CONTACTS 

SUBJECTS
Mastectomy Surgery Left Breast Removed for Palliation Strategy Propo

0903 -
0903 -    ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 26 0000. ref SDS 22 0000.
090502 -
090503 - Biopsies taken earlier on 051012 indicate a complete response to
090504 - treatment with no evidence of disease. ref SDS 0 L13H  Surgery today
090505 - for secondary IBC seems successful.  The doctor reports that a very
090506 - wide mastectomy and standard closure was accomplished without
090507 - complications. ref SDS 0 EG5L  This scope will be verified during a
090508 - follow up meeting on 051027. ref SDS 0 4M9H  Millie asked the doctor
090509 - today before surgery about the purpose of mastectomy for her patient
090510 - profile. ref SDS 0 8L9K  If surgery removed tissue previously infected
090511 - with microscopic cancer cells, then risk of relapse is reduced, which
090512 - in turn increases the chance for cancer-free survival. ref SDS 0 MP8K
090513 - The doctor advised that Millie would be in recovery for an hour, and
090514 - then can see visitors; this wound up taking 2.5 hours.  Finally
090515 - visited Millie in the late afternoon.  She was surprisingly alert and
090516 - energetic.  Millie was experiencing no pain; except for being in a
090517 - hospital, there was no evident reaction to having just come through a
090518 - major operation. ref SDS 0 QZ84  Kaiser should perform post-op Time
090519 - Out to explain the scope of work performed, and provide an as-built
090520 - drawing showing how this surgery was accomplished. ref SDS 0 6D4F
090522 -         ..
090523 -        [On 051022 Millie goes home from hospital. ref SDS 30 0001
090525 -         ..
090526 -        [On 051025 Gloria calls to advise the doctor has not submitted
090527 -        notification of ending Coumadin treatment for pulmonary emboli.
090528 -        ref SDS 30 0001
090530 -         ..
090531 -        [On 051026 Gloria called and advised Millie that the primary
090532 -        care physician changed the prescription on 051007 for ending
090533 -        Coumadin treatment, and ordered treatments resumed for
090534 -        pulmonary emboli, because Millie is a cancer patient, as
090535 -        required by Kaiser's guidance. ref SDS 31 PO7J
090537 -         ..
090538 -        [On 060417 physical therapyst finds improvement treating
090539 -        lymphedemia; explains that removal of lymph nodes during
090540 -        surgery on 051021 may have triggered increased symptoms of
090541 -        lymphedema. ref SDS 43 2Z9M
090543 -         ..
090544 -        [On 060623 red rash and rising CA 15-3 indicate IBC cancer
090545 -        relapse 8 months after surgery. ref SDS 45 025H
090546 -
090547 -
090548 -
090549 -
090551 -  ..
0906 -
0907 -
0908 - Progress
0909 -
090901 - Medical History Missing Required to Admit Patient for Surgery
090902 - Admitting for Surgery Patient History Prepared by Surgeon Missing
090903 -
090904 - We arrived in the surgery admitting department, and in about 20
090905 - minutes Millie was called for administration, similar to the first
090906 - surgery on 020312. ref SDS 1 7U43
090908 -  ..
090909 - The attendant worked with Millie obtaining information to prepare
090910 - Kaiser's computer files, including customer account, address, date of
090911 - birth, and other data previously presented, and so already known, to
090912 - Kaiser on numerous occassions over the past four (4) years.  This
090913 - seems to conflict with the report on 041013 that Kaiser has developed
090914 - effective Knowledge Management support. ref SDS 7 W14V
090916 -  ..
090917 - The attendant said that Kaiser's records are missing a report on
090918 - patient history which is required to be prepared by the surgeon in
090919 - order to admit a patient for surgery.  There is a note in Millie's
090920 - record that the surgeon prepared a report on scope and justification
090921 - for the operation today, but the report is not in the record.  The
090922 - attendant said that she would notify the surgeon to find this part of
090923 - the record.
090925 -  ..
090926 - The discussion today was not clear on whether the missing part of the
090927 - surgeon's record is the due diligence "workup" that presents the
090928 - purpose and planning for the surgery today, as discussed in the letter
090929 - prepared on 051019, ref SDS 28 LQ4F, and earlier on 051012 asking for
090930 - clarification of palliation strategy and local control rationale.
090931 - ref SDS 26 ZK6O
090932 -
090933 -     [On 051027 the doctor reported this document was subsequently
090934 -     prepared, and was not important for the patient to review.
090935 -     ref SDS 34 PO5J
090937 -      ..
090938 -     [On 051121 primary care physician found the surgeon's post-op
090939 -     report, and could not find the pre-op patient history, which was
090940 -     missing today. ref SDS 35 355G
090942 -      ..
090943 -     [On 061024 case study medical practice computer access limited
090944 -     even with everything on the computer, people can't find details
090945 -     stored in parts of the computer (software modules) that are not
090946 -     frequently used. ref SDS 47 JD9L
090947 -
090948 -
090949 -
090951 -  ..
0910 -
0911 -
0912 - 1147
0913 -
091301 - After Millie's records were completed on the computer, per above,
091302 - ref SDS 0 QV9M, a nurse took us up to the 2nd floor pre-op area.  Ron
091303 - and I stayed in the waiting room, while Millie went ahead and dressed
091304 - down to prepare for the operation.
091305 -
091306 -
091307 -
091308 -
091309 -
0914 -

