CONTACTS 

SUBJECTS
Exercise Class Millie Maintaining Physical Conditioning 1 Day After

1103 -
1103 -    ..
1104 - Summary/Objective
1105 -
110501 - Follow up ref SDS 35 0000.
110502 -
110503 - Yesterday Millie had her first chemotherapy treatment at Kaiser in
110504 - Walnut Creek, ref SDS 35 407N, after being diagnosed with IBC relapse
110505 - on 060711. ref SDS 33 025H
110507 -  ..
110508 - After the treatment, she was very tired, and went to bed early about
110509 - 1800, shortly after having dinner.
110511 -  ..
110512 - This morning she was up at the regular time.  She went to exercise
110513 - class, which aligns with recommendations to maintain an active life
110514 - style for physical and emotional strength.
110516 -  ..
110517 - Mil saw her daughter, Pam, who was also at exercise class this
110518 - morning.  Pam invited Millie to dinner this evening.
110520 -  ..
110521 - Family visits like today, and going to the movies with grandchildren
110522 - (see below. ref SDS 0 3D7H) greatly helps Millie keep engaged in life
110523 - with forward expectations, called out by medical professionals on
110524 - recovering and living with cancer, reported on....
110525 -
110526 -        Primary care physician................ 030606, ref SDS 4 LZ3L
110527 -        Primary care physician................ 031205, ref SDS 5 GW8F
110528 -        Doctor Guardino at Stanford........... 041019, ref SDS 17 NN6N
110529 -        Article............................... 050609, ref SDS 24 F88M
110530 -        Primary care physician................ 060217, ref SDS 32 Y642
110531 -
110532 -
110533 -
110534 -
1106 -

SUBJECTS
Family Dinner with Pam and Bill and Nolan Son Ron Jr and His Family

1303 -
1304 - 1633
130501 -  ..
130502 - Family Event Millie Keeping Engaged Maintains Quality of Life
130503 -
130504 - Pam called and said the power is out in their area of Clayton, and may
130505 - not be restored until OA 2000.  Since the temperature is about 108
130506 - degrees today, this will present difficult conditions without power
130507 - for air conditioning at Pam's house.
130509 -  ..
130510 - Millie decided to go to dinner at Pam and Bill's.  She had made
130511 - potato salad, and took this along to contribute.
130513 -  ..
130514 - Turned out that Ron and Kim, and Stephanie and Amy also came to dinner
130515 - at Pam and Bill's so they had a nice family event.  This follows up
130516 - Millie's event last Sunday, when she went to the movies with
130517 - Stephanie, who had called and suggested an outing with Grandmother.
130518 - Stephanie recently returned from doing her junior year in France as
130519 - part of a college exchange program at the University of California in
130520 - Santa Barbara.
130522 -  ..
130523 - Family engagement complements exercise for maintaining quality of life
130524 - while undergoing cancer treatment, per above, ref SDS 0 0001, citing
130525 - prior guidance. ref SDS 0 KT8G
130526 -
130527 -
130528 -
1306 -

SUBJECTS
Family Genetic Disposition for Blood Clots Millie's Son Requires Con

3303 -
330401 -  ..
330402 - Family Genetic Disposition for Blood Clots Hypercoagulable State
330403 -
330404 - Follow up ref SDS 34 0001.
330405 -
330406 - A first-degree family member (son age 51) reported during the visit
330407 - today that while in the hospital for the second time suffering
330408 - pulmonary emboli, reported on 060714, ref SDS 34 0001, the doctor was
330409 - advised about family history on related symptoms diagnosed for
330410 - Millie's mother, and another family member, previously reported to
330411 - Kaiser in Millie's case on 040812. ref SDS 13 MG5K  Tests that
330412 - evidently found a genetic cause for blood clots.  As a result,
330413 - continuing treatments with Coumadin will be required for life to avoid
330414 - blood clots in the case of the family member.
330415 -
330416 -     [On 060724 notified Kaiser of family history genetic disposition
330417 -     for blood clot problems. ref SDS 36 NL5Q
330419 -      ..
330420 -     [On 060726 letter from Arlette says Kaiser received this notice
330421 -     and forwarded to primary care physician. ref SDS 37 0001
330423 -      ..
330424 -     [On 060808 backup doctor does not discuss new report on genetic
330425 -     cause of pulmonary emboli. ref SDS 38 9W4L
330427 -      ..
330428 -     [On 060825 doctor removes Coumadin (Warfarin) treatment for
330429 -     pulmonary emboli, to correct error in medical chart. ref SDS 40
330430 -     U66N
330432 -      ..
330433 -     [On 060929 patient reports symptoms of pulmonary emboli,
330434 -     ref SDS 42 B56N, doctor orders CT test, ref SDS 42 DY5M, and
330435 -     requests coagulapathy report on son's genetic disposition for
330436 -     pulmonary embolims. ref SDS 42 QT6N
330438 -      ..
330439 -     [On 061002 Millie diagnosed with pulmonary emboli recurrence, and
330440 -     begins treatment with Lovenox and Coumadin again. ref SDS 44 MI5I
330442 -      ..
330443 -     [On 061012 CT test report received; confirms pulmonary embolism
330444 -     recurrence, reconciles pattern of symptoms, ref SDS 46 N26L;
330445 -     current conditions seem less severe than PE on 041103, ref SDS 46
330446 -     7E7G, except new finding of enlarged right ventricle presents new
330447 -     problem of heart disorder. ref SDS 46 7E5L
330449 -      ..
330450 -     [On 061102 coagulapathy report received on family history;
330451 -     indicates possible finding Millie has increased genetic risk for
330452 -     blood clots, including pulmonary embolism. ref SDS 50 KJ3H
330454 -      ..
330455 -     [On 061102 date conflict showing test results were not available
330456 -     until mid-August may represent misunderstanding today. ref SDS 50
330457 -     L49L
330459 -  ..
330460 - Hypercoagulable state work up to evaluate genetic disposition for
330461 - blood clots was proposed by Doctor Bailey in a 2nd opinion on 050922,
330462 - citing family history, reported initially to Kaiser on 040812,
330463 - ref SDS 13 MG4G, and then later personal history of blood clot issues
330464 - diagnosed on 041104. ref SDS 18 RZ4I  Doctor Bailey maintained that
330465 - these factors require risk assessment for surgery that inherently
330466 - entails blood clot risks. ref SDS 27 XD9X
330467 -
330468 -     [On 061110 primary care physician received the coagulapathy
330469 -     report on first-degree relative submitted today on 061103,
330470 -     ref SDS 51 VR6F; the paragraph on risks and follow up to
330471 -     treat pulmonary emboli, ref SDS 51 N18S, was highlighted in
330472 -     the doctor's printed version, ref SDS 53 N18S; the doctor
330473 -     advised that the report shows positive findings for
330474 -     acquired rather than inherited DNA genetic risk for blood
330475 -     clots, and in this case pulmonary emboli, ref SDS 53 626L;
330476 -     the doctor recommended against further measures to evaluate
330477 -     patient profile, including defer hypercoagulable state work
330478 -     up, and indicated no adjustments required in diagnosis and
330479 -     treatment. ref SDS 53 JT6N
330481 -  ..
330482 - Research at that time on 050922 found that cancer patients can acquire
330483 - secondary hypercoagulable conditions for increased blood clots that
330484 - compound primary genetic factors. ref SDS 27 2G6G
330486 -  ..
330487 - On 051007 the primary care physician noted Kaiser's policy to treat
330488 - cancer patients for life when diagnosed with pulmonary emboli.
330489 - ref SDS 28 QG5H  The doctor further ordered Coumadin treatments
330490 - stopped because Millie had originally been diagnosed with pulmonary
330491 - emboli while being treated with Avastin, and this chemotherapy drug
330492 - agent has side effects of pulmonary emboli, reported by reference in a
330493 - meeting with the protocol nurse on 040402. ref SDS 6 Z95O
330494 - Additionally, Millie had been treated for pulmonary emboli during the
330495 - preceeding year without relapse. ref SDS 28 XN7K
330497 -  ..
330498 - The Coagulation Treatment Clinic staff reported on 051026 that
330499 - Coumadin treatments were continued under Kaiser's policy to treat
330500 - patient's for life with Millie's medical history of stage IV cancer.
330501 - ref SDS 30 PO7J
330503 -  ..
330504 - The order to end Coumadin treatments was then confirmed during a
330505 - meeting on 051121. ref SDS 31 RZ4I
330507 -  ..
330508 - Further, at that time, on 051121, the doctor explained hypercoagulable
330509 - state work up recommended in Doctor Bailey's 2nd opinion is not
330510 - required for the same reasoning. ref SDS 31 GW7G
330511 -
330512 -
330513 -
330514 -
3306 -

