CONTACTS
0201 - Kaiser Permante
020101 - Dr. Craig Boulris, M.D.; Orthopedic Surgon
020102 - Orthopedic Department
SUBJECTS
Email Fails Examination Xray Medical Records Lost Collaboration Meet
1403 -
1403 - ..
1404 - Summary/Objective
1405 -
140501 - Follow up ref SDS 60 0000, ref SDS 59 0000.
140502 -
140503 - Craig recommended a particular oral medication, ref SDS 0 9633, to
140504 - supplement exercise that builds strength, as treatment of knee
140505 - problems. Knee replacement may be needed in 10 years on left leg.
140506 - ref SDS 0 9733 He will submit a report confirming the name of the
140507 - medication and other findings. The examination was delayed and
140508 - incomplete because medical history and xrays were not submitted in
140509 - time for Craig to prepare for the meeting. Craig said Kaiser's
140510 - policies prevent giving his email address to expedite communication
140511 - with web mail. He is worried that getting medical history via web
140512 - mail will not be effective because he does not have a good way to use
140513 - this information to guide a medical examination. I will work with
140514 - Patient Assistance to solve this problem. ref SDS 0 2040 Since the
140515 - medical records were not provided, Craig ordered another set of xrays,
140516 - and this resulted in another mistake when the Kaiser ID was switched
140517 - with another patient. ref SDS 0 6305 After this was resolved, got
140518 - good advice on treatment options, and developed ideas for follow up.
140519 - ref SDS 0 7388
140520 -
140521 - [On 990913 submitted record to Craig. ref SDS 63 7728]
140523 - ..
140524 - [On 990916 record forwarded to Craig. ref SDS 65 0001]
140526 - ..
140527 - ..
140528 - [On 990927 submitted issues from report. ref SDS 68 0001]
140530 - ..
140531 - [On 990928 Craig received issues from report. ref SDS 69 0001]
140533 - ..
140534 - [On 991011 Craig submitted clarifications. ref SDS 73 0001]
140536 - ..
140537 - [On 000124 follow up examination. ref SDS 78 0001
140538 -
140539 -
140541 - ..
1406 -
1407 -
1408 - Progress
1409 -
140901 - Xrays on Knees and Medical History Not Submitted to Boulris
140902 -
140903 - Follow up ref SDS 60 9890, ref SDS 59 0584.
140904 -
140905 - Craig advised that Kaiser Park Shadelands did not submit xrays taken
140906 - on 990813, ref SDS 57 1457, and did not submit medical history for him
140907 - to prepare for meeting today.
140909 - ..
140910 - This conflicts with the record on...
140911 -
140912 - 1. On 990625 Kaiser's Team Care policy calls for doctors to
140913 - review medical history. ref SDS 41 6970
140915 - ..
140916 - 2. On 990907, ref SDS 61 1080, requesting Patient Assistance to
140917 - ensure that xrays and medical history were submitted to Craig
140918 - for the meeting today. ref DIP 9 0001
140919 -
140920 - [On 990913 received letter from Mark Mangrai that he was sick
140921 - last week and as a result was unable to take action on the
140922 - request sent on 990907. ref SDS 63 8058]
140924 - ..
140925 - [On 990912 article on front page of Sunday papers cites high
140926 - cost of medical mistakes. ref SDS 62 0001]
140928 - ..
140929 - [On 991006 Team Care policy to provide medical history and
140930 - xrays to team members was not followed because a doctor does
140931 - like web mail. ref SDS 71 0002]
140933 - ..
140934 - [On 991008 requested meeting with medical management to review
140935 - procedures. ref SDS 72 9055]
140937 - ..
140938 - [On 000121 Kaiser emphasizes careful handling of patient
140939 - records, and plans to roll out electronic system in late 2001
140940 - to improve present system. ref SDS 77 7654]
140942 - ..
140943 - [On 000211 Dale Ames was misdiagnosed, and wrong xrays used.
140944 - ref SDS 80 3600]
140946 - ..
140947 - 3. 990829 submitted ref DIP 8 4270 to remind Kaiser's staff about
140948 - submitting xrays and medical history to Craig. ref SDS 60 7387
140950 - ..
140951 - 4. 990813 submitted ref DIP 7 5810 requesting medical history be
140952 - submitted to support meeting with orthopedic doctor.
140953 - ref SDS 57 1457
140955 - ..
140956 - As a result, a second set of xrays were taken.
140958 - ..
140959 - Craig said this will only take 15 minutes, and then we can proceed
140960 - with the planned meeting; however, it took 45 minutes due to problem
140961 - reported below. ref SDS 0 6305
140962 -
140963 - Consideration is needed to review Kaiser procedures that encumber
140964 - the patient for half of a work day, considering travel and
140965 - traffic, to take xrays weeks in advance of a meeting, which can be
140966 - accomplished on-site within 20 minutes on the day of the meeting.
140967 -
140969 - ..