SUBJECTS
Pre-op Preparations for Mastectomy Surgery Blood Tested for Pulmonar

1303 -
1304 - 1217
130501 -  ..
130502 - Pre-op Preparations Blood Tested for Pulmonary Emboli
130503 -
130504 - The nurse came to the waiting room and invited Ron and I to visit Mil
130505 - in the pre-op room.  She was on the gurney, and an IV was connected to
130506 - her port catheter.  Millie said she had to explain to the nurse how to
130507 - make this connection, which preliminarily was merely supplying saline
130508 - that keeps the port clear.
130510 -  ..
130511 - Since the port is being used today, Millie will not need the port
130512 - flushed on 051028, as scheduled on 050916. ref SDS 16 LA3O
130514 -  ..
130515 - Port will require being flushed in 4 weeks.
130516 -
130517 -     [On 051121 primary care physician submitted a schedule to Millie
130518 -     for getting the port flushed on 051202. ref SDS 35 SH5N
130520 -  ..
130521 - Surgery was scheduled for 1200, but events were behind schedule.
130523 -  ..
130524 - We had a good visit with Millie in the pre-op area while waiting for
130525 - the Surgery Department to clear other activities for operating on
130526 - Millie.
130528 -  ..
130529 - A nurse came into the room to draw blood for a test to evaluate
130530 - pulmonary emboli.  This addresses in part risks cited by the surgeon
130531 - on 050923, ref SDS 19 KF6I, and cited in the notice prepared for the
130532 - surgeon on 051019. ref SDS 28 D163  On 051007 the primary care
130533 - physician ended treatment with Coumadin for pulmonary emboli.
130534 - ref SDS 24 EQ7K  Earlier, on 050922 Doctor Bailey in a second opinion
130535 - cited risks of surgery for patient history of pulmonary emboli,
130536 - ref SDS 18 6Z5Q, and recommended a work up on Millie's hypercoagulable
130537 - state. ref SDS 18 XD9X
130539 -  ..
130540 - How will the doctor follow up Coumadin treatment for pulmonary emboli
130541 - since there are no further meetings scheduled with primary care
130542 - physician?
130544 -  ..
130545 - Millie suggested calling and reminding Gloria that the doctor ended
130546 - Coumadin treatments, following up Gloria's call on 051006. ref SDS 23
130547 - 5F5W  She feels that even though the doctor told the patient to end
130548 - Coumadin treatments, he may not have had time to enter an actual order
130549 - into the computer system, or otherwise notify Kaiser's Coagulation
130550 - Treatment Clinic in Martinez.  Millie wants to make sure that Gloria
130551 - gets the word, and is not put to a lot of extra work.
130552 -
130553 -     [...see below called Gloria and explained the primary care
130554 -     physician ended Coumadin treatments. ref SDS 0 RR9G
130556 -      ..
130557 -     [On 051025 Gloria advises that the Coagulation Treatment Clinic
130558 -     was not notified that Millie's Coumadin treatments were ended for
130559 -     pulmonary emboli. ref SDS 31 WN9O
130561 -  ..
130562 - Since the operation today is in the Kaiser Martinez clinic, the nurse
130563 - was very familiar with drawing blood from Millie on a mostly weekly
130564 - basis during the past year of being treated with Coumadin.  Millie was
130565 - very pleased to see the nurse, because she was very experienced and
130566 - has always hit the right vien on the first try.  The nurse said she
130567 - cannot use the port catheter installed to reduce the use of a needle
130568 - that caused Millie's arm to swell badly in 2004, reported on 040318.
130569 - ref SDS 3 CO3G  The nurse said she is not trained to use the port
130570 - catheter.  It was not clear why Millie was able to explain to another
130571 - nurse how to use the port catheter to connect an IV, but the nurse who
130572 - drew blood for the coagulation test, could not use the port as well.
130573 -
130574 -
130575 -
130577 -  ..
1306 -
1307 -
1308 - 1335
1309 -
130901 - The nurse came into the pre-op patient preparation room and
130902 - transported Millie on the gurney through the hall, down the elevator
130903 - and into the surgery department on the first floor.  The nurse said
130904 - that we can visit Millie in this pre-op area after Millie is released
130905 - from recovery about an hour following surgery.
130906 -
130907 -     [...see below turned out this was a mistake; Millie was taken to
130908 -     the 1st floor inpatient care area after surgery and recover.
130909 -     ref SDS 0 QY5N
130911 -  ..
130912 - Ron and I walked along, and then wished Millie good luck at the doors
130913 - leading into the surgery department.
130914 -
130915 -
130916 -
130917 -
130918 -
1310 -

SUBJECTS
Surgery Successful Surgeon Reports Scope Surgery Very Wide Mastectom
Axillary Node Disection Not Performed to Remove More Lymph Nodes Doc