SUBJECTS
Pulmnary Emboli Define Symptoms Blood Clots Lungs Cough Shortness Br

4603 -
460401 -         ..
460402 -    1.  Pulmonary Embolism Defined Causes Symptoms
460403 -
460404 -
460405 -        Published by Emedicinehealth...
460406 -
460407 -        a.  Definition...
460408 -
460409 -                    http://www.emedicinehealth.com/pulmonary_embolism/article_em.htm
460411 -             ..
460412 -            Pulmonary embolism (PE) is a blood clot in the lung.
460413 -            ref OF 2 TU4K
460415 -             ..
460416 -            The clot prevents any further blood from traveling to that
460417 -            section of the lung. ref OF 2 I85J
460419 -             ..
460420 -            When no blood reaches a section of the lung, that portion
460421 -            of the lung dies because no blood or oxygen is reaching it.
460422 -            ref OF 2 196F
460424 -             ..
460425 -        b.  Symptoms...
460426 -
460427 -                    http://www.emedicinehealth.com/pulmonary_embolism/page3_em.htm
460428 -
460429 -             1)  Chest pain:
460431 -                  ..
460432 -             2)  Shortness of breath, ref OF 2 F27U
460434 -                  ..
460435 -             3)  Anxiety or apprehension
460437 -                  ..
460438 -             4)  Cough:  Usually, this cough is dry, but it may be
460439 -                 associated with blood. ref OF 2 F27O
460441 -  ..
460442 - On 041211 Millie had a bad incident of spitting up blood while
460443 - coughing; this was after she ended treatment with the Avasting trial,
460444 - and had been treated with Coumadin for about a month. ref SDS 22 0001
460446 -                  ..
460447 -             5)  Sweating
460449 -                  ..
460450 -             6)  Passing out
460452 -                  ..
460453 -             7)  Dizziness
460455 -  ..
460456 - Dizziness is not listed in this article, but is shown in many others.
460457 -
460458 -                  [On 061012 CT test reports enlarged right ventricle
460459 -                  compounds pulmonary embolism; research lists
460460 -                  dizziness and lightheadness as symptoms. ref SDS 46
460461 -                  IR46
460463 -  ..
460464 - Another source says in part...
460465 -
460466 -        National Heart Lung and Blood Institute
460467 -
460468 -              http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_signs.html
460469 -
460470 -        Signs and symptoms of pulmonary embolism vary depending on the
460471 -        amount of blood flow blocked in the lung by clots. Large clots
460472 -        or many clots are life threatening and cause more severe
460473 -        symptoms. Smaller clots cause fewer symptoms or no symptoms at
460474 -        all. It is important that you see your doctor immediately if
460475 -        you have any symptoms of pulmonary embolism or deep vein
460476 -        thrombosis (DVT).
460477 -
460478 -
460479 -
460480 -
4605 -

