did not have enough time today to present Kaiser's work
190407 - plan for switching treatment to a targeted drug, requested in Millie's
190408 - letter to the medical team on 100301 0005, ref SDS 63 OP6V, and in the
190409 - event that shingles recurs, and requires stopping chemotherapy with
190410 - Abraxane.
190412 -  ..
190413 - Millie's letter on 100301 requested standard of care for
190414 - evidenced-based medical practice, required by Kaiser's policies,
190415 - reported on 090520 1153, ref SDS 32 4M9G, requires good-faith
190416 - performance of due process determining trade-offs for alternative
190417 - treatment modalities that extend life with a quality that makes life
190418 - worthwhile. ref SDS 63 OO8U
190420 -  ..
190421 - Millie suffers increased exposure to danger of losing her life because
190422 - Kaiser has failed to provide due process presenting trade-offs for the
190423 - patient to choose treatment that can be effective for both shingles
190424 - and cancer in time to be effective, as called out in for standard of
190425 - care, reviewed in the letter to the medical team on 090725 2017.
190426 - ref SDS 37 T58U
190428 -  ..
190429 - Millie has been patient reminding the team to provide due process for
190430 - standard of care comparing treatments for effectiveness, side effects,
190431 - and cost, shown in the case study on 090725 2017. ref SDS 37 X66O
190432 -
190433 -            [On 100304 2251 Millie asks the medical team again to
190434 -            submit analysis of trade-offs for treatments "targeted" to
190435 -            Millie's patient profile which do not injure the bone
190436 -            marrow, and so reduce recurrence of shingles, and permit
190437 -            concurrent treatment with cancer and shingles, in the event
190438 -            that shingles does recur. ref SDS 65 OQ4Y
190440 -             ..
190441 -            [On 100305 0822 Millie asks medical team again to submit
190442 -            analysis of trade-offs for treatments "targeted" to
190443 -            Millie's patient profile that do not degrade bone marrow,
190444 -            and so reduce risk of shingles recurrence, and in any event
190445 -            can be given concurrently with treatment for shingles if
190446 -            this disease does recur. ref SDS 66 0W3W
190448 -             ..
190449 -            [On 100319 0843 Millie's letter to medical team reports
190450 -            initial recovery from 10th relapse after 2 treatments with
190451 -            Abraxane gives time to complete review and compare
190452 -            trade-offs for alternative oncology treatments in time for
190453 -            Millie to recover from the 11th relapse by treating
190454 -            Millie's cancer as a chronic disease. ref SDS 72 1T5V
190455 -
190456 -
190457 -
1905 -

SUBJECTS
Default Null Subject Account for Blank Record

2003 -
200401 -  ..
200402 - Securemail Not Submitted for Patient Review
200403 -
200404 - Doctor Johnson did not submit the content of a "securemail" received
200405 - on 100208, and reported to the medical team that this has content
200406 - could not be accessed, reported also in the letter to the team on
200407 - 100301 0005. ref SDS 63 OP7T
200408 -
200409 -        [On 100309 1238 Millie's letter notifies the medical team that
200410 -        Kaiser's letter submitted on 100208 has still not been
200411 -        received. ref SDS 68 HL5R
200413 -         ..
200414 -        [On 100309 1238 Millie requests documentation for approving
200415 -        communication, including confidential information, using the
200416 -        domestic email addresses at Kaiser, and in order to provide
200417 -        timely, accurate coordination among the doctors collaborating
200418 -        to provid Millie's health care. ref SDS 68 HL6R
200419 -
200420 -
200421 -
200422 -
2005 -

SUBJECTS
Default Null Subject Account for Blank Record

2103 -
210401 -  ..
210402 - Authorization Blood Draws Power Port Primary Care Physician
210403 - Power Port Blood Draws Authorization Primary Care Physician
210404 - Blood Draws Power Port Authorization Primary Care Physician
210405 -
210406 - Doctor Johnson did not have time today to prepare instructions to the
210407 - Oncology Chemotherapy Infusion Clinic at Kaiser's Walnut Creek office
210408 - to perform blood draws using Millie's Power Port, and in order to
210409 - provide timely care required for Millie's patient profile, and
210410 - requested in Millie's letter to the medical team on 100301 0005.
210411 - ref SDS 63 OP5T
210412 -
210413 -
210414 -
2105 -