2404 -
2405 - 1500
240601 -  ..
240602 - Scope of Surgery Very Wide Mastectomy with Standard Closure
240603 -
240604 - The doctor visited with us in the waiting room.  Introduced Millie's
240605 - son, Ron.
240607 -  ..
240608 - Surgery was originally considered by Tumor Board review on 040416,
240609 - shown by report received on 040517. ref SDS 6 VH7H  Radiation of left
240610 - supraclavicular post surgery was considered by the Tumor Board.
240611 - ref SDS 6 F78G  Due diligence "Time Out" procedures on risks of
240612 - surgery were presented on 051018. ref SDS 27 OX9N
240614 -  ..
240615 - The doctor was smiling and reported a favorable surgery, with no
240616 - complications.  The surgeon seemed very pleased with results today,
240617 - and crossed her fingers on both hands while voicing hopes that
240618 - boundaries determined on 050727 by visual observation of eliminated
240619 - IBC, ref SDS 11 JV5J, will be verified with favorable biopsy on tissue
240620 - removed today, like the thin skin test biopsies taken on 051012, and
240621 - received today, per below. ref SDS 0 N65J
240622 -
240623 -     [...see below on scope of surgical incision. ref SDS 0 SD7L
240625 -      ..
240626 -     [On 051027 biopsy on surgical tissue very favorable; no evidence
240627 -     of inflammatory breast cancer (IBC) found. ref SDS 34 U05M
240629 -      ..
240630 -     [On 060217 doctor describes swelling left axilla as post op
240631 -     edema. ref SDS 37 T56K
240633 -      ..
240634 -     [On 060306 examination at lyphedema clinic showed worsening
240635 -     condition; follow up meeting for personalized treatment scheduled.
240636 -     ref SDS 38 Q05H
240638 -      ..
240639 -     [On 060308 lymphedema symptoms increase, report at work.
240640 -     ref SDS 39 0001
240642 -      ..
240643 -     [On 060314 physical therapy treatment and new guidance for
240644 -     lymphedema; begin regimin of personal massage treatments to reduce
240645 -     swelling left arm. ref SDS 40 Q05H
240647 -      ..
240648 -     [On 060328 symptoms improve shown by slight decrease in
240649 -     measurements of left forearm. ref SDS 42 HO7F
240651 -  ..
240652 - If so, Millie may have a period of months or years of disease-free
240653 - survival from implementing recommendations by Doctor Guardino at
240654 - Stanford, reported on 041209, ref SDS 8 SN97, and in particular the
240655 - proposal by Doctor Grissom, received on 050920, ref SDS 17 XL8U, and
240656 - supported by Doctor Bailey in a 2nd opinion received on 050922.
240657 - ref SDS 18 XD8P  Surgery today seems to have addressed the purpose of
240658 - disease-free survival by reducing the risk of relapse.  Removing
240659 - breast skin previously infected with IBC, but which could contain
240660 - microscopic cancer cells not detected by testing, helps avoid relapse,
240661 - cited by the surgeon on 050923, ref SDS 19 KF6I, and later by primary
240662 - care physician on 051007. ref SDS 24 I482
240663 -
240664 -     [On 051022 doctor met with Millie for examination to confirm
240665 -     release from the hospital, and the doctor was pointedly pleased
240666 -     with results of surgery so far. ref SDS 30 NE89
240668 -      ..
240669 -     [On 051026 Millie experiencing physicial and emotional side
240670 -     effects from surgery. ref SDS 32 KG5I
240672 -      ..
240673 -     [On 051027 not enough time for doctor to present guidance nor
240674 -     orientation on dealing with physicial and emotional trauma of
240675 -     major surgery. ref SDS 34 EM4O
240677 -      ..
240678 -     [On 060623 red rash and rising CA 15-3 indicate IBC cancer relapse
240679 -     8 months after surgery. ref SDS 45 025H
240681 -      ..
240682 -     [On 060711 patient diagnosed IBC relapse left breast.
240683 -     ref SDS 46 025H
240685 -  ..
240686 - Millie advised later, after release from recovery, that the doctor
240687 - reported not having performed another axillary lymph node dissection
240688 - proposed by Doctor Shim in a 2nd opinion received on 050907,
240689 - ref SDS 12 JS4H, and in order to reduce the risk of further lymphedema
240690 - by minimizing loss of lymphatics required by mastectomy surgery.
240692 -  ..
240693 - Subsequent inspection of the surgical wound, shows a sutured incision
240694 - extending under the left arm, per below, ref SDS 0 4M9H, and so the
240695 - scope of this work requires further inquiry during the meeting
240696 - scheduled on 051027, also, per below. ref SDS 0 6K4J
240697 -
240698 -     [On 051027 doctor confirmed that axillary node dissection was not
240699 -     performed in order to avoid risk of lymphedema, ref SDS 34 LI3K;
240700 -     there was no discussion on the risk of lymphadenopathy based on
240701 -     patient history and new findings of ductal carcinoma in situ
240702 -     (DCIS) discovered by the biopsy performed on tissue from the
240703 -     surgery today. ref SDS 34 UW6U
240705 -      ..
240706 -     [On 060106 patient reports new swelling, large bulge under left
240707 -     axillary; initial diagnosis is lymphadema. ref SDS 36 S164
240709 -      ..
240710 -     [On 060217 PET scan test finds no evidence metastatic disease;
240711 -     doctor describes swelling left axilla as post op localized edema.
240712 -     ref SDS 37 T56K
240714 -      ..
240715 -     [On 060306 lymphedema symptoms escalating. ref SDS 38 J34I
240717 -      ..
240718 -     [On 060320 letter to primary care physician requests meeting with
240719 -     surgeon to review work on 051021 for clues about cause and
240720 -     treatment for lymphedema. ref SDS 41 VR6M
240722 -      ..
240723 -     [On 060328 symptoms improve shown by slight decrease in
240724 -     measurements of left forearm. ref SDS 42 HO7F
240726 -      ..
240727 -     [On 060417 therapyst finds decreased swelling, marked improvement
240728 -     compared to examination on 060314; explains that removal of lymph
240729 -     nodes during surgery on 051021 may have triggered increased
240730 -     symptoms of lymphedema. ref SDS 43 2Z9M
240732 -      ..
240733 -     [On 061027 Millie hospitalized during cancer treatment cycle with
240734 -     temperature 102.6, ref SDS 48 HP52; severe red rash and swelling
240735 -     envelops left arm and shoulder; diagnosis cellulitus caused by
240736 -     reaction to tramua from fall that broke middle finger of left hand
240737 -     on 060914, creating complications of lymphedema from loss of
240738 -     lymphatics removed during surgery today for left breast mastectomy
240739 -     to treat IBC with no evidence of disease. ref SDS 48 V759
240741 -  ..
240742 - The doctor was asked about the scope and boundary of surgery?  Was
240743 - surgical removal within or beyond the test biopsy surgeries taken on
240744 - 051012, ref SDS 26 DG6J, and for the purpose of removing microscopic
240745 - cancer cells with a very wide mastectomy that reduces risk of relapse,
240746 - as planned on 050923, ref SDS 19 E863, and presented in the letter
240747 - prepared on 051019 asking that Kaiser take Time Out to perform
240748 - requirements for due diligence? ref SDS 28 DZ56  (...below, the doctor
240749 - explained to Millie prior to surgery the purpose to remove microscopic
240750 - cancer cells that would otherwise cause relapse. ref SDS 0 8L9K)
240751 -
240752 -     [On 051022 Millie examined the surgical wound and found an
240753 -     incision line above the breast line; she asked why the incision
240754 -     was made above the left breast? ref SDS 30 4Q5M
240756 -      ..
240757 -     [On 051027 the surgeon explained having performed a standard
240758 -     mastectomy that extended above the upper two test biopsies, and
240759 -     below the two lower test biopsies. ref SDS 34 RA3H
240761 -  ..
240762 - The doctor described having performed a very wide mastectomy with
240763 - standard closure.  She advised of having found no obvious cancer tumor
240764 - mass, and so none was removed, which aligns with PET scan test
240765 - findings reported on 051007. ref SDS 24 L66M, and cited in the letter
240766 - prepared on 051019 for Kaiser to take a Time Out and perform due
240767 - diligence on the purpose of mastectomy surgery in this case.
240768 - ref SDS 28 D137  Today, the doctor showed with her finger making a
240769 - circular motion the wide outline of the surgical incision on her own
240770 - left breast.  This seemed to define an area above the upper two (2)
240771 - test biopsies and below the two (2) lower biopsies, as discussed on
240772 - 050923 in connection with immediate reconstructive plastic surgery to
240773 - close the wound. ref SDS 19 E863
240774 -
240775 -     [...below, the doctor's post op report describes an incision
240776 -     beyond the perimeter of test biopsies; there is no diagram in the
240777 -     report, ref SDS 29 TH50, and describes closure without
240778 -     complications. ref SDS 29 8B8J
240780 -      ..
240781 -     [On 050122 Millie's friend who has been a surgical nurse for 30