SUBJECTS
Wicked Problems Pulmonary Emboli Diagnosis Blood Clots Lungs Common

7203 -
720401 -  ..
720402 - Pulmonary Emboli Wicked Problems Common Symptoms Conceal Cause Effect
720403 - Wicked Problems Common Symptoms Conceal Cause Effect Pulmonary Emboli
720404 -
720405 - The next article confirms that pulmonary embolism is difficult to
720406 - diagnose, ref SDS 0 DT5N, as stated in the article reviewed above.
720407 - ref SDS 0 LK6M
720409 -  ..
720410 - Difficult diagnosis arises because symptoms of fatigue, shortness of
720411 - breath, coughing, heavy chest that occur with pulmonary emboli, per
720412 - above, ref SDS 0 VS4F, all occur in varying degrees that present no
720413 - actual maladies, and, also, commonly occur for other medical problems
720414 - which are not life threatening, e.g., the flue.
720415 -
720416 -               [On 080911 article on why doctors make mistakes common
720417 -               symptoms often mask diagnosis, preventing essential
720418 -               treatment while prescribing unnecessary treatment.
720419 -               ref SDS 61 U23V
720421 -                ..
720422 -               [On 081230 case study Millie's patient history shows
720423 -               dilemma balancing pausing treatments and reducing
720424 -               treatments in order to maintain sufficient blood counts
720425 -               that enable treatment with sunitinib "targeted" cancer
720426 -               treatment, while reducing or eliminating
720427 -               cyclophosphamide that may be resisted by Millie's
720428 -               mutated cancer cells, and which may be causing low blood
720429 -               counts that prevent treatment with sunitinib.
720430 -               ref SDS 63 I87N
720432 -  ..
720433 - Cancer increases risk of pulmonary emboli, ref SDS 0 KN5L, and
720434 - chemotherapy treatment for cancer causes side effects of weakness,
720435 - fatigue, which lead to shortness of breath from lack of fitness, as
720436 - related by the primary care physician on 050729. ref SDS 25 RZ4I
720437 -
720438 -               [On 061012 CT test report received; confirms pulmonary
720439 -               embolism recurrence, reconciles pattern of symptoms,
720440 -               ref SDS 46 N26L; current conditions seem less severe
720441 -               than PE on 041103, ref SDS 46 7E7G, except new finding
720442 -               of enlarged right ventricle presents new problem of
720443 -               heart disorder. ref SDS 46 7E5L
720445 -  ..
720446 - As a result, fatigue climbing stairs does not, per se, establish
720447 - pulmonary embolism.  Therefore, patients die spontaneously from this
720448 - disease that is only discovered by autopsy, and that symptoms were
720449 - regularly reported in the medical chart, but were too spread out for
720450 - busy doctors to recognize the profile for pulmonary emboli.
720451 - ref SDS 0 7P9F
720453 -  ..
720454 - Common symptoms create "noise" of "wicked problems" that prevent
720455 - timely diagnosis by recognizing "signal" of actual disease which
720456 - requires treatment, illustrated by the record on 991010 reporting on
720457 - NASA's loss of a Mars space project. ref SDS 1 3066
720459 -  ..
720460 - Pulmonary embolism therefore presents a "wicked problem" that took 6
720461 - months from initial symptoms on 040517, until initial diagnosis and
720462 - treatment was prescribed on 041104, as shown in the case study below.
720463 - ref SDS 0 6G6O
720464 -
720465 -     [On 060821 patient seeks 2nd opinion on performing hypercoagulable
720466 -     state work up to reduce risk of recurrence. ref SDS 39 U56I
720468 -      ..
720469 -     [On 061108 example "wicked problem" patient experiences symptoms
720470 -     that relate to enlarged right ventricle, and pulmonary embolism,
720471 -     cough clearing throat, fatigue, after treatment with coumadin;
720472 -     reluctant to notify doctor because this focuses on mortality that
720473 -     is easier to manage when suppressed, i.e., denial. ref SDS 52 VR6F
720475 -      ..
720476 -     [On 090312 0800 example "wicked problem" distinguishing response
720477 -     to treatment for IBC with radiation and hyperthermia because
720478 -     symptoms of IBC look very similar to side effects of treament,
720479 -     ref SDS 65 YX40, especially without CA 15-3 cancer marker to guide
720480 -     analysis. ref SDS 65 YX5F
720482 -  ..
720483 - Diagnosing IBC was another "wicked problem" that took nearly 18
720484 - months, as reviewed on 040517. ref SDS 9 S66O  In that case, similar
720485 - problem of overlapping symptoms occurred with IBC being diagnosed as
720486 - cellulitus initially on 030109. ref SDS 3 0T6N
720488 -  ..
720489 - Similarly, diagnosing cancer in the left axillary was a "wicked
720490 - problem." ref SDS 9 SU7G
720491 -
720492 -     [On 060929 diagnosis of IBC relapse seems like a "wicked problem,"
720493 -     because Doctor Benz finds no measureable disease. ref SDS 43 VD6H
720494 -
720495 -     [On 070419 "wicked problem" diagnosis erratic inflammation on
720496 -     upper left arm many possible causes, including progression of IBC,
720497 -     cat bite, Cellulitis, etc. ref SDS 60 S57H
720499 -      ..
720500 -     [On 080911 article on why doctors make mistakes common symptoms
720501 -     often mask diagnosis, preventing essential treatment while
720502 -     prescribing unnecessary treatment. ref SDS 61 U23V
720504 -  ..
720505 - Treating the punch biopsy wound on 041202 that landed Millie in the
720506 - Emergency Room with fears of IBC spinning out control, further
720507 - illustrate the challenge of "wicked problems." ref SDS 20 4Q94
720509 -  ..
720510 - The facts that Millie has stage IV cancer, that she was treated with a
720511 - chemotherapy agent with documented history causing pulmonary embolism,
720512 - and has family history of cardio-pulmonary problems, together provided
720513 - criteria that justified timely investigation for pulmonary embolism,
720514 - when symptoms were first reported, per case study below. ref SDS 0
720515 - 6G6O
720516 -
720517 -
720519 -  ..
720520 - False Positive Noise Overwhelms Signal Patient Got Wrong CT for PE
720521 -
720522 - The big question is why two earlier CT scans did not identify
720523 - pulmonary embolism?
720525 -  ..
720526 - Why did the CT scan on 041103 identify pulmonary embolism, and the
720527 - previous two (2) did not, as reported the next day on 041104?
720528 - ref SDS 18 4Y9G
720529 -
720530 -        [On 061020 primary care physician discloses that CT scans for
720531 -        pulmonary embolism are different from CT scans Millie normally
720532 -        gets for cancer assessment; this apparently created a false
720533 -        positive that misled the doctor and the patient to believe that
720534 -        symptoms of pulmonary embolism were benign, rather than to
720535 -        investigate by ordering a proper test. ref SDS 48 5A4J
720537 -  ..
720538 - Why were CT scans ordered a month earlier than scheduled for quarterly
720539 - criteria for the Avastin trial?
720541 -  ..
720542 - Was the order for the CT scan on 041103 different from the prior two
720543 - scans, and did this cause the analyst to make a review that was not
720544 - performed previously?
720546 -  ..
720547 - It appears that Doctor Benz at UCSF may have played a role in alerting
720548 - Kaiser to perform a specialized CT scan on 041103 to look for
720549 - pulmonary emboli, as reported on 041104, ref SDS 18 RZ4I, following
720550 - examination by Doctor Benz at USC for a 2nd opinion on 041018.
720551 - ref SDS 16 LX96
720552 -
720553 -
720554 -
720555 -
720556 -
720557 -
7206 -