140970 - Email Hampers Management, Need Communication Metrics for Web Mail
140971 - Doctor Does Not Have Time to Review Medical History on the Web
140972 -
140973 - I offered to submit the medical history via web mail for Craig to
140974 - review, and we can reschedule the meeting so he has time to be
140975 - prepared, per Kaiser policy reported on 990625. ref SDS 41 6970
140977 - ..
140978 - Craig does not want to do this, similar to Syed on 990802, ref SDS 54
140979 - 9108, and Sylvia on 990625. ref SDS 41 1846
140981 - ..
140982 - Craig advised he does not need to review medical history, because
140983 - xrays, examination and discussion with the patient are sufficient to
140984 - treat the patient. Reliance on immediate impressions from sight and
140985 - sound is a common desire in medical practice, ref SDS 24 0866, and
140986 - among executives in business, reported on 990625. ref SDS 42 4914
140988 - ..
140989 - On 940728 Doctor Kory Zipperstein, who reviewed an actual SDS record,
140990 - reported that medical history saves time and money. ref SDS 15 0001
140992 - ..
140993 - Craig said he does not have time to examine medical history, as
140994 - reported previously by Doctor Sylvia Connolly on 990625. ref SDS 41
140995 - 2652 He noted that medical charts have history, but these are not
140996 - always available, as occurred today. He wants me to send a letter
140997 - that pulls together all of the relevant history he needs to review.
140998 -
140999 - [On 990912 article on front page of Sunday papers cites high cost
141000 - of medical mistakes. ref SDS 62 0001]
141002 - ..
141003 - [On 000121 Jeanne Bradley reported doctors are frustrated when
141004 - medical history is not submitted in time for meeting with a
141005 - patient. ref SDS 77 0783]
141007 - ..
141008 - I explained that critical history going back 10 - 20 years takes a lot
141009 - of time and effort to assemble, but that web mail links to relevant
141010 - portions of medical history. This expedites his time and my time.
141011 -
141012 - [On 991011 Craig reports having reviewed medical history,
141013 - and that it is not relevant to diagnosis. ref SDS 73 2303]
141015 - ..
141016 - Craig said Kaiser's policies prevent him from giving patients his
141017 - email address.
141019 - ..
141020 - Craig also worried that he would have to spend a lot of time searching
141021 - for relevant history if he gets web mail. He wants to save time.
141023 - ..
141024 - I explained, again, that web mail saves time by providing direct links
141025 - to relevant portions of medical history, and, also, provides the full
141026 - record, so that he can judge what needs further review, rather than
141027 - place the burden on the patient to guess about what is important for
141028 - effective medical practice.
141030 - ..
141031 - Craig clarified his concern about not using email for communicating
141032 - medical history.
141034 - ..
141035 - He said he is overwhelmed by email, which is pretty common everywhere,
141036 - as reported on 980807. ref SDS 30 2426
141038 - ..
141039 - If he gets an email today or tomorrow, then by the time we meet in a
141040 - few weeks, that email will be buried, lost or deleted and he won't be
141041 - able to remember what is relevant to our meeting, and he wont' be able
141042 - to find the email to review it during the meeting. He said that if he
141043 - can rely on talking to the patient, or getting a printed letter from
141044 - the patient, then his responsibility is limited to what the patient
141045 - can remember to say at the time. He can review the record during the
141046 - meeting with the patient, rather than prepare in advance of the
141047 - meeting.
141049 - ..
141050 - These issues were reviewed on 990625 concerning Kaiser's Healthwise
141051 - Handbook Guidelines for doctor patient partnership. ref SDS 41 9577
141053 - ..
141054 - Thanked Craig for considering this initiative, and apologized for
141055 - requesting consideration of methods beyond reach for conventional
141056 - medical practice.
141058 - ..
141059 - I explained that Welch web mail provides instant precision access to
141060 - relevant information, essential for comprehensive care. This
141061 - significantly improves conventional email, and improves by orders of
141062 - magnitude traditional medical practice using printed documents, as
141063 - seen, for example, from the record on 990802. ref SDS 54 0406
141065 - ..
141066 - Craig does not have experience with precision access in SDS records in
141067 - order to judge correctness of my representations today, so I stood
141068 - down on the issue.
141070 - ..
141071 - I will review with Patient Assistance how to help Kaiser accomplish
141072 - effective doctor/patient communcation without burdening the doctor's
141073 - time, as was done previusly on 990907. ref SDS 61 1080
141074 -
141075 - [On 990913 requested help from Patient Assistance. ref SDS 63 1269]
141076 -
141077 - [On 990924 Patient Assistance noted objections; reviewed advantages
141078 - of web mail again. ref SDS 66 9964]
141080 - ..
141081 - [On 990925 requested Pataient Assistance support again. ref SDS 68
141082 - 3966]
141084 - ..
