CONTACTS 

SUBJECTS
Meeting Doctor Examination 5th Review Prepare for Treatment #5 After

1903 -
1903 -    ..
1904 - Summary/Objective
1905 -
190501 - Follow up ref SDS F1 0000. ref SDS E7 0000.
190502 -
190503 - CA 15-3 increased slightly over the past 3 weeks, ref SDS 0 GJ5M; may
190504 - conflict with CT test on 060930 showing no evidence of metestatic
190505 - disease. ref SDS 0 NG6N  Examination found stable, possibly rising IBC
190506 - on left breast. ref SDS 0 XO5L  UCSF 2nd opinion discusses verifying
190507 - IBC relapse with measureable disease to participate in drug trials.
190508 - ref SDS 0 CR4O  Biopsy to verify IBC was not scheduled. ref SDS 0 KT7J
190509 - The doctor feels complex patient history can be simplified by tracking
190510 - fewer issues. ref SDS 0 MO4K  Emotional trauma rises from mounting
190511 - issues and challenges of complex patient history. ref SDS 0 Y642
190512 - Symptoms of pulmonary embolism may be less severe after treatment with
190513 - Coumadin resumed on 061002 following CT test diagnosis of recurrence.
190514 - ref SDS 0 CV5L  Failure of the Kaiser computer system to notify team
190515 - care elements of medications changes 3 weeks ago, was corrected today
190516 - by the patient telling the pharmacist, and the pharmacist telling the
190517 - Coagulation Treatment Clinic. ref SDS 0 YQ7L  The doctor's list of
190518 - current medications, however, still requires correction. ref SDS 0
190519 - SE86  Disclosure today that CT tests for pulmonary embolism require a
190520 - different order by the doctor from CT tests for cancer, explains why
190521 - tests did not find the problem in 2004, and again this year.
190522 - ref SDS 0 S56G  The doctor learned from the patient today that CT test
190523 - on 060930 found heart disorder of enlarged right ventricle, and
190524 - advised that the severity of the problem cannot be obtained from
190525 - Kaiser's analysts. ref SDS 0 VJ4J  Research indicates the disorder is
190526 - called Cor Pulmonale.  The doctor feels that Millie's symptoms are not
190527 - yet severe. ref SDS 0 ZD9N  Examination with stethoscope aligns with
190528 - research on assessing this type of problem, and did not find severe
190529 - symptoms. ref SDS 0 PC6H  The doctor received the wrong documents for
190530 - studying Millie's hypercoagulable state for genetic risk of pulmonary
190531 - emboli.  The patient is following up for Kaiser to review the scope of
190532 - the problem. ref SDS 0 626L  Progress continues strengthening
190533 - communications for doctor patient partnership. ref SDS 0 FE4I
190534 -
190535 -
190536 -
190537 -
190538 -
190540 -  ..
1906 -
1907 -
1908 - Progress
1909 -
190901 - Agenda Develop Work Plan Stage IV Breast Cancer 8 Mos after Mastectomy
190902 -
190903 - Follow up ref SDS F1 SM6M, ref SDS E7 SM6M.
190904 -
190905 - This is the 5th review meeting to begin the 13th overall, and 5th
190906 - chemotherapy cycle following start of treatments on 060711 for the 3rd
190907 - relapse of IBC. ref SDS C6 SM6M  The doctor had a hectic schedule
190908 - today, and was 30 minutes late.
190910 -  ..
190911 - Millie submitted ref DIT 1 0001 to the doctor with an agenda to guide
190912 - discussions, ref DIT 1 GF5N, and provided background to support the
190913 - doctor in preparing for the meeting.  Prior to starting the meeting,
190914 - Millie listed the agenda on the marking board...
190915 -
190916 -          [On 061110 doctor worked from agenda transferred into
190917 -          Kaiser's electronic Medical Chart, so Millie does not write
190918 -          the list on the marking board. ref SDS H0 K84N
190919 -
190920 -    1.  CA 15-3 review seems favorable................. ref SDS 0 GJ5M
190921 -    2.  Lymphedema worse due to broken finger.......... ref SDS 0 MW8J
190922 -    3.  CT test scope for PE LR Axillary............... ref SDS 0 EY5O
190923 -    4.  Breast exam IBC biopsy measurable disease...... ref SDS 0 025H
190924 -    5.  Treatment plan strategy........................ ref SDS 0 K36G
190925 -    6.  Doctor Benz 2nd Opinion trials................. ref SDS 0 KT7J
190926 -    7.  Pulmonary emboli how serious................... ref SDS 0 CV5L
190927 -    8.  Coumadin dose balance with Xeloda.............. ref SDS 0 YQ7L
190928 -    9.  Coagulopathy report family member.............. ref SDS 0 626L
190929 -   10.  Hypercoagulable state work up.................. ref SDS 0 ES3X
190931 -  ..