SUBJECTS
Pulmonary Emboli Blood Clots Treatment Prevention Article American F

9103 -
910401 -         ..
910402 -        45% Recurrent Pulmonary Emobli Die Research Literature
910403 -        Pulmonary Emboli Very Serious Very Difficult to Diagnose
910404 -
910406 -  ..
910407 - Several articles discuss pulmonary embolism...
910408 -
910409 -
910410 -    1.  Controversies in Pulmonary Embolism and Deep Venous Thrombosis
910411 -
910412 -        Published by American Family Physician, 991101 cover article:
910413 -        clinical opinion. ref OF 3 0001
910414 -
910415 -               http://www.aafp.org/afp/991101ap/1969.html
910417 -             ..
910418 -        a.  Pulmonary emoboli is difficult to diagnose. ref OF 3 FP5I
910420 -  ..
910421 - Reasons pulmonary emboli is difficult to diagnose are reviewed above
910422 - describing "wicked problems." ref SDS 0 346F
910424 -  ..
910425 - Research continues...
910426 -
910427 -        b.  10 percent have recurrent pulmonary embolism; the death
910428 -            rate ...is 45 percent. ref OF 3 O059
910429 -
910430 -               [On 061012 CT test report received; confirm pulmonary
910431 -               embolism recurrence, ref SDS 46 N26L; current conditions
910432 -               seems less severe than on 041103, ref SDS 46 7E7G,
910433 -               except new finding of enlarged right ventricle presents
910434 -               new problem of heart disorder. ref SDS 46 7E5L
910436 -                ..
910437 -               [On 090205 Doctor Hsu noted Millie was fortunate on
910438 -               060930 to survive recurrence of pulmonary embolism.
910439 -               ref SDS 64 3E7I
910441 -             ..
910442 -            Suspicion of pulmonary embolism and its prevention are
910443 -            critically important. ref OF 3 PW9N
910445 -             ..
910446 -            Studies show 70 percent of patients dying of pulmonary
910447 -            embolism recorded no suspicion of the diagnosis.
910448 -
910449 -               [On 070105 Kaiser proposes deferring referral to hear
910450 -               specialist for examination of enlarged right ventricle
910451 -               in combination with findings of pulmonary embolism in
910452 -               CT test on 060930, until clinical relevance which make
910453 -               take years for symptoms to become life threatening.
910454 -               ref SDS 59 XR4I
910456 -             ..
910457 -            In one hospitals, fatal pulmonary emboli were missed
910458 -            despite simultaneous and ongoing intense recruitment and
910459 -            evaluation of patients with suspected pulmonary embolism
910460 -            for entry into a multicenter clinical study
910462 -  ..
910463 - Another source...
910464 -
910465 -            E Medicine from Webmed
910466 -
910467 -              http://www.emedicine.com/EMERG/topic490.htm
910468 -
910469 -            Pulmonary Embolism
910470 -            Last Updated:  June 7, 2006
910472 -  ..
910473 - Article says in part...
910474 -
910475 -            Most cases of PE are diagnosed at autopsy, and most who
910476 -            die of PE have not had any diagnostic workup or treatment
910477 -            of the disease. In most cases, the diagnosis has not even
910478 -            been considered, even when classic signs and symptoms are
910479 -            documented in the medical chart. Sadly, appropriate
910480 -            diagnostic and therapeutic management often is withheld
910481 -            even when the potential diagnosis of PE has been
910482 -            considered explicitly and documented in the chart.
910483 -
910484 -                [On 061228 article MD Anderson reports IBC is similarly
910485 -                difficult to diagnose. ref SDS 57 XP5K
910487 -  ..
910488 - Controversies in Pulmonary... article continues...
910489 -
910490 -        c.  These results argue for defending physicians who, despite
910491 -            conscientious medical care, miss fatal pulmonary emboli in
910492 -            their patients.  The results also argue for highly
910493 -            aggressive prophylaxis if it can be given safely.
910494 -            ref OF 3 5QYQ
910496 -  ..
910497 - High risk of death for recurrent pulmonary emboli reflects Kaiser's
910498 - policy to treat cancer patients for life after initial diagnosis for
910499 - pulminary emboli, reported on 041104, ref SDS 18 4Y9G, and further
910500 - Kaiser's policy for the doctor to sign an order removing patient from
910501 - treatment for pulmonary emboli, reported on 051025. ref SDS 29 WN9O
910503 -  ..
910504 - Patient history shows risk factors and symptoms leading to eventual
910505 - diagnosis of pulmonary emboli by CT scan on 041104. ref SDS 0 6G6O
910507 -  ..
910508 - Millie has Inflammatory Breast Cancer (IBC), ref SDS 9 TO7L, which,
910509 - like pulmonary emboli, is also difficult to diagnose, shown by the
910510 - record on 040517. ref SDS 9 S65K
910511 -
910513 -         ..
910514 -        CT Test Criticized in 1999 for Missing Pulmonary Emboli
910515 -
910516 -
910517 - Article summary continues...
910518 -
910519 -        d.  CT tests for pulmomary emobli, as used at Kaiser, was
910520 -            criticized in 1999 for missing central clots in the middle
910521 -            (right) and lingular (left) pulmonary arteries because of
910522 -            their nearly horizontal take-off from the hila. ref OF 3
910523 -            5476
910525 -  ..
910526 - On 041104 CT testing after meeting with Doctor Benz at UCSF diagnosed
910527 - Millie with pulmonary emboli, ref SDS 18 RZ4I, after 6 months of
910528 - symptoms; two (2) prior CT tests during the period did not find
910529 - pulmonary emboli. ref SDS 18 WH6O
910531 -  ..
910532 - Article summary continues...
910533 -
910534 -        e.  In 1999, for low-molecular-weight heparins--enoxaparin
910535 -            (Lovenox), was the only treatment for venous
910536 -            thromboembolism approved by the U.S.  Food and Drug
910537 -            Administration (FDA). ref OF 3 5WUR
910539 -             ..
910540 -        f.  Enoxaparin (Lovenox) has been shown to be safe and
910541 -            effective in a dosage of 1 mg per kg given subcutaneously
910542 -            (below the epidermis - meaning by needle injection below
910543 -            the skin) twice daily. ref OF 3 5WVT
910545 -             ..
910546 -        g.  In 1999, once daily treatments seem problematic.
910547 -            trials. ref OF 3 5827
910549 -  ..
910550 - Millie receives twice daily treatments.
910552 -  ..
910553 - Article summary continues...
910554 -
910555 -        h.  Oncology patients have a high risk of recurrence.  In some
910556 -            cancer patients, thrombosis (blood clotting) may resist
910557 -            treatment despite a therapeutic International Normalized
910558 -            Ratio (INR). ref OF 3 QPXR
910560 -  ..
910561 - Retesting seems therefore useful to verify blood clot problem has been
910562 - cleared before ending treatment with enoxaparin (Lovenox), and relying
910563 - on Coumadin.
910565 -  ..
910566 - Originally, Millie was diagnosed by CT scan testing with pulmonary
910567 - emboli on 041104, ref SDS 18 RZ4I, and this was shown to be resolved by
910568 - another CT test on 041230. ref SDS 23 PW3K
910570 -  ..
910571 - Article summary continues...
910572 -
910573 -        i.  Stage II breast cancer patients show that the period of
910574 -            chemotherapy and the addition of tamoxifen to chemotherapy
910575 -            both increase blood clot risk. ref OF 3 6QYS
910577 -  ..
910578 - Millie was diagnosed stage IIA breast cancer on 020321. ref SDS 2
910579 - 6Q4U
910581 -  ..
910582 - Article summary continues...
910583 -
910584 -        j.  Stage IV breast cancer, brain tumors and abdominal
910585 -            adenocarcinomas also appear to be at high risk.
910586 -            Administering 1 mg of warfarin daily for six weeks to
910587 -            patients with metastatic breast cancer who were receiving
910588 -            chemotherapy and then adjusting the dosage (average dose:
910589 -            2.6 mg) to achieve an INR of 1.3 to 1.9 reduced the
910590 -            thrombosis rate by 85 percent with no excess bleeding.
910591 -            ref OF 3 6RRQ
910593 -  ..
910594 - Millie was diagnosed stage IV breast cancer on 040614. ref SDS 10 6M9H
910595 -
910596 -
910597 -
910598 -
9106 -