240782 -     years was amazed that a standard closure would be effective for a
240783 -     very wide mastectomy. ref SDS 30 4R4L
240785 -      ..
240786 -     [On 051027 the surgeon explained having performed a standard
240787 -     mastectomy where the incision formed a very wide oval that
240788 -     extended above the upper two test biopsies, and below the two
240789 -     lower test biopsies. ref SDS 34 RA3H
240791 -      ..
240792 -     [On 060320 letter to primary care physician requests meeting with
240793 -     surgeon to review work on 051021 for clues about cause and
240794 -     treatment for lymphedema. ref SDS 41 VR6M
240796 -      ..
240797 -     [On 060417 therapyst finds decreased swelling, marked improvement
240798 -     compared to examination on 060314; explains that removal of lymph
240799 -     nodes during surgery on 051021 may have triggered increased
240800 -     symptoms of lymphedema. ref SDS 43 2Z9M
240802 -      ..
240803 -     [On 060428 rising CA 15-3, and PET scan test rising FDG in right
240804 -     axilla, and left supraclavicular suggest possible IBC relapse
240805 -     scenario. ref SDS 44 QK7H
240807 -      ..
240808 -     [On 060623 red rash and rising CA 15-3 indicate IBC cancer relapse
240809 -     8 months after surgery. ref SDS 45 025H
240811 -  ..
240812 - The upper limit of removal demonstated by the doctor appeared to reach
240813 - beyond the line where the breast attaches to the chest, and so toward
240814 - the neck.  Per above, the doctor crossed her fingers on both hands
240815 - saying she is hopeful all of the skin infected with IBC was removed by
240816 - surgery today, ref SDS 0 E74F, as previously observed by the doctor on
240817 - 050324. ref SDS 9 YY7F  At that time on 050324, the surgeon was
240818 - concerned about not knowing the scope of skin to remove in order for
240819 - mastectomy surgery to be effective treating IBC involvement.
240820 - ref SDS 9 WH5L  Later, on 050727, when disease had subsided with
240821 - chemotherapy treatment using Taxoter and capecitabine (Xeloda), the
240822 - doctor planned to remove an area of breast skin wider than normal with
240823 - boundaries demonstrated by spreading her fingers about 2" above the
240824 - nipple of the left breast. ref SDS 11 JV5F  This scheme would have
240825 - left much of the previously infected skin in place on the breast.  The
240826 - doctor seems to have indicated today having performed a very wide
240827 - mastectomy to reduce the risk of relapse by removing microscopic
240828 - cancer cells. ref SDS 0 8K6N
240829 -
240830 -     [On 051022 Millie examined the surgical wound and found an
240831 -     incision line above the breast line; she asked why the incision
240832 -     was made above the left breast? ref SDS 30 5Q5I
240834 -      ..
240835 -     [On 051027 the surgeon explained having performed a standard
240836 -     mastectomy where the incision formed a very wide oval that
240837 -     extended above the upper two test biopsies, and below the two
240838 -     lower test biopsies. ref SDS 34 RA3H
240840 -  ..
240841 - Subsequent inspection of the surgical wound shows a sutured incision
240842 - approximately 4" - 5" long and extending below the left axilla.  It
240843 - seems to have been made below the breast line attachment to the chest,
240844 - contrary to impressions from discussion with the surgeon, per above,
240845 - ref SDS 0 SD7L, and therefore within the area previously infected with
240846 - IBC, reported by the surgeon on 050324, ref SDS 9 YY7F, although
240847 - certainly above the upper two test biopsies and also below the lower
240848 - two test biopsies, because these test incisions performed on 051012,
240849 - ref SDS 26 DG6J, are no longer visible.  Additionally, the incision
240850 - may have been along a line above the breast line, but was stretched
240851 - for closure, and so now appears slightly lower.  There is no evident
240852 - stretching of skin above the incision, but there must have been some,
240853 - because there is discernable stretching of the lower skin toward the
240854 - upper incision, although without severe distortion of skin tissue.
240856 -  ..
240857 - Since skin stretching along the length of the incision extending below
240858 - the axilla was not evident in pictures showing closure of a standard
240859 - mastectomy presented by the plastic surgeon on 050928 ref SDS 21 246J,
240860 - the implication is that a non-standard, possibly a very wide
240861 - mastectomy was accomplished for the purpose of reducing the risk of
240862 - relapse.  Since biopsies tested negative for cancer, per below,
240863 - ref SDS 0 LH6O, this scope of skin removal may turn out to be
240864 - adequate.  Absence of pre-op due diligence presenting a surgical plan
240865 - with layout of the incision indicates the record at this time does not
240866 - establish the operation removed all previously infected skin that may
240867 - contain microscopic cancer cells cited by the surgeon on 050923,
240868 - ref SDS 19 KF6I, and by primary care physician on 051007. ref SDS 24
240869 - I482
240871 -  ..
240872 - We need a diagram from the doctor to establish the actual outline of
240873 - surgical incision, and explanation of goals that guided the operation.
240874 -
240875 -     [...below, the doctor's post op report describes an incision
240876 -     beyond the perimeter of test biopsies; there is no diagram in the
240877 -     report, ref SDS 0 TH50, and describes closure without
240878 -     complications. ref SDS 0 8B8J
240880 -  ..
240881 - Research on the Internet finds no references to a "very wide
240882 - mastectomy," and only a few to a "wide mastectomy."  None describe a
240883 - range of skin removal that evidently occurred for Millie today.  No
240884 - published guidance was found for removing previously infected skin to
240885 - reduce the chance of relapse for IBC.
240886 -
240887 -     [On 051022 Janna expressed suprise that a standard closure can be
240888 -     effective for a very wide mastectomy, based on a long career
240889 -     assisting in surgical procedures. ref SDS 30 4R4L
240891 -      ..
240892 -     [On 051027 the surgeon explained having performed a standard
240893 -     mastectomy where the incision formed a very wide oval that
240894 -     extended above the upper two test biopsies, and below the two
240895 -     lower test biopsies. ref SDS 34 RA3H
240897 -  ..
240898 - On 050920 second opinion by Doctor Grissom proposed a "very wide
240899 - mastectomy" beyond the boundaries of biopsies taken to guide removing
240900 - skin previously infected with IBC and for the purpose of reducing the
240901 - chances of relapse from microscopic remnants of cancer that are not
240902 - detectable with testing. ref SDS 17 XL8U  Doctor Bailey made a similar
240903 - proposal in a second opinion received on 050922. ref SDS 18 XD8P
240904 - Today the doctor appears to have implemented proposals for a very wide
240905 - mastectomy that aimed to remove all of the previously infected tissue,
240906 - which is another way of saying surgically remove the cancer tumor that
240907 - resided in the skin, and thus reflects planning during the meeting on
240908 - 050923 when second opinions were discussed with the surgeon,
240909 - ref SDS 19 WH5L, and planning was made for a very wide mastectomy with
240910 - immediate reconstruction for the purpose of reducing the chances of
240911 - IBC to relapse. ref SDS 19 E863
240913 -  ..
240914 - At that time, on 050923, the surgeon noted that the plastic surgeon
240915 - might object to performing an immediate reconstruction. ref SDS 19
240916 - F144 The general surgeon further commented that if PET scan and biopsy
240917 - testing were favorable, finding no evidence of cancer, then a standard
240918 - mastectomy might be considered. ref SDS 19 4G4L  Subsequently, on
240919 - 050928 the plastic surgeon presented risks of immediate reconstructive
240920 - surgery, ref SDS 21 UM4I, and so recommended standard closure for a
240921 - very wide mastectomy, ref SDS 21 245N, which today the doctor seems to
240922 - explain was in fact accomplished. ref SDS 0 MM6M  A week later on
240923 - 051007 the primary care physician recommended the patient consent to a
240924 - standard mastectomy for a palliative treatment strategy, ref SDS 24
240925 - P64J, rather than for local control. ref SDS 24 6A4N  This seemed to
240926 - conflict with requirements for a very wide mastectomy to reduce the
240927 - risk of relapse by removing the involved skin previously infected with
240928 - IBC, and further conflicted with recommendations by Doctor Shim in a
240929 - second opinion discussed with the primary care physician on 050913
240930 - that proposed patient history presents opportunity for cure with
240931 - mastectomy surgery. ref SDS 15 TS5F
240933 -  ..
240934 - On 051012 the patient considered notifying Kaiser to perform Time Out