190932 - During the meeting, the doctor displayed the agenda submitted with
190933 - Millie's letter on the computer in the examination room.  He had used
190934 - Windows XP cut and paste tools to transfer the list from Millie's
190935 - letter into Kaiser's electronic Medical chart.  The doctor's notes in
190936 - the Medical Chart list only 7 items of the agenda. ref SDS 0 684G  He
190937 - used this list to guide discussions.  During the meeting three issues
190938 - were added to reflect lung and hear disorders discovered by recent
190939 - testing.  Review on 061012 shows the CT test on 060930 diagnosed
190940 - recurrent pulmonary embolism and a new issue of enlarged right
190941 - ventricle. ref SDS 0 NG6I  This change in patient profile requires
190942 - coordination of treatments for cancer. ref SDS 0 YQ7L  Therefore the
190943 - original list of 7 issues expanded to 10, as shown. ref SDS 0 NO6O
190945 -  ..
190946 - Kaiser's progress using computers to strengthen speed and accuracy of
190947 - communications for better meeting productivity is discussed further
190948 - below. ref SDS 0 FE4I
190950 -  ..
190951 - Scheduled next meeting in about 5 weeks after cycle 14 of treatment.
190952 - OA November 10, 2006
190953 -
190954 -
190955 -
1910 -

SUBJECTS
Patient History Agenda 7 Issues Too Many Makes Case Management Compl

4703 -
470401 -  ..
470402 - 7 Agenda Issues Overwhelm Case Management Too Complex to Remember
470403 - Complex Patient History 7 Agenda Issues Overwhelms Case Management
470404 -
470405 - The doctor commented that the agenda listing 7 issues for the meeting
470406 - today makes communication too complex. ref SDS 0 684G  He seemed to
470407 - say that half this number simplifies remembering critical details for
470408 - case management covering patient history the past 5 years.  The
470409 - doctor's progress notes for the examination today list 4 issues...
470411 -         ..
470412 -   11.  PE: [Physical Examination]
470413 -
470414 -        1.  CVS: S1, S2 RR
470415 -        2.  Chest wall: decreasing lesions on lower chest wall
470416 -        3.  Lung: Clear to A & P
470417 -        4.  Ext: decreased LUE edema
470418 -
470419 - ...shown below. ref SDS 0 ZL5W
470421 -  ..
470422 - While the meaning of this scope requires professional training and
470423 - experience, there appears to be significant difference in scope with
470424 - the agenda provided under the doctor/patient partnership model, per
470425 - above. ref SDS 0 NO6O
470426 -
470427 -     [On 070105 doctor frustrated that multiple issues are hard to
470428 -     manage; describes focusing on immediate problems rather than
470429 -     spending time on issues that are irrelevant to the current
470430 -     context. ref SDS H5 794K
470432 -      ..
470433 -     [On 090529 1751 health care doctors confused by complex
470434 -     documentation not maintained in a "well ordered" record.
470435 -     ref SDS J5 C25M
470437 -  ..
470438 - Review on 990303 shows research by Professor Miller at Harvard found
470439 - that people can manage from memory at most 7 subjects, and beyond 3
470440 - subjects become increasingly overwhelmed by limited span attention
470441 - causing errors to rise, ref SDS 3 5328, unless issues are written down
470442 - and tracked with traceability to original sources, as called out in
470443 - management standards reviewed on 950721. ref SDS 1 1740
470444 -
470446 -  ..
470447 - Patient History Complex Case Study Needs Careful Review Avoid Mistakes
470448 - Risk Mangement Complex Patient History Needs Adding Energy for Order
470449 - Case Study Complexity Patient Hisotry Requires Energy Maintain Order
470450 -
470451 - Doctors contributing to Millie's care have uniformly noted patient
470452 - history presents many issues in a very complex case...