SUBJECTS
Hypercoagulable State Work Up Scope Coumadin Requirements Article DV

9603 -
960401 -         ..
960402 -        Hypercoagulable State Work Up Scope Coumadin Requirements
960403 -        DVT and Pulmonary Embolism:  Part II. Treatment and Prevention
960404 -
960405 -
960406 -    2.  Published by American Family Physician, 040615
960407 -        Practical Therapeutics. ref OF 1 0001
960409 -             ..
960410 -        a.  Treatment goals stop clot propagation and prevent
960411 -            recurrence. ref OF 1 XN5G
960413 -             ..
960414 -        b.  About 30 percent of patients with pulmonary embolism have a
960415 -            thrombophilia, meaning either an acquired for genetic
960416 -            disposition for blood clots.  An extensive evaluation is
960417 -            suggested in patients younger than 50 years with an
960418 -            idiopathic episode of deep venous thrombosis, patients with
960419 -            recurrent blood clots, and patients with a family history
960420 -            of blood clots. ref OF 1 MW6F
960422 -             ..
960423 -        c.  Some patients require lifetime treatment. ref OF 1 009L
960424 -            Most patients with a genetic or unchangeable blood clot
960425 -            condition should receive lifetime anticoagulation.
960426 -            ref OF 1 9O9G
960428 -  ..
960429 - There was discussion of cancer patients getting continuing treatment
960430 - for pulmonary emboli, reported on 051007.  At that time, on 051107 the
960431 - doctor ended Millie's Coumadin treatments for pulmonary emboli.
960432 - ref SDS 28 QG5H  This change in treatment strategy was later confirmed
960433 - on 051127. ref SDS 31 RZ4I
960434 -
960435 -
960437 -  ..
960438 - Thrombophilic Risk Millie Extensive Evaluation Thrombophilias
960439 -
960440 -
960441 - Article summary continues...
960442 -
960443 -        d.  Pulmonary emboli work up requires careful history and
960444 -            physical examination.  Identify risk factors, ref OF 1
960445 -            018M,
960447 -             ..
960448 -        e.  Laboratory requires complete blood count, platelet count,
960449 -            prothrombin time, activated partial thromboplastin time
960450 -            (APTT), and comprehensive metabolic panel to look for
960451 -            electrolyte, renal, or hepatic abnormalities.  If an
960452 -            evaluation for thrombophilias is being considered, blood
960453 -            should be set aside for screening tests before treatment
960454 -            with heparin and warfarin is initiated. ref OF 1 014P
960456 -             ..
960457 -        f.  Patients with an idiopathic episode of venous
960458 -            thromboembolism who are younger than 50 years, patients
960459 -            with recurrent thrombosis, and patients with a family
960460 -            history of venous thromboembolism should be considered
960461 -            "strongly thrombophilic" and should undergo a more
960462 -            extensive evaluation for thrombophilias. ref OF 1 01FW
960463 -
960465 -  ..
960466 - Family History Defined 1st-degree Relative Episode Before Age of 50
960467 -
960468 - Millie's age, breast cancer status (2002 lumpectomy, 2004 IBC), family
960469 - history of blood clot problems (venous thromboembolic disease in a
960470 - first-degree relative before the age of 50, ref OF 1 F57G) reported to
960471 - Kaiser on 040812, ref SDS 13 MG5K, and pulmonary emboli diagnosed on
960472 - 041104, ref SDS 18 RZ4I, fit criteria for "strongly thrombophilic,"
960473 - that requires evaluation for thrombophilias.  Millie's risk factors
960474 - are further reviewed below. ref SDS 0 6G6O
960476 -  ..
960477 - On 050922 Doctor Bailey recommended in a second opinion performing a
960478 - hypercoagulable state work up, ref SDS 27 XD9X, which sounds like
960479 - scope in the article reviewed today.  Performing a hypercoagulable
960480 - state work up was discussed with primary care physician on 051007.
960481 - ref SDS 28 CW9J  At that time, treatment for pulmonary emboli was
960482 - ended because symptoms had been resolved by treatment, ref SDS 28
960483 - XN7K, and the surgery department had notified of risks performing
960484 - mastectomy surgery ordered by primary care physician for patients
960485 - being treated for pulmonary emboli. ref SDS 28 OH8K
960486 -
960488 -  ..
960489 - Factor V Prothrombin G20210A DNA Tests Genetic Risks Pulmonary Emboli
960490 - DNA Tests Genetic Risks Pulmonary Emboli Factor V Prothrombin G20210A
960491 -
960492 -
960493 - Article summary continues...
960494 -
960495 -        g.  Resistance to activated protein C with a clotting assay
960496 -            family that dilutes patient plasma in factor V-deficient
960497 -            plasma, or genetic test for factor V Leiden mutation,
960498 -            ref OF 1 L23K
960499 -
960500 -                [On 061102 review of family member DNA blood clot test
960501 -                on genetic risks lists factor V Leiden mutation tested
960502 -                negative. ref SDS 50 KJ3H
960504 -             ..
960505 -            Genetic test for prothrombin G20210A mutation
960506 -
960507 -                [On 061102 review of family member DNA blood clot test
960508 -                on genetic risks lists prothrombin G20210A mutation
960509 -                tested negative. ref SDS 50 KJ3H
960511 -             ..
960512 -            Clotting assay for lupus anticoagulant
960513 -
960514 -                [On 061102 review of family member DNA blood clot test
960515 -                on genetic risks lists lupis anticoagulant was
960516 -                detected. ref SDS 50 KJ3H
960518 -             ..
960519 -            ELISA for antiphospholipid antibodies
960521 -             ..
960522 -            Plasma homocysteine level
960523 -
960524 -
960526 -         ..
960527 -        Lovenox and Warfarin
960528 -        Treatment 1 Week, Prevention Continuous
960529 -
960530 -
960531 - Article summary continues...
960532 -
960533 -        h.  Once acute anticoagulation is achieved, warfarin is the
960534 -            drug of choice for long-term therapy to prevent clot
960535 -            recurrence.  A standard warfarin protocol includes starting
960536 -            treatment at 5 mg per day and titrating the dosage every
960537 -            three to seven days to achieve an INR between 2.0 and 3.0
960538 -            should be used. ref OF 1 M55S
960540 -  ..
960541 - This protocol to first treat to relieve coagulation, and then treat to
960542 - avoid recurrence of blood clots, reflects Millie's treatment for
960543 - pulmonary emboli begnning on 041104. ref SDS 18 N455
960544 -
960545 -                [On 061006 Millie's letter to doctor confirms
960546 -                instructions to take Coumadin concurrent with Lovenox,
960547 -                despite conflicts with prior prior practice, and
960548 -                standard practice in published guidance. ref SDS 45
960549 -                OP69
960550 -
960551 -
960552 -
960553 -
9606 -