240935 - requirements for the due diligence checklist, ref SDS 26 6D4F, that
240936 - would verify how "standard mastectomy" that leaves previously infected
240937 - skin in place will support a pallation strategy and otherwise advance
240938 - interests of the patient to reduce the risk of relapse. ref SDS 26
240939 - WV7I  On 051018 reluctance to request that Kaiser perform requirements
240940 - for risk management was reviewed, ref SDS 27 OM8H, and at that time
240941 - further consideration was presented on filing a notice for Kaiser to
240942 - perform due diligence. ref SDS 27 OX9N  Consideration was presented
240943 - again on 051019. ref SDS 28 V55K
240945 -  ..
240946 - After the operation at about 1810, Millie advised that in the
240947 - operating room prior to starting surgery at about 1340, per above,
240948 - ref SDS 0 8K5O, she asked the surgeon to explain the purpose of
240949 - mastectomy surgery in this case, as set out in Kaiser's Time Out
240950 - requirements for due diligence proposed in the filing on 051012,
240951 - ref SDS 26 IA5V, and again on 051019. ref SDS 28 LQ4F  Today, Millie
240952 - recalled the surgeon saying something along the lines that there might
240953 - be microscopic cancer cells that could grow and cause relapse.  This
240954 - explanation of the purpose for surgery aligns with prior analysis that
240955 - surgery today does not palliate (i.e., relieve) symptoms of desease,
240956 - but strives to remove the cause of disease in order to avoid relapse.
240958 -  ..
240959 - Asking about the purpose of surgery, when there is no time to
240960 - influence the work, rather than weeks in advance where there is ample
240961 - time to adjust course reflects emotional reaction to worry about
240962 - conflicting fears that was reviewed in the record on 051018.
240963 - ref SDS 27 OM8H
240965 -  ..
240966 - Today, the general surgeon may have reached for an innovation by
240967 - performing a very wide mastectomy to reduce risks of relapse, yet with
240968 - standard closure to avoid risks of immediate reconstruction.  When
240969 - asked how this was accomplished, i.e., removing a wide area of skin,
240970 - and closing the wound without transplanted tissue, the surgeon noted
240971 - that standard closure presented no complications.  Without observing
240972 - the procedure, explanation stretches the immagination, as the doctor
240973 - evidently stretched to close a very wide mastectomy proposed by
240974 - Grissom and Bailey, per above. ref SDS 0 E44M
240975 -
240976 -     [...below, the doctor's post op report describes an incision
240977 -     beyond the perimeter of test biopsies, ref SDS 0 TH50, and
240978 -     describes closure without complications. ref SDS 0 8B8J
240980 -      ..
240981 -     [On 051027 the surgeon explained having performed a standard
240982 -     mastectomy where the incision formed a very wide oval that
240983 -     extended above the upper two test biopsies, and below the two
240984 -     lower test biopsies. ref SDS 34 RA3H
240986 -  ..
240987 - In discussion today, per above, the surgeon commented that a tumor was
240988 - not encountered, and that this was expected based on PET scan and
240989 - mammography testing that were negative for cancer.
240991 -  ..
240992 - The doctor said that Millie will be in recovery for about an hour,
240993 - then she will be moved to a post-op room on the 2nd floor where she
240994 - will stay until tomorrow, when she can come home.
240995 -
240996 -     [On 051022 Millie released to go home the next day after
240997 -     mastectomy surgery. ref SDS 30 NE8J
240998 -
241000 -  ..
241001 - Surgeon's Post Operation Report
241002 -
241003 - The doctor's post-operation report says...
241004 -
241007 -    Operative (IP)
241008 -    Procedure Date:  051021
241009 -    Admit:  051021; Disch:  051022 at MTZ,
241015 -     ..
241016 -    Preoperative Diagnosis:  Inflammatory breast cancer.
241018 -     ..
241019 -    Postoperative Diagnosis:  Inflammatory breast cancer.
241020 -
241021 -        [On 051121 received post-op report from primary care physician.
241022 -        ref SDS 35 355G
241024 -     ..
241025 -    Procedure:  Left total mastectomy
241027 -     ..
241030 -     ..
241031 -    Antsthesia:  General
241033 -     ..
241034 -    FINDINGS:   Normal-appearing breast tissue with well-healed
241035 -    lumpectomy site and chronically thickened skin consistent with
241036 -    previous radiation.
241038 -     ..
241039 -    FINDINGS:    Normal-appearing breast tissue with well-healed
241040 -    lumpectomy site and chronically thickened skin consistent with
241041 -    previous radiation.
241043 -     ..
241044 -    PROCEDURE IN DETAIL:
241046 -     ..
241047 -    The patient was brought to the operating suite and placed on the
241048 -    table in the supine position and after induction of general
241049 -    anesthesia and intubation, the patient's left breast was scrubbed,
241050 -    prepped and draped in the routing manner.
241052 -     ..
241053 -    An elliptical incision was designed to include the previous skin
241054 -    biopsy site.  Incision was made along this line sharply followed by
241055 -    cautery dissection through the dermis and subcutaneous tissue.
241056 -    Both the inferior and upper flap.  Skin hooks were place and using
241057 -    traction and cautery dissection, the upper flap was then created,
241058 -    taking the breast tissue away from the subcutaneous tissue all the
241059 -    way down to the chest wall and including the pectoral fascia.  From
241060 -    the sternum medically to the upper portion of the pectoralis
241061 -    superiorly, the lateral border of the pectoralis laterally.
241063 -  ..
241064 - Surgeon described operation in relation to original objectives for
241065 - very wide mastectomy to remove infected tissue. ref SDS 0 EG5L
241066 -
241067 -          [On 060711 IBC relapse diagnosed. ref SDS 46 025H  Red rash
241068 -          concentrates left of sternum. ref SDS 46 8Z8G
241070 -  ..
241071 - Doctor's report continues...
241072 -
241073 -    Attention was then turned to the inferior flap, which was created
241074 -    in a like manner, elevating the skin and subcutaneous tissue off
241075 -    the underlying breast tissue, from the sternum medially to the
241076 -    insertion of the rectus inferiorly and to the anterior border of
241077 -    the latissimus laterally.  Once this was completed
241078 -    circumferentially, the breast was then removed from medial to
241079 -    lateral from the chest wall, taking the pectoralis fascia with it.
241081 -     ..
241082 -    The specimen was removed from the patient and marked with sutures
241083 -    for orientation.  The cavity was then examined for evidence of
241084 -    hemostasis, which was obtained with cautery.  The area was
241085 -    irrigated copiously with saline and aspirated until clear.
241087 -     ..
241088 -    Two 10-French Jackson-Pratt type drains were then placed in the
241089 -    wound and brought out inferiorly by separated stab wounds.
241091 -     ..
241092 -    The skin flaps were then closed with interrupted dermal 3-0
241093 -    polysorb suture and continuous 4-0 Biosyn subcuticular suture and
241094 -    Steri-strips.  At the completion of the case, sponge and needle
241095 -    count were correct.  Estimated blood loss was less than 20 Ml.  The
241096 -    patient was wrapped with an Ace wrap for compression and comfort
241097 -    and taken to the operating room extubated and in good condition.
241099 -     ..
241113 -  ..
241114 - The doctor has scheduled to examine Millie on 051027, next week on
241115 - Thursday.
241117 -  ..
241118 - Pending issues...
241119 -
241120 -    1.  Relapse evaluation schedule CA 15-3 test based on Millie's
241121 -        history of relapse while off chemotherapy to recouperate from
241122 -        surgery, per Doctor Bailey's 2nd opinion received on 050922.
241123 -        ref SDS 18 XD6U
241124 -
241125 -            [On 051027 examination by surgeon noted urgency of careful
241126 -            testing to assess strength of recovery. ref SDS 34 L05O
241128 -         ..
241129 -    2.  Blood vessel supply for delivering nutrients and treatment, if
241130 -        necessary, to the skin over the surgical closure, so that the
241131 -        wound will heal, cited in the letter prepared on 051019,
241132 -        ref SDS 28 DZ4W
241133 -
241134 -            [On 051027 doctor explains that stretching skin for
241135 -            standard closure satisfied requirements for future
241136 -            treatment in case of relapse. ref SDS 34 QY8K
241138 -         ..
241139 -    3.  Coumadin treatment for pulmonary emboli, per above. ref SDS 0
241140 -        QW6H
241141 -
241142 -            [On 051027 Coumadin treatments resumed; investigate
241143 -            hypercoagulable state work up with oncology department.
241144 -            ref SDS 34 6Y7X
241145 -
241146 -
241147 -
241148 -
241149 -
241150 -
2412 -