470453 -
470454 -    1.  Primary Care Physician.............. 020628, ref SDS 13 QB7H
470456 -         ..
470457 -    2.  Primary Care Physician.............. 020726, ref SDS 16 MO37
470459 -         ..
470460 -    3.  Surgeon............................. 040429, ref SDS 37 9H7M
470462 -         ..
470463 -    4.  Primary Care Physician.............. 040517, ref SDS 39 4Q65
470465 -         ..
470466 -    5.  Doctor Benz......................... 041018, ref SDS 49 QU6F
470468 -         ..
470469 -    6.  Doctor Kaufman...................... 041104, ref SDS 50 Q59K
470471 -         ..
470472 -    7.  Primary Care Physician.............. 041130, ref SDS 52 WL9M
470474 -         ..
470475 -    8.  Surgeon............................. 050324, ref SDS 61 WH5L
470477 -         ..
470478 -    9.  Doctor Shim......................... 050907, ref SDS 78 AE5P
470480 -         ..
470481 -   10.  Surgeon............................. 050923, ref SDS 85 NT9G
470483 -         ..
470484 -   11.  Surgeon............................. 051027, ref SDS 93 HC3L
470486 -         ..
470487 -   12.  Doctor Grissom...................... 060802, ref SDS D6 IT8P
470489 -         ..
470490 -   13.  Doctor Benz......................... 060821, ref SDS E6 YK6N
470492 -         ..
470493 -   14.  Medical issues grow from 32 to
470494 -        45 expanding complexity............. 070525, ref SDS H8 LU3J
470496 -         ..
470497 -   15.  Kaiser referral for treatment at
470498 -        UCSF very complicated............... 070130, ref SDS H7 2X6L
470500 -         ..
470501 -   16.  Patient has 45 medical issues on
470502 -        record of examination at
470503 -        Kaiser.............................. 070525, ref SDS H8 LU3J
470505 -         ..
470506 -   17.  UCSF account manager Bob Schwartz
470507 -        noted billing process in this
470508 -        case is very
470509 -        complex............................. 070823, ref SDS H9 RV6U
470511 -         ..
470512 -   18.  Kaiser Member Services - billings
470513 -        for referral to clinical trial
470514 -        complicated by patient history
470515 -        and coordination between
470516 -        Kaiser, Medicare
470517 -        and UCSF............................ 070829, ref SDS I0 RA85
470519 -         ..
470520 -   19.  UCSF billing impossible for anyone
470521 -        to understand correlations with
470522 -        services performed
470523 -        that justify
470524 -        payment............................. 070830, ref SDS I1 U96G
470526 -         ..
470527 -   20.  Clinical trial director UCSF discloses
470528 -        that billing procedures are "muddy"
470529 -        very complex........................ 070906, ref SDS I2 I49K
470531 -         ..
470532 -   21.  Doctor asks how Millie is coping with
470533 -        emotional trauma of complexity resolving
470534 -        dispute between Kaiser and UCSF for
470535 -        payment of care on referral
470536 -        by Kaiser to
470537 -        UCSF................................ 070921, ref SDS I3 QY9V
470539 -         ..
470540 -   22.  Doctor orders treatment with pills
470541 -        to relieve anxiety and mental health
470542 -        referral to cope with emotional trauma
470543 -        from Kaiser failure to perform payment
470544 -        duty for cancer patient on referral to
470545 -        UCSF for essential
470546 -        treatment........................... 070921, ref SDS I3 QY45
470548 -         ..
470549 -   23.  Mental Health Department therapyst
470550 -        coping with emotional trauma Millie's
470551 -        complex issues very
470552 -        difficult........................... 070926, ref SDS I4 QY5I
470554 -         ..
470555 -   24.  Kaiser failure to pay for Millie's
470556 -        treatment at UCSF on clinical trial
470557 -        prescribed by the doctor presents
470558 -        16 issues of complex
470559 -        analysis............................ 070927, ref SDS I5 WU6M
470561 -         ..
470562 -   25.  CMS Medicare Kaiser contract manager
470563 -        advises Kaiser's failure to pay
470564 -        for prescribed treatment presents
470565 -        complex issues of law, regulation,
470566 -        and health care public
470567 -        policy.............................. 071003, ref SDS I6 BZ40
470569 -         ..
470570 -   26.  Paula with Kaiser's Medical case
470571 -        resolution center reported Millie's
470572 -        case is very complex and so hard
470573 -        to understand....................... 071006, ref SDS I7 EX8K
470575 -         ..