SUBJECTS
Pulmonary Emboli High Risk Millie Patient History Case Study Mistake

AE03 -
AE0401 -  ..
AE0402 - Pulmonary Embolism Symptoms Missed for 5 Months Before Discovery
AE0403 - Kaiser Ordered Special CT Test after Doctor Benz 2nd Opinion at UCSF
AE0404 -
AE0405 -
AE0406 -    1.  CT test on 040410 comparing with
AE0407 -        test on 040307 showed no evidence
AE0408 -        pulmonary embolism.................... 040416, ref SDS 7 EH47
AE0410 -         ..
AE0411 -    2.  Chemotherapy treatment begins with
AE0412 -        Taxol/Avastin (bevacizumab) drug
AE0413 -        trial to treat breast cancer
AE0414 -        relapse............................... 040420, ref SDS 8 9Z5J
AE0416 -         ..
AE0417 -    3.  Side effects Avastin reviewed; nose
AE0418 -        bleeds most likely problem; no notice
AE0419 -        of pulmonary embolism side effects
AE0420 -        nor correlation of symptoms with side
AE0421 -        effects fatigue, weakness, loss of
AE0422 -        fitness, shortness of breath that
AE0423 -        commonly occur with
AE0424 -        chemotherapy.......................... 040420, ref SDS 8 TK5G
AE0426 -         ..
AE0427 -    4.  Difficulty breathing, heavy chest, coughing
AE0428 -        for several hours symptoms reported
AE0429 -        to Kaiser............................. 040517, ref SDS 9 RZ4I
AE0431 -         ..
AE0432 -    5.  Pulmonary embolism symptoms increase,
AE0433 -        persistant cough causes sore throat;
AE0434 -        doctor prescribes cough
AE0435 -        medicine.............................. 040614, ref SDS 10 RZ4I
AE0437 -         ..
AE0438 -    6.  Pulmonary embolism symptoms cough,
AE0439 -        shortness of breath, low energy
AE0440 -        continue; cough medicine helps sore
AE0441 -        throat................................ 040713, ref SDS 11 RZ4I
AE0443 -         ..
AE0444 -    7.  CT test on 040710 comparing with test
AE0445 -        on 040410 makes no findings of
AE0446 -        pulmonary embolism.................... 040811, ref SDS 12 WW68
AE0448 -         ..
AE0449 -    8.  Shortness of breath, heavy chest,
AE0450 -        cough, nose bleed, symptoms
AE0451 -        worsen................................ 040812, ref SDS 13 RZ4I
AE0453 -         ..
AE0454 -    9.  Genentec manufacturer of Avastin
AE0455 -        (bevacizumab) reports deaths from
AE0456 -        side effect pulmonary
AE0457 -        emboli................................ 040812, ref SDS 13 MG4G
AE0459 -         ..
AE0460 -   10.  Millie reports family history mother
AE0461 -        dying at age 40 about 50 years ago
AE0462 -        from blood clot related issues, and
AE0463 -        more recently in 2003 Millie's son
AE0464 -        now age 52, was hospitalized for
AE0465 -        pulmonary emboli...................... 040812, ref SDS 13 MG5K
AE0467 -         ..
AE0468 -   11.  Doctor explains that since Millie has
AE0469 -        not yet been diagnosed with pulmonary
AE0470 -        emboli, the Genentec warning does not
AE0471 -        require change in her treatment to
AE0472 -        avoid side effects and reduce
AE0473 -        risk of pulmonary
AE0474 -        emboli................................ 040812, ref SDS 13 W35K
AE0476 -         ..
AE0477 -   12.  Side effects cough about the same,
AE0478 -        fatigue, weakness, heavy chest increase,
AE0479 -        e.g., cannot walk up a flight of
AE0480 -        stairs................................ 040909, ref SDS 14 RZ4I
AE0482 -         ..
AE0483 -   13.  Doctor describes delimma that CT
AE0484 -        tests do not show cause of cough,
AE0485 -        fatigue, shortness of breath, heavy
AE0486 -        chest, patient rising symptoms has
AE0487 -        no explanation, diagnosis nor
AE0488 -        treatment............................. 040909, ref SDS 14 TN7F
AE0489 -
AE0490 -            [On 061020 test for pulmonary embolism
AE0491 -            requires specific order from the doctor
AE0492 -            for CT scan test to use specialized
AE0493 -            equipment. ref SDS 0 T44N
AE0495 -         ..
AE0496 -   14.  Patient considers getting 2nd opinion
AE0497 -        to assist Kaiser in resolving dilemma
AE0498 -        of chronic symptoms without
AE0499 -        diagnosis and
AE0500 -        treatment............................. 040909, ref SDS 14 M14J
AE0502 -         ..
AE0503 -   15.  CT test on 040921 comparing with test
AE0504 -        on 040710 makes no findings of
AE0505 -        pulmonary embolism.................... 041005, ref SDS 15 NL4O
AE0507 -         ..
AE0508 -   16.  Dilemma rising fatigue, difficulty breathing,
AE0509 -        heavy chest, cough increase; doctor recommends
AE0510 -        continue treatment Taxol bevacizumab (Avastin)
AE0511 -        in drug trial with documented deaths from
AE0512 -        pulmonary embolism, since CT tests show no
AE0513 -        evidence Millie has pulmonary embolism;
AE0514 -        Millie seeking 2nd opinion to resolve
AE0515 -        dilemma................................ 041005 ref SDS 15 RZ4I
AE0516 -
AE0517 -            [...061020 dilemma resolved pulmonary embolism requires
AE0518 -            thin slice spiral CT test to discover; Kaiser testing with
AE0519 -            protocol that cannot identify PE. ref SDS 0 T44N
AE0521 -         ..
AE0522 -   17.  Meeting UCSF 2nd opinion; Millie reports
AE0523 -        persistant cough, shortness of breath,
AE0524 -        heavy chest, fatigue, weakness rising
AE0525 -        for 5 months; Doctor Benz indicates could
AE0526 -        be lung cancer; recommends Kaiser investigate
AE0527 -        to resolve dilemma; recommends continuing
AE0528 -        treatment with Avastin chemotherapy
AE0529 -        drug trial............................ 041018, ref SDS 16 LX96
AE0531 -         ..
AE0532 -   18.  Meeting at Stanford for 2nd opinion;
AE0533 -        persistant cough, shortness of breath,
AE0534 -        tired, weak for 5 months; Doctor Guardino
AE0535 -        does not comment; recommends continuing
AE0536 -        treatment with Avastin chemotherapy
AE0537 -        trial................................. 041019, ref SDS 17 4G9H
AE0539 -         ..
AE0540 -   19.  CT scan Kaiser implements Benz 2nd
AE0541 -        opinion orders emergency test for next
AE0542 -        day on 041103 out of sequence and 1.5
AE0543 -        months early, specifies test method
AE0544 -        that can detect pulmonary
AE0545 -        embolism.............................. 041104, ref SDS 18 NL4N
AE0546 -
AE0547 -            [...061020 2 years later dilemma resolved pulmonary
AE0548 -            embolism requires thin slice spiral CT test to discover;
AE0549 -            Kaiser was testing with protocol that cannot identify PE.
AE0550 -            ref SDS 0 T44N
AE0552 -         ..
AE0553 -   20.  Pulmonary emboli Millie diagnosed
AE0554 -        by CT test on 041103; patient removed