141085 - [On 990928 report that Craig is using web mail. ref SDS 69 0001]
141086 -
141087 -
141088 -
141089 -
1411 -
SUBJECTS
Xray Left Right Knees Patient Identification Cards Switched Medical
2103 -
210401 - ..
210402 - Xray Knees Radiology Department
210403 - Patient Account Card Switched Medical Mistakes Radiology Department
210404 - Medical Mistakes Radiology Department Patient Account Card Switched
210405 - Radiology Department Patient Account Card Switched Medical Mistakes
210406 -
210407 - The medical assistant prepared a work order for new xrays.
210408 -
210409 - I took it to the xray department, and placed the work order in a
210410 - processing cabinet.
210412 - ..
210413 - The xray technician retrieved the work order about 15 mintues later,
210414 - and returned to his office to prepare for taking my xrays. He
210415 - returned in five minutes, and asked for someone else to come into the
210416 - xray room.
210418 - ..
210419 - I explained my understanding that I was next in line for xrays.
210421 - ..
210422 - The technician asked if I am so and so, and I gave my name. Since I
210423 - was only person in the waiting area, the technician exclaimed another
210424 - mistake has occurred, asked me to wait a minute. He went back to his
210425 - office and handed me the xray work order and asked if I was the person
210426 - on the work order.
210428 - ..
210429 - Since I was not, he concluded the work order was prepared incorrectly.
210431 - ..
210432 - He went to the medical administration area. A few minutes later, he
210433 - returned with the Medical Technician who prepared the work order. The
210434 - Medical Technician asked to see my Kaiser Card. I opened my wallet
210435 - and pulled out the card, and showed it to the technician. She asked
210436 - if I am so and so, and I gave my name.
210438 - ..
210439 - The Medical Technician said she filled out the xray work order
210440 - incorrectly, and that she gave me another patient's Kaiser Card. I
210441 - checked and saw I had my Kaiser card still in my wallet, even though
210442 - I had just handed a card to the Medical Technician.
210444 - ..
210445 - What seems to have happened is that there was another patient's Kaiser
210446 - card on the Medical Technician's desk for processing something else,
210447 - at the time the work order for my xrays was prepared. She used the
210448 - other patient's Kaiser account card to prepare the xray work order,
210449 - instead of asking for my Kaiser card, and then and gave the other
210450 - patient's Kaiser card to me, which I put in my wallet, assuming it was
210451 - mine, because she handed it to me.
210453 - ..
210454 - It was just a series of small mistake that the mind makes when rushed,
210455 - due to limited span of attention.
210456 -
210457 - [On 991001 space ship crashes on Mars due to small mistake.
210458 - ref SDS 70 0001]
210459 -
210460 - [On 050907 Kaiser attendant in Business Office submitted medical
210461 - records for 2nd opinion on the wrong patient. ref SDS 83 FB41
210463 - ..
210464 - The NWO... paper explains the compounding effect of small mistakes
210465 - over time. ref OF 4 JV3G In this case, we caught the problem early,
210466 - so harm was contained.
210468 - ..
210469 - Presumably, if I was on a bed, medicated and unable to speak, the same
210470 - mistakes could have been compounded by switching paperwork on an elbow
210471 - surgery for a heart transplant.
210472 -
210473 - [On 990912 article in Sunday Times about high cost of medical
210474 - mistakes. ref SDS 62 0001]
210476 - ..
210477 - [On 991008 requested meeting with medical management to review
210478 - procedures. ref SDS 72 6256]
210479 -
210480 -
210481 -
210482 -
2105 -
SUBJECTS
Left Knee Xray Moderate Degenerative Arthritis Osteoarthritis Can On
3003 -
300401 - ..
300402 - Left Knee Moderate Degenerative Arthritis Right Knee Less Severe
300403 - Xray Findings Moderate Narrowing Calcification Osteophytes Left Knee
300404 - Osteoarthritis Calcification Bone Spurs Fills Gap Removed Cartilage Left Knee
300405 - Degenerative Arthritis Can Only Get Worse Left and Right Knee Joints
300406 -
300407 - Follow up ref SDS 59 0879, ref SDS 57 1716.
300408 -
300409 - Explained background of injuries to both knees.
300411 - ..
300412 - While we talked, Craig examined the left and right knees, and
300413 - discussed potential treatments in a general way.
300415 - ..
300416 - Left knee suffered severe trauma in about July 1974 (or possibly the
300417 - year before in 1973) from industrial accident, falling 40' into a
300418 - pumping station under construction in West Sacramento. Fortunate to
300419 - land vertically between two large pumps rising about 4' with a space
300420 - of about 2' between them. Surgery was performed a week or so later
300421 - that removed cartilage from the inside of the left knee.
300423 - ..
300424 - From 1974 - 1986, there was no appreciable pain in either knee from
300425 - running 5 - 12 miles 4 - 7 days a week.
300427 - ..
300428 - In about 1986 began playing tennis 1 - 2 hours 4 - 7 times a week.
300430 - ..