470576 -   27.  Financial engineering UCSF billing
470577 -        irregularities create confusing
470578 -        complexity to prevent discovery of
470579 -        conflicts with agreement Kaiser
470580 -        would pay for treatment on
470581 -        referral to UCSF a year
470582 -        earlier............................. 071006, ref SDS I7 454M
470584 -         ..
470585 -   28.  Billings from UCSF increase to $20K per
470586 -        annum from another business unit no
470587 -        explanation of total charges nor
470588 -        correlation with costs paid by clinical
470589 -        trial and Kaiser promised a year
470590 -        earlier............................. 071006, ref SDS I7 PRWW
470592 -         ..
470593 -   29.  UCSF customer account representative
470594 -        overwhelmed by complexity of problems
470595 -        in Millie's case cannot cope with
470596 -        emotional trauma communicating; asks
470597 -        Kaiser to notify patient not to notify
470598 -        UCSF of efforts solving problems
470599 -        so that Kaiser can
470600 -        send payment to
470601 -        UCSF................................ 071009, ref SDS I8 X65I
470603 -         ..
470604 -   30.  Kaiser representative overwhelmed by
470605 -        emotional trauma cannot cope with
470606 -        complexity of Millie's case driven
470607 -        to misrepresent billing dispute as
470608 -        sensitive medical conditions invokes
470609 -        HIPPA regulations to prevent protecting
470610 -        enfeebled patient from emotionally
470611 -        traumatic threats and harrassment
470612 -        as Kaiser and UCSF try to solve
470613 -        differences........................ 071009, ref SDS I8 JW7M
470615 -         ..
470616 -   31.  Complex referral coordination confuses
470617 -        patient UCSF says blood tests paid for
470618 -        clinical trial, but invoices say payment
470619 -        denied; patient forced to get lab work
470620 -        done at Kaiser to assist Kaiser with
470621 -        cost containment, which caused
470622 -        confusion at UCSF interpreting
470623 -        results at Kaiser for
470624 -        treatment at
470625 -        UCSF............................... 071024, ref SDS I9 EP5W
470627 -         ..
470628 -   32.  UCSF Billing irregularities overwhelm
470629 -        patient with conflicting confusion to
470630 -        extract payment without correlation
470631 -        to services in order to cope with
470632 -        emotional trauma................... 071026, ref SDS J0 UW5J
470634 -         ..
470635 -   33.  UCSF emotional demand for payment
470636 -        within 1 week to cope with complex
470637 -        claim for medical services which
470638 -        nobody understands; refuses to
470639 -        meet and explain justification
470640 -        for charges that conflict
470641 -        with patient
470642 -        history............................ 071026, ref SDS J0 SU5V
470644 -         ..
470645 -   34.  UCSF increases emotional trauma
470646 -        threatens fragile cancer patient with
470647 -        emotional harrassment of collection
470648 -        agency action for charges
470649 -        that nobody can
470650 -        justify............................ 071031, ref SDS J1 P753
470652 -         ..
470653 -   35.  UCSF increases emotional trauma for
470654 -        patient threatens termination fo essential
470655 -        treatment because patient is easier
470656 -        target for collection than experiencing
470657 -        emotional trauma of justifying charges
470658 -        and recovery from Kaiser for
470659 -        referral........................... 071031, ref SDS J1 PSSQ
470661 -         ..
470662 -   36.  Patient emotional trauma rises conflicting
470663 -        Kaiser report doctor make a "mistake"
470664 -        referring Millie to UCSF for treatment
470665 -        that has proven effective and following
470666 -        pattern and practice of paying for
470667 -        effective treatment on clinical trials
470668 -        which aligns with EOC contract provisions
470669 -        because Kaiser wants to transfer 100% of
470670 -        cost for care to others by prescribing
470671 -        treatment on clinical trial and
470672 -        calling it a self-
470673 -        referral........................... 071204, ref SDS J2 TH8L
470675 -         ..
470676 -        UCSF requests help finding UCSF planning
470677 -        for treating Millie's cancer as a chronic
470678 -        disease; explains Millie's patient
470679 -        profile too complex takes a lot
470680 -        time to find critical
470681 -        details............................ 090121, ref SDS J3 Y67L
470682 -        patient assembles list of UCSF
470683 -        treatment planns................... 090121, ref SDS J3 EV53
470685 -         ..