AE0555 -        from Avastin drug trial; resolves
AE0556 -        dilemma persistent fatigue, cough,
AE0557 -        shortness of breath, heavy chest
AE0558 -        for past 6 months; no explanation why
AE0559 -        prior 2 CT tests did not diagnose
AE0560 -        pulmonary embolism during 6 months
AE0561 -        treatment with Avastin; risk pulmonary
AE0562 -        embolism not disclosed to patient on
AE0563 -        040402 for consent to participate
AE0564 -        in Avastin drug
AE0565 -        trial................................. 041104, ref SDS 18 RZ4I
AE0567 -         ..
AE0568 -   21.  Kaiser policy cancer patients diagnosed
AE0569 -        pulmonary embolism are treated with
AE0570 -        Coumadin (warfarin) for
AE0571 -        life.................................. 041104, ref SDS 18 4Y9G
AE0573 -         ..
AE0574 -   22.  UCSF 2nd opinion cites patient cough
AE0575 -        and heavy chest, and shortness of
AE0576 -        breath; says this is "unclear,"
AE0577 -        does not propose investigation for
AE0578 -        lung cancer; but says matter is under
AE0579 -        investigation without specifying by
AE0580 -        whom or in what manner................ 041117, ref SDS 19 OT5Q
AE0582 -         ..
AE0583 -        Implication that after examination
AE0584 -        on 041018, ref SDS 0 M89N, Doctor
AE0585 -        Benz may have informally suggested
AE0586 -        that Kaiser investigate for
AE0587 -        pulmonary emboli...................... 041117, ref SDS 19 U26I
AE0589 -         ..
AE0590 -   23.  Stanford 2nd opinion cites patient
AE0591 -        cough and shortness of breath;
AE0592 -        offers no ideas for diagnosis
AE0593 -        and treatment......................... 041209, ref SDS 21 O18R
AE0595 -         ..
AE0596 -   24.  Symptoms pulmonary embolism
AE0597 -        completely ended...................... 041230, ref SDS 23 RZ4I
AE0599 -         ..
AE0600 -        CT test reports no visualization of
AE0601 -        pulmonary embolism.................... 041230, ref SDS 23 PW3K
AE0603 -         ..
AE0604 -   25.  Hypercoagulable state work
AE0605 -        up recommended in 2nd
AE0606 -        opinion............................... 050922, ref SDS 27 XD9X
AE0608 -         ..
AE0609 -   26.  Patient extreme high risk
AE0610 -        for complications from
AE0611 -        mastectomy surgery due to
AE0612 -        history of treatment for
AE0613 -        pulmonary emboli...................... 051007, ref SDS 28 KJ5O
AE0615 -         ..
AE0616 -   27.  Pulmonary emboli treatment
AE0617 -        stopped............................... 051007, ref SDS 28 XN7K
AE0619 -         ..
AE0620 -   28.  Kaiser policy requires continuing
AE0621 -        treatment of pulmonary emboli for
AE0622 -        cancer patients....................... 051026, ref SDS 30 PO85
AE0624 -         ..
AE0625 -   29.  Millie's treatment for pulmonary
AE0626 -        emboli stopped because problem
AE0627 -        discovered during treatment
AE0628 -        on Avastin drug trial
AE0629 -        during 2004........................... 051121, ref SDS 31 RZ4I
AE0631 -         ..
AE0632 -   30.  Son age 51 hospitalized 2nd time
AE0633 -        for recurrence pulmonary
AE0634 -        embolism.............................. 060722, ref SDS 0 3D9T
AE0636 -         ..
AE0637 -   31.  Cancer patient high risk for recurrence
AE0638 -        pulmonary embolism, which
AE0639 -        is resistant to
AE0640 -        treatment............................. 060722, ref SDS 0 KN5L
AE0642 -         ..
AE0643 -   32.  Stage II breast cancer diagnosed
AE0644 -        020321 increased risk of pulmonary
AE0645 -        emboli................................ 060722, ref SDS 0 KN6H
AE0647 -         ..
AE0648 -   33.  Stage IV breast cancer diagnosed 040614
AE0649 -        further increased risk for pulmonary
AE0650 -        emboli................................ 060722, ref SDS 0 PRVQ
AE0652 -         ..
AE0653 -   34.  45% patients die who suffer recurrence
AE0654 -        of pulmonary embolism................. 060722, ref SDS 0 BI5J
AE0656 -         ..
AE0657 -   35.  Pulmonary embolism mostly diagnosed
AE0658 -        during autopsy after death; symptoms
AE0659 -        pulmonary embolism often well
AE0660 -        documented in Medical Chart
AE0661 -        but diagnosis overlooked by
AE0662 -        doctors............................... 060722, ref SDS 0 7P9F
AE0664 -         ..
AE0665 -   36.  Wicked problem symptoms pulmonary embolism
AE0666 -        similar to side effects of chemotherapy
AE0667 -        and other much less severe maladies make
AE0668 -        diagnosis of pulmonary embolism
AE0669 -        for timely treatment very
AE0670 -        difficult............................. 060722, ref SDS 0 346F
AE0672 -         ..
AE0673 -   37.  Patient falls at BART station due
AE0674 -        to fatigue, dizziness, shortness
AE0675 -        of breath; injures finger on left
AE0676 -        hand causing lymphedema on
AE0677 -        left arm to increase
AE0678 -        significantly......................... 060914, ref SDS 41 ZQ5I
AE0680 -         ..
AE0681 -   38.  Patient reports continues fatigue,
AE0682 -        weakness, shortness of breath, heavy
AE0683 -        chest side effects of chemotherapy
AE0684 -        and symptoms of pulmonary emboli;
AE0685 -        asks about testing for PE recurrence;
AE0686 -        doctor orders CT test pulmonary emboli
AE0687 -        recurrence............................ 060929, ref SDS 42 B56N
AE0689 -         ..
AE0690 -   39.  Patient reports continued loss of
AE0691 -        energy, difficult breathing common
AE0692 -        side effects of chemotherapy, and
AE0693 -        symptoms of pulmonary
AE0694 -        emboli................................ 060929, ref SDS 42 B56N
AE0696 -         ..
AE0697 -   40.  Patient requests CT scan to evaluate
AE0698 -        pulmonary emboli and distant
AE0699 -        metastatic disease.................... 060629, ref SDS 42 DY5M
AE0701 -         ..
AE0702 -   41.  Doctor orders CT test for distant
AE0703 -        metastasis, and for pulmonary emboli;
AE0704 -        specifies date of test that made
AE0705 -        original diagnosis on 041103
AE0706 -        to compare same location.............. 060929, ref SDS 42 DY7G
AE0708 -         ..
AE0709 -   42.  Doctor asks patient to obtain from her
AE0710 -        son's doctor the report on coagulapathy
AE0711 -        showing genetic disposition for blood
AE0712 -        clots, which was reported to Kaiser
AE0713 -        on 060724............................. 060929, ref SDS 42 NU4N
AE0715 -         ..
AE0716 -   43.  Pulmonary emboli recurrence diagnosed
AE0717 -        by CT test on 060930; Millie must resume
AE0718 -        treatment for life, previously ended
AE0719 -        on 051007............................. 061002, ref SDS 44 MI5I
AE0721 -         ..