300431 - On 881010, left knee suffered severe pain from playing tennis.
300432 - Examination and xray by Doctor Glick indicated furthering narrowing of
300433 - joint space. ref SDS 1 6295 The next day remedial arthroscopic
300434 - surgery was performed, reported on 881011 0830. ref SDS 2 6800 Two
300435 - separate tears in different cartilage members were repaired; the
300436 - doctor also found ligiment was likely removed during the first surgery
300437 - in 1973 or 74. ref SDS 3 007R In the past few years pain has
300438 - increased in the left knee an hour or so after playing tennis
300440 - ..
300441 - Right knee has suffered minor injuries - in 1971 banged right knee on
300442 - rocks in industrial accident. It was enough to cause bleeding, but
300443 - did not notice impaired use of knee. Earlier in 1968 during trials
300444 - for Olympic wrestling team, knee was twisted severely. Required
300445 - drainage and hospitialized for a week or so in traction at Fort Lewis
300446 - in Washington. Subsequently did not notice impaired knee function.
300447 - In past 6 months, right knee has gradually begun to hurt similar to
300448 - the left knee an hour or so after playing tennis.
300450 - ..
300451 - After presenting patient history of knee issues, the xrays performed
300452 - earlier today, per above, ref SDS 0 O595, and along with radiology
300453 - report, were ready for review.
300455 - ..
300456 - Craig presented the radiology report on the xray just performed, per
300457 - above, ref SDS 0 6305, which says...
300458 -
300459 - Patient Provider Catatory View FR DATE TO DATE
300460 - 05519189 Radiology Report
300461 -
300462 - Patient 1 of 1 Personal Physician: SYED E NAQVI MD SHA
300463 - Welch, Rod 70/M Radiology Report Exam 1 of 1
300464 - Page 1 of 2
300465 -
300467 - ..
300468 - KNEES
300469 - Ordered by: CRAIG M BOULRIS MD on 09/10/1999 1514 at WCR OUTPATIENT
300470 - Performed in: WCR - Read by DALE M JUNG MD
300471 -
300472 - -- HISTORY --
300473 - None provided.
300475 - ..
300476 - -- FINDINGS -- There is moderate narrowing of the
300477 - knee joint space on the left both medial and laterially.
300478 - Spurring of the articular surfaces is seen. Patellofemoral
300479 - joint space also shows narrowing. The right knee shows
300480 - only slight narrowing of the medial tibial femoral joint
300481 - space with slight spurring. There are no fractures.
300482 -
300483 - -- IMPRESSION --
300484 - Degeneration change more severe on the left than on the
300485 - right.
300487 - ..
300488 - RAD.REP
300490 - ..
300491 - Craig showed the xray film. He pointed out in the xray arthritic
300492 - condition of the left knee, as described in the report Findings, per
300493 - above. ref SDS 0 SY78 The xray film shows the gap between the top
300494 - femeral and lower tibia bones on the left side of the left knee joint
300495 - appears normal, indicating normal cartelage. However, the lower leg
300496 - (tibia) bone appears to have grown upwards filling the gap where
300497 - cartelage was removed on the right side of the left knee joint during
300498 - surgery in 1974. Thus, the tibia bone now seems to be nearly touching
300499 - the upper femeral bone on the inside of the left knee joint. Craig
300500 - diagnosed severe pain in the left knee arises from this condition of
300501 - "moderate" narrowing, which he further advised constitutes
300502 - "degenerative arthritis" caused by calcification and osteophytes (also
300503 - called "bone spurs" in the xray findings, per above, ref SDS 0 SY78).
300504 - Another term he used was "osteoarthritis."
300505 -
300506 - [On 990925 1058 received Craig's letter submitting his
300507 - opinion that radiographs show some osteoarthritis in left
300508 - knee with diminution of the medial joint space due to
300509 - calcification in the meniscal area, and, early osteophytes
300510 - formed on the femoral condyles. ref SDS 67 3088
300512 - ..
300513 - He said this condition of degenerative arthritis (also called
300514 - "osteoarthritis") cannot improve, and will get worse over time.
300515 - Without treatment and by stopping high stress activity, the left knee
300516 - will likely require knee replacement in 10 years. Continuing current
300517 - high stress activity running, particularly changing directions quickly
300518 - that occurs in tennis, football, basketball, etc., then without
300519 - treatment the left knee could require knee replacement in as little as
300520 - 5 years.
300522 - ..
300523 - I did not mention this to Craig during the meeting, today, but I was
300524 - struck that xray study today of the left knee looked very much the
300525 - same condition shown by the prior xray study 10 years ago on 881010,
300526 - where the outer side has a nearly normal gap between the upper and
300527 - lower leg bones, and the upper bone on the inner side is angled down
300528 - to fill the space where cartelage was partially removed during the
300529 - knee operation in 1974. In both studies, the upper and lower leg
300530 - bones seem nearly touching on the inside, symptomatic of degenerative
300531 - arthritis. ref SDS 1 6295
300533 - ..