470686 -   37.  Millie's case more complex than when
470687 -        Doctor Benz reviewed the record at UCSF
470688 -        on 060821, prevents proactive planning
470689 -        for strategy to treat cancer as chronic
470690 -        disease in time to be effective
470691 -        after hyperthermia
470692 -        treatment.......................... 090204, ref SDS J4 278T
470694 -         ..
470695 -   38.  Complex patient history very confusing
470696 -        to primary care physician; difficulty
470697 -        creating a well ordered record transforms
470698 -        confusing complexity into
470699 -        misleading case
470700 -        management......................... 090529, ref SDS J5 SZ9J
470702 -         ..
470703 -   39.  Primary care physician confuses "chemotherapy"
470704 -        rejected by patient, with patient request for
470705 -        therapy "targeted" to cancer; patient forced
470706 -        to enter Hospice to avoid pain of chemotherapy
470707 -        defers meeting with doctor until Kaiser
470708 -        determines entitlement to standard of
470709 -        care recovering from cancer spreading
470710 -        caused by UCSF medical mistakes and
470711 -        using "targeted" agents that are
470712 -        more effective and do not cause
470713 -        pain and suffering caused by
470714 -        chemotherapy.................... 100630, ref SDS J6 036C
470715 -
470717 -  ..
470718 - Complexity theory reviewed on 040312, ref SDS 31 1D6I, requires adding
470719 - energy for order and structure to discover patterns in Millie's
470720 - patient history listed on 050812 and leading to mastectomy,
470721 - ref SDS 74 6L4M, and for the current period post surgery treating IBC
470722 - relapse, listed in the record on 060722. ref SDS D2 QG5L  Accurate
470723 - order, structure, and pattern make complexity predictable to aid
470724 - diagnosis and treatment.  When order degrades, entropy increases.
470725 - Complexity becomes a crushing liabilty that overwhelms span of
470726 - attention, as set out on 040312 reviewing the locality principle that
470727 - guides transformation of information into the power of knowledge for
470728 - controlling the future. ref SDS 31 W46M
470729 -
470730 -
470731 -
4708 -

SUBJECTS
Complex Patient History 32 Issues Overwhelms Span of Attention Drive

4803 -
480401 -  ..
480402 - Complex Patient History Tracking 32 Issues
480403 -
480404 - Sampling of issues patient history diagnosis and treatment...
480405 -
480406 -    1.  CA 15-3 monitors advance of cancer response to treatment
480407 -    2.  Lymphedema complicated by mastectomy surgery
480408 -    3.  Broken finger from minor fall complicates lymphedema
480409 -    4.  Esophagitis reflux digestion issues
480410 -    5.  Immune system chemotherapy increases risk of infection
480411 -    6.  Chemotherapy increase risk of infection
480412 -    7.  Cat bites increase risk of infection complicates lymphedema
480413 -    8.  Pneumonia chemotherapy increases risk of infection
480414 -    9.  Metastatic cancer increases risk pulmonary embolism
480415 -   10.  Lymphadenopathy left axilla local regional metastasis
480416 -   11.  Lymphadenopathy right axilla distant metastasis
480417 -   12.  Lymphadenopathy left supraclavicular diagnose metastatic cancer
480418 -   13.  Mastectomy surgery impact on cancer treatment and lymphedema
480419 -   14.  Breast cancer secondary IBC 3rd relapse
480420 -   15.  Cancer mutates slow response chemotherapy treatment
480421 -   16.  Blood vessels removed mastectomy slow chemotherapy treatments
480422 -   17.  Treatment options, strategy, planning, schedule
480423 -   18.  Drug trials increase declining pool chemotherapy agents
480424 -   19.  UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
480425 -   20.  Pulmonary embolism blood clots in lungs
480426 -   21.  INR weekly adjustments Coumadin treatment blood clots
480427 -   22.  Enlarged right ventricle heart problem core pulmonale
480428 -   23.  Dizziness symptom enlarged right ventricle cor pulmonale
480429 -   24.  Fatigue shortness breath side effect chemotheapy loss fitness
480430 -   25.  Fatigue shortness breath symptom pulmonary embolism
480431 -   26.  Shortness breath fatigue dizzy symptoms pulmonary embolism
480432 -   27.  Coagulapathy hypercoagulable state work up genetic risks
480433 -   28.  Testing resolution of errors (see Benz 2nd opinions)
480434 -   29.  Testing distant metastatic disease
480435 -   30.  Testing resolution pulmonary emoblism and heart disease
480436 -   31.  Communication hectic schedule not enough time to manage details
480437 -   32.  Emotional stress and well being
480438 -
480439 -
480440 -
480441 -
4805 -

SUBJECTS
Vitals Obtain from Infusion Clinic Progress Note Meeting Doctor John

5003 -
500401 -  ..