SUBJECTS
Default Null Subject Account for Blank Record

2203 -
220401 -  ..
220402 - Kaiser's Medical Chart Knowledge Management System
220403 -
220405 -  ..
220406 - Late this evening Millie tried to access Kaiser's medical chart for
220407 - Doctor Johnson's report on the meeting today.
220409 -  ..
220410 - Got a message saying the system is temporarily out of service for
220411 - repairs or improvement.
220413 -  ..
220414 - Finally access to Kaiser's Knowledge Management system was restored OA
220415 - 100315, using an alternate URL address provided in a letter from
220416 - Kaiser.  Was able to retrieve the doctor's report in the medical chart
220417 - for the meeting at Kaiser today.
220418 -
220419 -    1.  Received: 3/2/10 9:32 AM
220420 -
220421 -        Subject:  Visit 03/03/10
220429 -         ..
220430 -        Patient presents with: RECHECK
220431 -
220433 -         ..
220434 -        History of Present Illness:
220435 -
220436 -        Follow up
220437 -
220439 -        The patient is a 74 Y female with a history of IBC of left
220440 -        breast who was initially diagnosed 03/04/02.  S/P AC x's 4 from
220441 -        04/23/02 through 07/01/02 followed by Taxotere ending 12/04/02.
220442 -        She had recurrent disease noted initially in the cervical LN's
220443 -        03/03/04.  On E2100 Study with Taxol/Avastin, but she had a PE
220444 -        noted on CT 11/03/2004.  Then, because of progression of
220445 -        disease, the patient was started on Taxotere and Xeloda
220446 -        4/15/05.  She had a total of 8 cycles ending 9/16/05.  She had
220447 -        a palliative left mastectomy performed 10/21/05.  Then her left
220448 -        chest lesions began expanding again.  The patient started
220449 -        Taxotere and Xeloda again 07/21/06 for 7 cycles.  She was
220450 -        started on a Clinical Trial 02/01/07 at UCSF and was randomized
220451 -        to the Erbitux only (no Carbo) Arm.  She had weekly Carboplatin
220452 -        added 03/13/08 because of progression of disease.  Her disease
220453 -        progressed again and she began a Phase I/II Study of Sunitinib
220454 -        (SU11248) at UCSF 11/14/08.  Lengthy discussion about current
220455 -        status and response to therapy.  Because of cytopenias, MTX to
220456 -        be D/C'd and Sutent and CTX held and then dose reduced.  The
220457 -        patient started hyperthermia/XRT at UCSF 02/19/09 and completed
220458 -        it 03/17/09.  She has started the MPA Clinical Trial at UCSF
220459 -        06/16/09 but this has been D/C'd.  She started Gemzar 07/28/09
220460 -        and received Cycle #4 11/05/09.  Because of evidence of
220461 -        progression she was switched to Navelbine 11/18/09.  She states
220462 -        that her lymphedema bilaterally is improved.  Percocet alone is
220463 -        helping pain.  She developed a rash on her right forehead the
220464 -        first of the year which was shingles.  She continues taking
220465 -        Acyclovir and Prednisone.  She was seen by Ophthalmology
220466 -        01/11/10 and her eyes are fine.  She feels much better with
220467 -        less DOE.  However, erythema and nodularity have moved to her
220468 -        right breast.  Her 2nd exacerbation of shingles have now
220469 -        subsided.
220471 -         ..
220472 -    2.  Current medications:
220473 -
220474 -        HYDROCODONE/ACETAMINOPH 5-5
220475 -        WARFARIN 4 MG TABLETS
220476 -        LUMIGAN 0.03% EYE DROPS (2.
220477 -        TIMOLOL MALEATE 0.5% EYE DR
220478 -        OXYCODONE W/APAP 5-325 MG T
220479 -        AEROCHAMBER Z-STAT/PLUS W/O
220480 -        QVAR 80 MCG ORAL INHALER
220481 -        ALBUTEROL HFA 90MCG ORAL IN
220482 -        GUAIFEN/CODEIN 100-10MG/5ML
220483 -        LORAZEPAM 1 MG TABLETS
220485 -         ..
220486 -    3.  Review of systems:
220487 -
220488 -        Follow up
220489 -
220490 -        a.  Constitutional: Appetite and energy level are improving.
220491 -            Plans on taking trip to the Mediterranean in May; 12 day
220492 -            cruise
220494 -             ..
220495 -        b.  Eyes: Seen by Ophthalmology 01/11/10; no evidence of ocular
220496 -            involvement with shingles
220498 -             ..