300534 - [On 000124 Doctor Vincent Yamomoto in Orthopedics
300535 - Department at Kaiser in Walnut Creek diagnosed left knee
300536 - degenerative arthritis will continue to worsen, and require
300537 - knee replacement in 5 years. ref SDS 78 HU5O
300539 - ..
300540 - [On 151216 1130 new xray of left leg seems to show even gap
300541 - between the upper and lower leg bones, indicating the
300542 - cartelage has repaired from regimen hiking 11 miles per day
300543 - (10,000 miles past 4 years), with Glucosamine Chondroitine.
300544 - ref SDS 84 GO5K
300546 - ..
300547 - [On 151229 1239 met with Erica, Director of Imaging
300548 - Services for Diablo service Area, ref SDS 85 LK45; she
300549 - submitted copy of xray study on the left knee, performed on
300550 - 990910, at the Kaiser Radiology Department in Walnut Creek;
300551 - the report said simply "There is moderate narrowing of the
300552 - knee joint space on the left both medial and laterially.
300553 - Spurring of the articular surfaces is seen. Patellofemoral
300554 - joint space also shows narrowing." ref SDS 85 03A4
300556 - ..
300557 - I asked what accounts for the significant pain the right knee, that
300558 - seems similar to pain in the left knee, as reported in the record on
300559 - 990625, ref SDS 41 4420, if the right knee seems to be in better shape
300560 - than the left knee in the xrays?
300562 - ..
300563 - The doctor explained the xray shows the right knee has only mild
300564 - degenerative arthritis, which much less severe than significant
300565 - narrowing occurring in the left knee, described as "moderate" in the
300566 - xray report. ref SDS 0 SY78
300568 - ..
300569 - Craig speculated there may be pockets of cartilage that are missing in
300570 - the right knee that don't show up on the xray. These pockects
300571 - evidently cause pain during exercise. He drew a plan view diagram of
300572 - the cartilage surface to illustrate how isolated cartilage could be
300573 - missing from interior areas, but are not shown in a standard xray
300574 - because the angle of the camera is limited by the configuration of the
300575 - knee. (See also below. ref SDS 0 7872)
300576 -
300577 - [On 991011 Craig advises that the cause of comparable pain in the
300578 - right knee is not known. ref SDS 73 3088]
300580 - ..
300581 - [On 991018 article says MRI may be able to show cause of pain,
300582 - ref SDS 74 4620, submitted letter requesting comment. ref SDS 74
300583 - 0001]
300585 - ..
300586 - [On 000124 Vincint suggests causes of pain in right knee and says
300587 - MRI will not show pockets of cartilage missing. ref SDS 78 2860]
300589 - ..
300590 - We reviewed symptoms set out in the record on 990625, ref SDS 41 4420,
300591 - and, also, medical history, in a general way based on the same record.
300592 - ref SDS 41 5152
300593 -
300594 - [On 990915 Jeanne submitted medical history to Craig. ref SDS 64
300595 - 2255]
300597 - ..
300598 - The doctor examined the knees by bending them in various directions,
300599 - similar to the method used by Sylvia on 990625, ref SDS 41 0882, and
300600 - he asked if there is pain when sitting for extended periods, per
300601 - meeting with Christy on 990816. ref SDS 59 8769
300603 - ..
300604 - Craig advised that his father was an active athlete, and had a knee
300605 - replacement. Not sure if he said the work had to be re-done, or will
300606 - require re-work soon, because the cement fails over time. The main
300607 - point is that knee replacement does not restore a condition that
300608 - supports athletic stress on the knee. His dad has changed to activity
300609 - that is less stressful to knees, like swimming and biking.
300611 - ..
300612 - I mentioned having started biking.
300614 - ..
300615 - Craig indicated mountain biking provides a comparable workout to
300616 - running. He does mountain biking, and looks to be in pretty good
300617 - shape.
300618 -
300619 - [On 990927 reported good results from biking. ref SDS 68 0001]
300620 -
300621 -
300622 -
300623 -
300624 -
3007 -
SUBJECTS
Left Knee Right Knee Pain Relief Cortisone Injection Not Recommended
3903 -
390401 - ..
390402 - Cortisone Not Recommended Pain Relief Does Not Prevent Continued Failure of Knee
390403 - Pain Relief Does Not Prevent Continued Failure of Knee Cortisone Not Recommended
390404 -
390405 - Craig advised that cortisone injections can relieve pain, which was
390406 - cited in the letter from Sylvia received on 990706. ref SDS 45 0045
390407 -
390408 - I asked if this fixes the underlying problem that causes the pain?
390410 - ..
390411 - Craig advised cortisone does not solve the problem I have,
390412 - particularly in the left knee of degenerative arthritis, which worsens
390413 - with use.
390414 -
390415 -
390416 -
3905 -
SUBJECTS
Left Knee Replacement 10 Years Prognosis Without High Stress Activit
5203 -
520401 - ..