SUBJECTS
Recovery 2.5 Hours Delays Millie Release to Inpatient Care

2503 -
2504 - 1517
250501 -  ..
250502 - Recovery 2.5 Hours Delays Millie Release to Inpatient Care
250503 - Family Friends Notify Millie Recovering from Surgery Seems Successful
250504 -
250505 - Called Marilyn, Steve, Drisc and Bob, Dorothy, Janna, Mother and Bob.
250506 -
250507 - Ron called Kim.
250508 -
250510 -  ..
2506 -
2507 -
2508 - 1536
2509 -
250901 - Called for Gloria in the Coagoalulation Treatment Clinic, as requested
250902 - by Millie, per above, ref SDS 0 RO8M, and left a message reminding
250903 - Gloria that on 051007 the doctor ended Millie's Coumadin treatments.
250905 -      ..
250906 -     [On 051025 Gloria called Millie and said she received the message
250907 -     today, and that the doctor has not notified the Anticoagulant
250908 -     clinic to end treatments with Coumadin; Gloria is coordinating to
250909 -     complete the record on notice requirements for ending Coumdain
250910 -     treatment. ref SDS 30 DI9H
250912 -      ..
250913 -     [On 051026 Gloria called and advised Millie that the primary care
250914 -     physician changed the prescription on 051007 for ending Coumadin
250915 -     treatment, and ordered treatments resumed for pulmonary emboli,
250916 -     because Millie is a cancer patient, as required by Kaiser's
250917 -     guidance. ref SDS 31 PO7J
250918 -
250919 -
250921 -  ..
2510 -
2511 -
2512 - 1610
2513 -
251301 - The attendant said that Millie has still not been moved from recovry.
251302 -
251304 -  ..
2514 -
2515 -
2516 - 1618
2517 -
251701 - Walked back to the 2nd floor pre-op patient area and talked to a
251702 - nurse, per planning earlier today.
251704 -  ..
251705 - The attendant behind the counter said she recalled overhearing the
251706 - nurse say earlier that Millie would be brought back to pre-op for
251707 - post-op care, per above, ref SDS 0 8K5O, but that this was a mistake,
251708 - because Millie is staying in the hospital overnight, so she will
251709 - actually be taken to the first floor patient care area and is assigned
251710 - to room 1106B.
251712 -  ..
251713 - Walked down to inpatient care on the first floor, and asked to see
251714 - Millie in room 1106B.
251716 -  ..
251717 - The nurse said Millie is awake and will be brought to the in-patient
251718 - care area shortly.  She apologized and said the nurses had some
251719 - emergencies to handle which has delayed bringing Millie from recovery.
251720 - The emergencies did not involve Millie, except to delay her transport
251721 - to the in-patient care area.
251723 -  ..
251724 - Walked to the waiting area, and explained emergency delays, but that
251725 - the nurse expects to call us shortly after Millie is settled into her
251726 - room.
251728 -  ..
251729 - Ron said he has a vollyball referree commitment this evening in
251730 - Oakland.  He will have to leave in 20 minutes or so in order to arrive
251731 - in time.
251733 -  ..
251734 - We are having the same delay problems this time with post-recovery
251735 - that happened during the first surgery on 020312 when recovery took
251736 - 2.5 hours instead of 1. ref SDS 1 H58I
251738 -  ..
251739 - The volunteer attendant came over several times to say they are still
251740 - waiting for Millie to be released from recovery.
251741 -
251742 -
251744 -  ..
2518 -
2519 -
2520 - 1645
2521 -
252101 - Ron had to leave to meet his commitment in Oakland.
252102 -
252104 -  ..
2522 -
2523 -
2524 - 1730
2525 -
252501 - The attendant notified that Millie can be visited in her room for
252502 - inpatient care in about 10 minutes.
252503 -
252504 -
252505 -
252506 -
252507 -
2526 -