220499 -        c.  ENT: No nose bleeds.
220501 -             ..
220502 -        d.  Cardiovascular: No SOB, palpitations or chest pain
220504 -             ..
220505 -        e.  Respiratory: No hemoptysis or cough. Some DOE noted
220506 -            GI: No nausea, vomiting or diarrhea
220507 -            GU: No hematuria or dysuria
220509 -             ..
220510 -        f.  Musculoskeletal: Left neck spasm and right shoulder pain
220511 -            stable with Robaxin
220513 -             ..
220514 -        g.  Skin: Pruritis of chest wall resolved
220516 -             ..
220517 -        h.  Neurological: No confusion, sensory changes or motor
220518 -            weakness
220520 -             ..
220521 -        i.  Psychiatric: Anxious
220522 -
220524 -         ..
220525 -        Physical Exam:
220526 -
220527 -        Follow up
220528 -
220529 -        a.  ECOG Performance Score 0
220530 -
220531 -        b.  BP 119/76
220532 -            Pulse 77
220533 -            Temp (Src) 98.6 F (37 C) (Oral)
220534 -            Wt 136 lb 6.4 oz (61.871 kg)
220535 -            SpO2 98%
220537 -             ..
220538 -        c.  Head: shingles right side of forehead largely gone
220540 -             ..
220541 -        d.  Eyes: normal conjunctiva
220543 -             ..
220544 -        e.  Mouth: normal mucosa
220546 -             ..
220547 -        f.  Lymph: no nodes palpable in neck or axillae
220549 -             ..
220550 -        g.  Breasts: evidence of erythema to other breast. Less edema
220551 -            in both arms
220553 -             ..
220554 -        h.  Lungs: clear to percussion and auscultation
220556 -             ..
220557 -        i.  Heart: regular without murmur or gallop
220559 -             ..
220560 -        j.  Abd: soft with normal bowel sounds. No masses or
220561 -            organomegaly
220563 -             ..
220564 -        k.  Ext: Edema increasing in both arms now
220566 -             ..
220567 -        l.  Bones: no tenderness
220569 -             ..
220570 -        m.  Neuro: awake, alert, and oriented. Moves all extremities
220571 -            well. Normal gait.
220573 -         ..
220574 -    4.  Lab:
220575 -
220576 -        Follow up
220577 -
220578 -        Creatinine 0.66 mg/dL
220579 -        ALT (SGPT) 33 U/L
220581 -         ..
220582 -        Anticoag Ther? WARFARIN
220583 -        PT, Patient H 18.1 Sec
220584 -        PT INR 1.8 Ratio
220586 -         ..
220587 -        WBC 4.0 K/uL
220588 -        RBC 4.05 M/uL
220589 -        Hemoglobin 12.1 g/dL
220590 -        Hematocrit 36.7 %
220591 -        MCV 91 fL
220592 -        RDW H 20.5 %
220593 -        Plt H 454 K/uL
220595 -         ..
220596 -        CA 15-3
220597 -        -----------------------------------
220598 -        02/16/10 10:58 | 328 H
220599 -        02/02/10 10:15 | 275 H
220600 -        01/11/10 10:47 | 212 H
220601 -        12/22/09 09:44 | 248 H
220602 -        12/15/09 08:50 | 211 H
220603 -        11/24/09 09:30 | 262 H
220604 -        11/03/09 08:40 | 299 H
220605 -        10/20/09 10:44 | 299 H
220606 -        10/06/09 09:15 | 343 H
220607 -        09/29/09 09:45 | 297 H
220608 -        09/21/09 05:35 | 302 H
220609 -        09/08/09 12:29 | 346 H
220610 -        08/25/09 10:13 | 335 H
220611 -        08/10/09 10:59 | 350 ?
220613 -         ..
220614 -    5.  Imaging:
220615 -
220616 -
220617 -        1.  02/18/10 CT THORAX W CONTRAST - received on 100228 2216.
220618 -            ref SDS 62 GU5L
220619 -
220620 -            a.  Mild interval improvement of the patchy ground glass
220621 -                opacities bilaterally.  There are still a few patchy
220622 -                densities noted predominantly in the bilateral lung
220623 -                bases.  [...Doctor Johnson quotes from test summary in
220624 -                the Impression section, 100228 2216, ref SDS 62
220625 -                IN6I...]
220627 -                 ..
220628 -            b.  New area of subsegmental atelectasis vs
220629 -                post-inflammatory scarring right upper lobe.
220631 -                 ..
220632 -            c.  Resolution of small left pleural effusion.
220634 -             ..
220635 -        2.  01/19/10 MRI BRAIN WO/W CONTRAST(STD) -
220636 -
220637 -            No significant abnormalities.