520402 - Knee Replacement Needed in 10 Years Without High Stress Activity
520403 -
520404 - Craig seemed to say again emphasizing that without treatment, then
520405 - even giving up high stress activity like tennis, that in 10 years I
520406 - will likely need a knee replacement to recover from advancing
520407 - osteoarthritis, per above. ref SDS 0 UW4N
520409 - ..
520410 - Since knee replacement does not support an active life, this is not a
520411 - good solution at this time.
520412 -
520413 - [On 990925 Craig's written report for the meeting today on
520414 - 990910, confirms diagnosis that evaluation indicates knee
520415 - replacement may be needed in 10 years. ref SDS 67 2951]
520417 - ..
520418 - [On 000124 0830 Doctor Vincent Yomamoto diagnosed knee
520419 - replacement may be needed in 5 years. ref SDS 79 HU5O
520420 -
520421 -
520422 -
5205 -
SUBJECTS
Cartilage Replacement Experimental Knee Treatments Osteoarthritis De
6903 -
690401 - ..
690402 - Cartilage Replacement Still Experimental; No Effective Cure
690403 - Injection Therapies Treat Isolated Pockets Not General Arthritis
690404 -
690405 - Craig explained that cartilage and its integration with bone and other
690406 - components is highly complex, and therefore impossible to replicate
690407 - with present technology.
690409 - ..
690410 - Craig drew a series of sketches to explain his impression from
690411 - extensive research and experience, that some injection therapies help
690412 - by providing lubrication, but none have been effective in restoring
690413 - pervasive loss of cartilage that has been removed by surgery, or worn
690414 - away through degenerative arthritis (also "osteoarthritis"), as shown
690415 - in the xray of left knee, per above. ref SDS 0 SY78
690417 - ..
690418 - Since we did not have the list of new therapies, ref OF 2 0001,
690419 - reported on 990625, ref SDS 41 5400, we could not address them
690420 - individually; except, Craig specifically does not recommend Synvisc,
690421 - which was cited in my letter to Syed, ref DIP 6 5841, on 990731.
690422 - ref SDS 53 0001
690423 -
690424 - [On 990924 Doctor Boulris recommends Synvisc. ref SDS 67 3955
690425 - and ref SDS 67 0770]
690427 - ..
690428 - [On 991011 Craig says success for Synvisc treatment has not been
690429 - as high as he would like to see. ref SDS 73 3942]
690431 - ..
690432 - [On 000124 Vincint was familiar with article on 8 new therapies
690433 - from work with another patient. ref SDS 78 2772]
690435 - ..
690436 - Craig seems to have a good knowledge of effective treatments, as well
690437 - as current fads being promoted in journals and the Internet. He seems
690438 - comfortable using the Internet.
690439 -
690440 - [On 990915 all of Kaiser's providers do not have access to the
690441 - Internet on their office computers. ref SDS 64 4524]
690443 - ..
690444 - Since the medical history was not submitted, ref SDS 41 5152, Craig
690445 - was unable to review all of the treatments submitted in the record on
690446 - 990625, when Sylvia made the initial examination. ref SDS 41 5400
690447 - This conflicts with the objective cited by Sylvia in the call on
690448 - 990701. ref SDS 44 0855
690449 -
690451 - ..
690452 - Hyaluronic Acid Treatment with Synvisc
690453 -
690454 - Craig did mention, however, during the meeting today consideration of
690455 - "hyaluronic acid" treatments with Synvisc. This happens to be cited
690456 - in the list of 8 new therapies. ref OF 2 7921 He seemed to indicate
690457 - these are not effective for my case. Hopefully, he can clarify this
690458 - in his report.
690460 - ..
690461 - [On 990925 the report makes general reference to "injectible"
690462 - therapies, but does not review the 8 new therapies, except for
690463 - Synvisc. ref SDS 67 0770]
690465 - ..
690466 - [On 991011 Craig confirmed recommendation to consider using
690467 - Synvisc, which is Hylauronic Acid injection treatment.
690468 - ref SDS 73 3942]
690470 - ..
690471 - [On 000124 Doctor Vincint Yamamoto advised the article on 8 new
690472 - therapies was helpful, based on prior work with another patient.
690473 - ref SDS 78 2065]
690474 -
690475 -
6905 -
SUBJECTS
Examination Knees Cartilage Loss Prescribe Strengthen Muscles Around
9203 -
920401 - ..
920402 - Muscle Strength, Some Pill Therapies are Helpful to Knee Joints
920403 -
920404 - Craig confirmed Christy's recommendation on 990819 that exercise can
920405 - be a significant factor in relieving stress on the knee joint that
920406 - causes wear during exercise. ref SDS 59 5612
920407 -
920408 - [On 991011 received letter from Craig confirming advantages of
920409 - exercise to build strength, reduce weight. ref SDS 73 9588]
920411 - ..