SUBJECTS
Post-op Pain Minimal Energy High Recovery Mastectomy Surgery Left Br

2603 -
2604 - 1740
260501 -  ..
260502 - Post-op Visit Millie Pain Free Surprisingly Energetic Vitals Excellent
260503 -
260504 - Finally saw Millie.   She was amazingly normal, energetic and vibrant;
260505 - her voice was very strong.  An IV was connected, but no breathing
260506 - equipment was evident.  Explained that Ron had to leave for a
260507 - commitment in Oakland, but he heard the doctor's favorable report
260508 - earlier today, per above. ref SDS 0 EG5L
260510 -  ..
260511 - This is markedly different from the first surgery on 020312; at that
260512 - time, Millie seemed understandably weak, and tired, she was connected
260513 - to breathing equipment, and asked for water on several occassions.
260514 - ref SDS 1 7X5V  Since the surgery today was much more serious than the
260515 - first surgery on 020327, Millie's seemingly faster recovery today
260516 - seems unexpected.
260518 -  ..
260519 - Millie asked for her glasses so she could read.  I got them from her
260520 - personal affects bag stored in a locker in her room.
260522 -  ..
260523 - Mil advised that she was ready to leave Recovery within an hour after
260524 - surgery, but the nurses did not have time for taking her to the
260525 - inpatient care area.  This aligns with the surgery at Kaiser in Walunt
260526 - Creek on 020312, when Millie was, also, several hours late getting out
260527 - of the recovery department due to personnel issues. ref SDS 1 7Y31
260528 - Earlier, the nurse said the Recovery department was backed up working
260529 - on some emergencies. ref SDS 0 7H3F
260531 -  ..
260532 - Millie was having difficulty reaching with her left hand to get water
260533 - and other things on the bedside tray, since it was positioned on the
260534 - side with stiches from the operation.  I rolled the tray stand to the
260535 - right side, so she was more comfortable handling things.  The nurse
260536 - showed where her telephone was located, and I moved this to the
260537 - bedside tray for easy access.
260539 -  ..
260540 - A nurse took Millie's vitals, and commented that Millie has very
260541 - favorable low blood pressure and pulse.  She asked if Millie is an
260542 - athlete?  Her temperature was slightly low at 98.0, well within normal
260543 - for a surgery patient.
260545 -  ..
260546 - At 1810, Another nurse took Millie's order for dinner.
260548 -  ..
260549 - Mil explained plans to watch a particular television program at 2200,
260550 - which sounded ambitious.
260552 -  ..
260553 - The nurse said Millie can ask for pain medication when needed, and
260554 - also a sleep aid.  Millie said that she has not had any pain so far.
260555 -
260556 -
260557 -
260558 -
260559 -
260560 -
2606 -

SUBJECTS
Mastectomy Surgery Today Due Diligence Time Out Risk Management Perf

3503 -
350401 -  ..
350402 - As Built Drawing Required for Due Diligence Post-op Time Out
350403 - Time Out Due Diligence Risk Analysis Scope Purpose of Surgery
350404 -
350405 - Follow up ref SDS 26 6D4F.
350407 -  ..
350408 - There is no record of Kaiser performing "Time Out" requirements for
350409 - due diligence in this case, as shown in the letter prepared on 051019.
350410 - ref SDS 28 V55K  The missing surgeon's report on patient history
350411 - required for admitting a patient for surgery, per above, ref SDS 0
350412 - QV4H, may contain Kaiser's work on due diligence.
350414 -  ..
350415 - The doctor indicates an ad hoc decision was made using spontaneous
350416 - layout of a very wide mastectomy, and a standard closure was
350417 - accomplished, per above. ref SDS 0 MP8K
350419 -  ..
350420 - We need the doctor to prepare an as built showing the actual work
350421 - performed, and how this differs from a standard mastectomy, per above.
350422 - ref SDS 0 E48N
350423 -
350424 -        [On 051027 surgeon advised that surgeon's patient history
350425 -        required for admitting patient to have an operation is not
350426 -        important and not necessary for the patient to review; not
350427 -        enough time for doctor to submit an as-built showing the actual
350428 -        work performed. ref SDS 34 PO5J
350429 -
350430 -
350431 -
350432 -
350433 -
3505 -