AE0722 -   44.  CT scan report received for test on
AE0723 -        060930; analyst failed to perform
AE0724 -        doctor's order to compare prior
AE0725 -        test on 041103 for trend
AE0726 -        analysis.............................. 061012, ref SDS 46 M431
AE0728 -         ..
AE0729 -   45.  Heart disorder enlarged right ventricle
AE0730 -        Cor Pulmonale reported in CT test
AE0731 -        findings.............................. 061012, ref SDS 46 7E5L
AE0732 -
AE0747 -         ..
AE0748 -   47.  CT test for pulmonary embolism more
AE0749 -        rigorous than CT test for cancer,
AE0750 -        requires specific order by doctor to
AE0751 -        use new, improved technology (thin
AE0752 -        sliced)............................... 061020, ref SDS 48 S56G
AE0753 -
AE0754 -           [...explains dilemma why prior CT tests
AE0755 -           in 2004 failed to report pulmonary embolism,
AE0756 -           reported on 040909, ref SDS 0 N48P, until
AE0757 -           special order, reported on 041104.
AE0758 -           ref SDS 0 SV3K
AE0760 -         ..
AE0761 -   48.  Millie seems less fatigued and suffers
AE0762 -        less shortness of breath after starting
AE0763 -        treatments on 061002; however,
AE0764 -        symptoms continue.................... 061020, ref SDS 48 VD4G
AE0766 -         ..
AE0767 -   49.  Symptoms fatigue, shortness of breath,
AE0768 -        weakness continue despite treatment;
AE0769 -        Millie asks prognosis for getting
AE0770 -        back in the gym to improve fitness,
AE0771 -        which previously was attributed to
AE0772 -        symptoms for pulmonary
AE0773 -        embolism............................. 061027, ref SDS 49 0C4I
AE0775 -         ..
AE0776 -   50.  Recovery recurrence pulmonary embolism
AE0777 -        symptoms slower that following first
AE0778 -        diagnosis in 2004.................... 061027, ref SDS 49 MS5P
AE0780 -         ..
AE0781 -   51.  First-degree relative (son age 51)
AE0782 -        indicates family member coagulapathy
AE0783 -        report on hypercoagulable state work
AE0784 -        up finds DNA evidence of genetic
AE0785 -        disposition for pulmonary
AE0786 -        embolism.............................. 061101, ref SDS 50 VR6F
AE0788 -         ..
AE0789 -   52.  Symptons of pulmonary embolism and
AE0790 -        Cor Pulmonale from enlarged right
AE0791 -        ventricle cause shortness of breath,
AE0792 -        fatigue, weakness, heavy chest, cough
AE0793 -        continue after a month of treatment,
AE0794 -        and with normal exertion climbing
AE0795 -        stairs walking to work,
AE0796 -        shopping.............................. 061110, ref SDS 53 VD4G
AE0798 -         ..
AE0799 -   53.  Symptoms pulmonary embolism and
AE0800 -        enlarged right ventricle worsening,
AE0801 -        rather than recovering as occured with
AE0802 -        prior pulmonary embolism, reported on
AE0803 -        041230, ref SDS 0 VE4H, doctor orders
AE0804 -        CT test to examine pulmonary embolism
AE0805 -        and enlarged right ventricle, and compare
AE0806 -        with original CT scan on 041103 that
AE0807 -        diagnosed pulmonary embolims to evaluate
AE0808 -        recovery, i.e., improvement, stable,
AE0809 -        or worse, as was done previously on
AE0810 -        041230................................ 061208, ref SDS 54 Q93H
AE0812 -         ..
AE0813 -   54.  Examination by heart specialist of
AE0814 -        rising symptoms for heart disorder
AE0815 -        Cor Pulmonale from enlarged right
AE0816 -        ventricle requested by Millie for
AE0817 -        clearance to resume exercise in
AE0818 -        the gym and restore
AE0819 -        fitness............................... 061218, ref SDS 55 HX6V
AE0821 -         ..
AE0822 -   55.  Referral deferred to heart specialist for
AE0823 -        examination of heart disorder Cor Pulmonale
AE0824 -        with symptoms rising; doctor explains
AE0825 -        this potential problem will most likely
AE0826 -        not become clinically relevant considering
AE0827 -        that it takes years to progress to a
AE0828 -        point where it becomes life
AE0829 -        threatening........................... 061218, ref SDS 55 XQ5H
AE0831 -         ..
AE0832 -   56.  Patient worried after 3 months treatment
AE0833 -        symptoms increase chronic fatigue, weakness,
AE0834 -        shortness of breath with normal activity;
AE0835 -        requests examination by heart specialist
AE0836 -        evaluate heart disorder enlarged
AE0837 -        right ventricle Cor Pulmonale
AE0838 -        and pulmonary
AE0839 -        embolism.............................. 061227, ref SDS 56 645I
AE0841 -         ..
AE0842 -   57.  CT test on 061227 failed to perform
AE0843 -        doctor's order on 061208 to test
AE0844 -        recovery from pulmonary embolism, and
AE0845 -        evaluate heart disorder Cor Pulmonale
AE0846 -        for enlarged right ventricle, shown by
AE0847 -        pathology report received from
AE0848 -        Kaiser................................ 070102, ref SDS 58 AK9H
AE0850 -         ..
AE0851 -   58.  Lung damage may be permanent from Millie's
AE0852 -        recurrance of pulmonary embolism; doctor
AE0853 -        advises patient may never recover former
AE0854 -        exercise level before pulmonary embolism
AE0855 -        symptoms began in August 2006, to
AE0856 -        maintain fitness and strengthen immune
AE0857 -        system for recovering from
AE0858 -        cancer................................ 070105, ref SDS 59 MA9K
AE0860 -         ..
AE0861 -   59.  Doctor advises clinical examination and
AE0862 -        Sa02 diagnostics seem favorable for
AE0863 -        patient to resume working out in
AE0864 -        the gym, but be
AE0865 -        careful............................... 070105, ref SDS 59 G35K
AE0867 -         ..
AE0868 -   60.  Examination of heart disorder Cor
AE0869 -        Pulmanele by heart specialist requested
AE0870 -        again to verify clinical analysis in
AE0871 -        advance of resuming working out in the
AE0872 -        gym based on context of patient history
AE0873 -        and high risk of death from mistaken
AE0874 -        medical advice in the absence
AE0875 -        of affirmative test
AE0876 -        results............................... 070105, ref SDS 59 SU4L
AE0878 -         ..
AE0879 -   61.  Referral for examination of continuing
AE0880 -        symptoms of enlarged right ventricle
AE0881 -        deferred in context of allocating time
AE0882 -        for referral to UCSF for treatment of
AE0883 -        IBC based on rising symptoms of
AE0884 -        this serious cancer
AE0885 -        disease............................... 070105, ref SDS 59 794K
AE0886 -
AE0887 -
AE0888 -
AE0889 -
AE0890 -
AE0891 -
AE0892 -
AE0893 -
AE09 -