920412 - [On 000124 Doctor Yamamoto suggested special shoes to reduce
920413 - stress on knees during exercise. ref SDS 78 4160]
920415 - ..
920416 - He explained advantages of taking certain medications, like ibuprofen
920417 - (Motrin). Craig seemed to advise that medications should be taken
920418 - before exercise, rather than afterwards, because medication retards
920419 - swelling from inflamation.
920421 - ..
920422 - I asked why preventing swelling is useful, despite not treating the
920423 - cause of swelling.
920425 - ..
920426 - Craig explained it, but I did not follow the explanation. Hopefully
920427 - this will be covered in his report. ref SDS 0 3555
920428 -
920429 - [On 990924 the report does not cover this point. ref SDS 67 4524]
920431 - ..
920432 - Craig said Glucosamine Chondroitin pills has been found effective for
920433 - knee joint support, either as a lubricant or other form of aid, rather
920434 - than a mere pain and swelling treatment. He said it has been
920435 - succesful on dogs and horses in Europe. Evidently it has been used on
920436 - humans with success.
920438 - ..
920439 - Craig says it can it be purchased from Costco at a cost of $30 for a
920440 - month supply.
920441 -
920442 - [On 990925 Glucosamine is the medication. ref SDS 67 3120]
920443 -
920444 - [On 991011 purchased Glucosamine Chondroitin. ref SDS 73 2478]
920446 - ..
920447 - [On 991026 Don Harms recommends Glucosamine and Chondroitin.
920448 - ref SDS 75 3392]
920450 - ..
920451 - [On 991125 Steve considering this treatment. ref SDS 76 7654]
920453 - ..
920454 - [On 000124 Doctor Vincent Yamamoto 2nd opinion at Kaiser
920455 - uses Glucosamine and Chrondroitin and reports success in
920456 - treating knee pain, but no restoration of cartilage.
920457 - ref SDS 79 1680]
920459 - ..
920460 - [On 030807 case study shows personal history using liquid
920461 - Glucosamine Chondroiten and clincial research. ref SDS 81
920462 - FN9N
920464 - ..
920465 - [On 040529 0248 report that Glucosamine Chondroitin in
920466 - liquid form relieved knee pain from hiking 3 - 10 miles per
920467 - day. ref SDS 82 MN9P
920469 - ..
920470 - We should try to get some liturature on this.
920472 - ..
920473 - This clarifies Sylvia's comments on 990701, saying Kaiser does not
920474 - recommend pill therapies for knees. ref SDS 44 2015]
920475 -
920476 - [On 990915 Jeanne Bradley printed this record for Doctor Connolly.
920477 - ref SDS 64 0001]
920479 - ..
920480 - I asked Craig to submit a report explaining the various therapy
920481 - options he discussed today, setting out which seem most appropriate
920482 - and promising to achieve the objective of remaining active.
920484 - ..
920485 - Craig will include the name of the medication he recommends, in his
920486 - report.
920487 -
920488 - [On 990916 Jeanne submitted this record to Craig for reference in
920489 - preparing his report. ref SDS 65 0001]
920490 -
920491 - [On 990925 received Craig's report. ref SDS 67 0001]
920492 -
920493 -
920494 -
920495 -
9205 -
SUBJECTS
Default Null Subject Account for Blank Record
9303 -
930401 - ..
930402 - Medical Chart Progress Notes Orthopedic Surgery Consultation
930403 -
930404 -
930405 - [On 990925 received Craig's report, developed issues. ref SDS 67
930406 - 0001
930407 -
930408 - 1. KAISER PERMANENTE - WALNUT CREEK
930409 - ORTHOPEDIC SURGERY CONSULTATION
930411 - ..
930412 - 2. Patient
930419 - ..
930420 - 4. Date............................ September 10, 1999
930422 - ..
930423 - 5. Consultant
930424 - Craig M. Boulris, M.D.
930426 - ..
930427 - 6. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old male
930428 - with bilateral knee pain intermittently over the last several
930429 - years. He has had a previous left knee surgery for medial
930430 - meniscus tear 20 years ago .
930432 - ..
930433 - Patient history of injuries and prior surgeries on left knee was
930434 - presented during meeting reported above. ref SDS 0 L36I
930436 - ..
930437 - Kaiser examination report continues...
930438 -
930439 - He complains primarily of pain after 20 minutes or so of
930440 - playing tennis. He is not particularly tender here today but
930441 - does have pain with activities. He has tried anti-inflammatory
930442 - pills, physical therapy, and would like to discuss his knee
930443 - condition further.
930445 - ..
930446 - 7. PHYSICAL EXAMINATION: On physical exam, he has a full range of
930447 - motion. The left knee has a scar in the sagittal plane
930448 - consistent with medial meniscectomy. His joint lines
930449 - ""medially and laterally are nontender bilaterally today.
930450 - McMurray t~sting is negative. He has no pain with maximal
930451 - flexion of the knee. Lachman and ligamentous testing is
930452 - normal. The patella itself is nontender and only has mild
930453 - clicking through a full range of motion.