500402 - Vitals Show Stable Medical Condition
500403 -
500404 - Follow up ref SDS F1 KB5L, ref SDS E7 KB5L.
500406 -                           ..
500407 -                          Bld Prssr    Pulse  Temp   Weight   SaO2
500408 -     ..
500409 -    061020................. 140  79     67     99.8    151     97
500410 -    060929................. 141  78     66     98.3
500411 -    060825................. 139  79     73     98.1
500412 -    060711................. 172 87     54     97.5    147
500413 -    060623................. 141 87     71     98.0    147     99%
500414 -    060428................. 129 73     80     99.4    149     99%
500415 -    060217................. 153 81     61     98.6    150     99%
500416 -
500417 - ...per Doctor's report, shown below, vitals were obtained from work by
500418 - the Infusion Clinic giving treatment today. ref SDS 0 JQ4J
500419 -
500420 -
500421 -
500422 -
500423 -
500424 -
5005 -

SUBJECTS
CA 15-3 56 Rise Slightly from 51 Reverse 2 Months Decline Indicates

6003 -
600401 -  ..
600402 - CA 15-3 Cancer Marker 56 Rises Slightly from Prior Test on 060928
600403 -
600404 - Follow up ref SDS F1 087J, ref SDS E7 087J.
600405 -
600406 - The test yesterday shows CA 15-3 cancer marker at 51 has ticked up
600407 - slightly the past 3 weeks during cycle 4...
600409 -           ..
600410 -          Test Date                         Date Received
600411 -          061019......... 56 H............. 061020, ref SDS 0 087J
600412 -          060928......... 51 H............. 060929, ref SDS F1 087J
600413 -          060907......... 68 H............. 060929, ref SDS F1 087J
600414 -          060813......... 73 H............. 060817, ref SDS E5 U24M
600415 -          060809......... 87 H............. 060810, ref SDS E3 2N5J
600416 -          060708......... 71 H............. 060711, ref SDS C6 087J
600417 -          060616......... 63 H............. 060623, ref SDS C4 UQ5Q
600418 -          060522......... 59 H............. 060605, ref SDS B9 UQ5Q
600419 -          060501......... 49 H............. 060522, ref SDS B6 MC4F
600420 -          060421......... 44 H............. 060428, ref SDS A8 087J
600421 -          060330......... 40 H............. 060428, ref SDS A8 087J
600422 -          060303......... 36............... 060428, ref SDS A8 087J
600423 -          060210......... 33............... 060217, ref SDS 98 087J
600424 -          060109......... 34............... 060126, ref SDS 97 KV59
600425 -          051223......... 34............... 060106, ref SDS 96 087J
600426 -          051202......... 28............... 060106, ref SDS 96 087J
600427 -          051116......... 31............... 051121, ref SDS 94 087J
600428 -          051109......... 30............... 051121, ref SDS 94 087J
600429 -          051102......... 34............... 051121, ref SDS 94 087J
600430 -          050909......... 45 H............. 051007, ref SDS 87 087J
600431 -          050826......... 45 H............. 050913, ref SDS 81 087J
600432 -          050819......... 45 H............. 050913, ref SDS 81 087J
600433 -          050812......... 39 .............. 050819, ref SDS 74 3K6L
600434 -          050729......... 45 H............. 050819, ref SDS 74 EA5G
600435 -          050708......... 46 H............. 050729, ref SDS 73 087J
600436 -          050701......... 37 .............. 050729, ref SDS 73 087J
600437 -          050617......... 45 H............. 050729, ref SDS 73 087J
600438 -          050527......... 56 H............. 050610, ref SDS 70 087J
600439 -          050512......... 67 H............. 050520, ref SDS 68 087J
600440 -          050506......... 80 H............. 050520, ref SDS 68 087J
600441 -  ..