SUBJECTS
Biopsy Received Pathology Findings for Biopsies Taken on 051012 to D

4103 -
410401 -  ..
410402 - Biopsies Indicate Complete Response to Treatment Local Disease
410403 - Complete Response to Treatment Local Control Biopsies Negative IBC
410404 - Local Control Biopsies Negative Suggest Complete Response to Treatment
410405 -
410406 - Follow up ref SDS 26 DG6J.
410408 -  ..
410409 - While we were waiting for Millie to be taken from pre-op into the
410410 - surgery department, the nurse submitted the latest lab report...
410411 -
410413 -
410414 -    ...for blood drawn on 050916, when Millie received treatment in the
410415 -    Chemotherapy Clinic.  This report shows the numbers in the notes of
410416 -    the primary care physician for the meeting on 051007 and received
410417 -    on 051011. ref SDS 25 WB3R
410419 -     ..
410420 -    This report updates figures in the record on 050916 for the lab the
410421 -    day before on 050915. ref SDS 16 Q659
410423 -  ..
410424 - When the surgeon briefed results of the mastectomy operation this
410425 - afternoon, about 1500, per above, ref SDS 0 EG5L, she advised that the
410426 - analysts pathology report on biopsies performed 051012, ref SDS 26
410427 - DG6J, was submitted to Millie prior to the operation, and was placed
410428 - in the plastic bag with her personal affects stored beneath the
410429 - surgery gurney.
410431 -  ..
410432 - Kaiser Permanente Walnut Creek
410433 - 1425 South Main Street
410434 - Walnut Creek, CA  94596
410435 - 925 295 4340
410437 -  ..
410438 - Terri M. Strinkirchner, MD, Chief of Pathology
410439 - David S. Forth, MD, Laboratory Director
410440 - LL Brewer, MD
410441 - JB Burkes, MD
410442 - CS Chen, MD
410443 - LK Finely, MD
410444 - KA Grise, MD
410445 - JW Walsh, MD
410446 -
410448 -  ..
410452 - Facility:    Walnut Creek                 Obtained:       051012
410453 - Service:     Surgery                      Accessioned:    051013
410456 -  ..
410457 - SURGICAL PATHOLOGICAL CONSULTATION REPORT
410459 -  ..
410460 - SPECIMEN(S):
410461 -
410462 -    A.  LEFT BREAST BIOPSY TOP MEDIAL
410463 -    B.  LEFT BREAST BIOPSY TOP LATERAL
410464 -    C.  LEFT BREAST BIOPSY BOTTOM MEDIAL
410465 -    D.  LEFT BREAST BIOPSY BOTTOM LATERAL
410467 -  ..
410468 - CLINCIAL DATA:
410469 -
410470 -    LEFT BREAST BIOPSIES
410472 -  ..
410473 - GROSS DESCRIPTION:
410474 -
410475 -    A.  Received designated "1 left breast biopsy, top medial" is a
410476 -        specimen consisting of an unoriented elipse of pale tan skin
410477 -        measuring 1.4 x 0.4 x 0.3 cm which has blank ink on the
410478 -        surface.  The surgical margins are inked.  The tips are
410479 -        submitted in 1 and the remainder of the specimen are submitted
410480 -        in 2.
410482 -         ..
410483 -    B.  Received designated "2 left breast biopsy, top lateral" is a
410484 -        specimen consisting of an unoriented elipse of pale tan skin
410485 -        measuring 2 x 0.3 x 0.3 cm which has blank ink on the
410486 -        surface.  The surgical margins are inked.  The tips are
410487 -        submitted in 1 and the remainder of the specimen are submitted
410488 -        in 2.
410490 -         ..
410491 -    C.  Received designated "3 left breast biopsy, bottom medial" is a
410492 -        specimen consisting of an unoriented elipse of pale tan skin
410493 -        measuring 1.5. x 0.4 x 0.4 cm which has blank ink on the
410494 -        surface.  The surgical margins are inked.  The tips are
410495 -        submitted in 1 and the remainder of the specimen are submitted
410496 -        in 2.
410498 -         ..
410499 -    D.  Received designated "4 left breast biopsy, bottom lateral" is a
410500 -        specimen consisting of an unoriented elipse of pale tan skin
410501 -        measuring 1.8 x 0.5 x 0.2 cm which has blank ink on the
410502 -        surface.  The surgical margins are inked.  The tips are
410503 -        submitted in 1 and the remainder of the specimen are submitted
410504 -        in 2.  (rj)  KMR/prv
410506 -  ..
410507 - FINAL DIAGNOSIS:
410508 -
410509 -    A-D:  Left breast biopsy, top medial and lateral and bottom medial
410510 -          and lateral.
410511 -
410512 -          •  Negative for residual inflammatory carcinoma.
410514 -  ..
410515 - This demonstrates correction of the problem discovered by the biopsy
410516 - taken on 044019, and reported on 040517 that diagnosed IBC.
410517 - ref SDS 6 7D6F  Presents strong evidence of complete response to
410518 - treatment that was the purpose of taking biopsies, reported on 051012.
410519 - ref SDS 26 VM8J
410521 -  ..
410522 - Biopsy findings continue...
410523 -
410524 -          •  Mild superficial dermal hyalinization and periviscular
410525 -             chronic inflammation (see comment).
410527 -  ..
410528 - This aligns with diagnosis on 040402 of reaction to radiation.
410529 - ref SDS 4 IM6J
410531 -  ..
410532 - Biopsy findings continue...
410533 -
410534 -    051014
410536 -     ..
410537 -    Karen M. Rowley, MD
410538 -    (signed copy in chart)
410539 -
410540 -
410541 -
4106 -

SUBJECTS
Radiation Reaction Mild Inflammation Left Breast Findings Pathology

4603 -
460401 -  ..
460402 - Radiation Reaction Causes Mild Inflammation
460403 -
460404 - Biopsy findings continue...
460405 -
460406 - COMMENT:
460407 -
460408 -    There are mild/minimal changes of superficial dermal hyalinization
460409 -    with an occassional enlarged fibroblast noted.  In the bottom
460410 -    medial and lateral biopsies perivascular chronic inflammation is
460411 -    also noted.  The skin surfaces are variably atrophic, with all of
460412 -    these changes suggesting minimal to mild radiation effect.  No
460413 -    residual carcinoma is seen on the multiple step sections of the
460414 -    biopsies.
460416 -  ..
460417 - This report supports prior diagnoses and examinations.
460419 -  ..
460420 - Case study shows...
460421 -
460422 -            CT test finds skin thickening
460423 -            may be from prior radiation;
460424 -            notes invasion of the dermal
460425 -            lymphatics from known breast
460426 -            cancer can present similarly.
460427 -            Correlate clinically............ 030710, ref SDS 2 GJ69
460429 -             ..
460430 -            Diagnosis changed from
460431 -            cellulitus to reaction to
460432 -            radiation....................... 040402, ref SDS 4 IM6J
460434 -             ..
460435 -            CT test shows no evidence
460436 -            of cancer in left breast,
460437 -            treatment for inflammation
460438 -            reaction to radiation
460439 -            ended........................... 040416, ref SDS 5 IM6J
460441 -             ..
460442 -            Slight coloration, flushness
460443 -            found by Doctor Bailey.......... 050909, ref SDS 13 1G4N
460444 -
460445 -
460447 -  ..
460448 - Biopsy report concludes...
460450 -  ..
460451 - Fee codes:
460452 -
460453 -    88305; 88305; 88305; 88305
460455 -  ..
460456 - END OF REPORT
460457 -
460458 -
460459 -
460460 -
460461 -
460462 -
460463 -
4605 -