930455 - ..
930456 - 8. His radiographs shows mild to moderate arthritis of the left
930457 - knee with diminution of the medial joint space in particular
930458 - with some calcification in the meniscal area. There are some
930459 - early osteophytes which are formed on the femoral condyles.
930460 - The right knee is in much better condition with just some
930461 - minimal irregularity of the medial femoral condyle. No
930462 - significant diminution of joint space on these radiographs and
930463 - no osteophyte formation.
930465 - ..
930466 - Sounds like calcification and osteophytes on femoral condyles (bone
930467 - spurs) may contribute to joint closure causing pain.
930469 - ..
930470 - Kaiser examination report continues...
930471 -
930472 - 9. IMPRESSION: Osteoarthritis, moderate in left knee and mild in
930473 - right knee.
930475 - ..
930476 - 10. We had a lengthy discussion about management options which
930477 - initially would include those that he has already tried, namely
930478 - anti-inflammatory pills, Tylenol, physical therapy, activity
930479 - modification, perhaps wearing a Neoprene brace to keep his knee
930480 - a little warmer while playing tennis, and premedicating himself
930481 - with anti-inflammatories before playing tennis. If possible,
930482 - it would be beneficial for him to play on a clay court or
930483 - doubles as opposed to singles tennis on a hard court. We
930484 - discussed the overall negative effect of repetitive high load
930485 - type sports on articular cartilage. He would like to try to
930486 - get another ten years out of his left knee or more before
930487 - needing intervention. I told him at some point down the road
930488 - he is likely to need a knee replacement, at least on the left
930489 - side.
930491 - ..
930492 - 11. In the meantime, other than the measures already discussed, we
930493 - discussed possible use of injectables which include cortisone,
930494 - hydriodic acid, Synvisc. The pros and cons of these were all
930495 - discussed with the patient.
930497 - ..
930498 - 12. He can have three to five cortisone shots per joint annually .
930500 - ..
930501 - 13. Hydriodic acid is somewhat outdated now and has been replaced
930502 - by Synvisc which I think, should the cortisone fail, we could
930503 - try a dose of three injections in series.
930505 - ..
930506 - 14. We also discussed the use of Glucosamine. There has been some
930507 - early evidence to suggest that this may retard the rate of wear
930508 - of cartilage. It has been combined with Chondroitin sulfate
930509 - and the efficacy of Chondroitin sulfate is somewhat more
930510 - questionable. We also discussed the possibility of a
930511 - debridement of the knee arthroscopically to try to temporize
930512 - the need for a total knee replacement. The patient is going to
930513 - treat himself with. the most conservative measures first and
930514 - return if he desires an injection of cortisone.
930516 - ..
930517 - Aligns with discussion of trying Glucosamine Chondroitin, during the
930518 - meeting, per above. ref SDS 0 5628
930519 -
930520 - [On 990927 requested more specific prescription for using
930521 - Glucosamine and Chrondriton. ref SDS 68 0001]
930522 -
930523 - [On 991011 research on the web indicates that Chontroitin
930524 - with Glucosamine repairs cartilage. ref SDS 73 5933]
930526 - ..
930527 - [On 991011 purchased Glucosamine Chondroitin pills at
930528 - Costco. ref SDS 73 2478 Research indicates this might be
930529 - effective line of care. ref SDS 73 0546
930531 - ..
930532 - [On 991026 Don Harms recommends Glucosamine and Chondroitin.
930533 - ref SDS 75 3392]
930535 - ..
930536 - [On 991125 Steve considering this treatment. ref SDS 76 7654]
930538 - ..
930539 - [On 000124 Doctor Vincent Yamamoto 2nd opinion at Kaiser
930540 - uses Glucosamine and Chrondroitin and reports success in
930541 - treating knee pain, but no restoration of cartilage.
930542 - ref SDS 79 1680]
930544 - ..
930545 - [On 030807 case study shows personal history using liquid
930546 - Glucosamine Chondroiten and clincial research. ref SDS 81
930547 - FN9N
930549 - ..
930550 - [On 040529 0248 report that Glucosamine Chondroitin in
930551 - liquid form relieved knee pain from hiking 3 - 10 miles per
930552 - day. ref SDS 82 MN9P
930554 - ..
930555 - 15. Craig M. Boulris, MD
930557 - ..
930558 - 16. CMB:cb
930559 - D: 9-13-99
930560 - T: 9-21-99
930567 - ..
930568 - 18. THIS T.P.M.G. REPORT HAS
930569 - NOT BEEN REVIEWED BY THE
930570 - DICTATING PHYSICIAN
930571 -
930572 -
930573 -
930574 -
930575 -
930576 -
930577 -
930578 -
930579 -
930580 -
930581 -
930582 -
930583 -
930584 -
9306 -
Distribution. . . . See "CONTACTS"