220639 -             ..
220640 -            09/19/09 CT THORAX W CONTRAST -
220641 -
220642 -            a.  No pulmonary emboli on a technically good study.
220643 -
220644 -            b.  The lungs show multiple areas of groundglass opacity
220645 -                and multiple small areas of more confluent density.
220647 -                 ..
220648 -            c.  Tiny left pleural effusion.
220650 -                 ..
220651 -            d.  S/P left mastectomy.
220653 -                 ..
220654 -            e.  A few additional minor findings, as described above.
220656 -                 ..
220657 -            f.  Since July 20, 2009 CT scan of the chest, there has
220658 -                been resolution of many of the pulmonary opacities but
220659 -                there are now many new ones, especially in the left
220660 -                lower lobe and in the right upper lobe.  The left
220661 -                pleural effusion is much smaller.  Otherwise, no
220662 -                change.
220664 -             ..
220665 -        3.  09/19/09 CHEST, SINGLE
220667 -             ..
220668 -        4.  07/31/09 RIBS, UNILATERAL, 2 VIEWS -
220669 -
220670 -            Right ribs appear intact
220672 -             ..
220673 -        5.  07/20/09 CT THORAX W CONTRAST -
220674 -
220675 -            a.  Negative for pulmonary embolus.
220676 -
220677 -            b.  New small left pleural effusion.  No pleural
220678 -                enhancement or evidence of loculation.
220680 -                 ..
220681 -            c.  Otherwise stable chest CT compared with recent
220682 -                examination from one month earlier.
220684 -             ..
220685 -        6.  06/12/09 CT THORAX, ABDOMEN, PELVIS W CONTRAST
220687 -             ..
220688 -        7.  06/12/09 CT NECK W CONTRAST
220690 -             ..
220691 -        8.  03/17/09 DXA BONE DENSITY, AXIAL -
220692 -
220693 -            a.  Bone mineral density calculated for the LUMBAR SPINE
220694 -                is statistically consistent with osteopenia.
220695 -
220696 -            b.  Bone mineral density calculated for the TOTAL HIP is
220697 -                statistically consistent with osteopenia.
220699 -             ..
220700 -        9.  01/22/09 SHOULDER, COMPLETE 2+ VIEWS -
220702 -             ..
220703 -            Orthopedic follow up.  See Orthopedic note for details.
220704 -            S/P reduction of anterior shoulder dislocation.
220706 -             ..
220707 -       10.  01/22/09 SHOULDER, ONE VIEW -
220708 -
220709 -            Dislocation, right shoulder.  Fracture right humeral head
220711 -             ..
220712 -       11.  01/22/09 CT CERV SPINE W/O CONTRAST -
220714 -             ..
220715 -            Degenerative changes of the cervical spine without evidence
220716 -            of acute C spine fracture or loss in alignment.
220718 -             ..
220719 -       12.  01/22/09 CT HEAD W/O CONTRAST -
220720 -
220721 -            a. No evidence of acute infarct or hemorrhage.
220722 -
220723 -            b. Sinus disease. Mild nasal septal deviation to the right.
220725 -         ..
220726 -    6.  Assessment:
220727 -
220728 -        Follow up
220729 -
220730 -        1.  Shingles exacerbation; improved but has mild neuropathy
220731 -
220732 -        2.  Metastatic breast cancer (IBC) lung, lymph node and chest
220733 -            wall; CT stable
220735 -             ..
220736 -        3.  Anemia due to chemotherapy
220738 -             ..
220739 -        4.  Cancer pain mild (left anterior chest wall and LUE pain)
220740 -            and improved on Percocet
220742 -             ..
220743 -        5.  Lymphedema slightly worse
220744 -
220746 -         ..
220747 -    7.  Plan:
220748 -
220749 -        Follow up
220750 -
220751 -        1.  D/C Navelbine
220752 -
220753 -        2.  Switch to Abraxane 100 mg/m2 or 150 mg/m2 iv qw x 3 weeks
220754 -            every 4 weeks; to start 03/03/10
220756 -             ..
220757 -        3.  Continue serial CA 15-3's
220758 -        4.  POLST completed
220759 -        5.  AD (Advance Directive) obtained
220760 -        6.  RTC one month
220761 -
220764 -
220765 -
220766 -
220767 -
220768 -
2208 -






































L>