600442 -          050415.........105 H............. 050422, ref SDS 65 087J
600443 -          050325.........100 H............. 050329, ref SDS 63 087J
600444 -          050318.........101 H............. 050325, ref SDS 62 2N5J
600445 -          050304......... 88 H............. 050311, ref SDS 59 087J
600446 -          050225......... 95 H............. 050308, ref SDS 58 0001
600447 -          050211......... 78 H............. 050214, ref SDS 57 02BB
600448 -          050128......... 67 H............. 050204, ref SDS 56 087J
600449 -          041228......... 56 H............. 041230, ref SDS 55 087J
600450 -          041204......... 43 H............. 041210, ref SDS 54 087J
600451 -          041007......... 39............... 041104, ref SDS 50 087J
600452 -          040923......... 49 H............. 041005, ref SDS 48 087J
600453 -          040908......... 44 H............. 040909, ref SDS 47 087J
600454 -          040825......... 47 H............. 040909, ref SDS 47 087J
600455 -          040811......... 42 H............. 040812, ref SDS 46 087J
600456 -          040728......... 43 H............. 040729, ref SDS 44 2N5J
600457 -          040712......... 47 H............. 040713, ref SDS 43 087J
600458 -          040614......... 55 H............. 040615, ref SDS 42 PX6X
600459 -          040517......... 78 H............. 040601, ref SDS 40 2N5J
600460 -          040311......... 70 H............. 040318, ref SDS 32 SM6M
600461 -          040205......... 60 H............. 040211, ref SDS 29 SM6M
600462 -          031201......... 62 H............. 031205, ref SDS 28 SM6M
600463 -          030912......... 66 H............. 030915, ref SDS 27 SM6M
600464 -          030708......... 68 H............. 030710, ref SDS 26 SM6M
600465 -          030503......... 54 H............. 030508, ref SDS 24 SM6M
600466 -          030403......... 45 H............. 030508, ref SDS 24 SM6M
600467 -          030215......... 46 H............. 030220, ref SDS 23 5E6L
600468 -          030106......... 37 H............. 030109, ref SDS 22 SM6M
600469 -          021202......... 41 H?............ 021204, ref SDS 21 SP5G
600470 -          021111......... 36 H?............ 021113, ref SDS 20 Y65I
600471 -          021023......... 33 H?............ 021023, ref SDS 19 SQ5I
600472 -          020930......... 33 H?..39........ 021002, ref SDS 18 SQ5I
600473 -          020917......... 36 H?............ 020924, ref SDS 17 SQ5I
600474 -          020717......... 59 H?............ 020726, ref SDS 16 YN5K
600475 -          020629......... 75 H ............ 020705, ref SDS 14 UX6I
600476 -          020608........  67 H ............ 020614, ref SDS 12 0001
600477 -          020603........ 108 H ............ 020607, ref SDS 11 X67F
600478 -          020511........ 117 H ............ 020603, ref SDS 10 PJ4J
600479 -          020419......... 81 H ............ 020430, ref SDS 8 7N5H
600480 -          020321......... 85 H ............ 020405, ref SDS 7 6T8K
600481 -
600482 -
600483 -
600484 -
600486 -  ..
6005 -
6006 -
6007 - Analysis
6008 -
600801 - CA 15-3 56 Cancer Marker Test Tomorrow Influence Treatment Decision
600802 -
600803 - Follow up ref SDS F1 GJ5M, ref SDS E7 GJ5M.
600804 -
600805 - Slight rise of CA 15-3 cancer marker from 51 to 56, together with
600806 - favorable report from the CT test on 060930, shown by review on 061012
600807 - finding no evidence of distant metastasis, ref SDS F6 2967, taken
600808 - together seems consistent with stable to rising IBC activity on the
600809 - left breast area, reported previously on 060929, ref SDS F1 FQ6G, and
600810 - seen again during examination today, reported below, ref SDS 0 XO5L,
600811 - including doctor's comments noting no evidence of distant metastasis.
600812 - ref SDS 0 YQ6I
600814 -  ..
600815 - Effectivenss of chemotherapy protocol may be starting to fail in the
600816 - treatment of cancer cells that infect the red rash area under scenario
600817 - #2, and due to "pockets of resistance," possibly increased by
600818 - mastectomy surgery on 051021 that removed blood vessels, as further
600819 - discussed below. ref SDS 0 725L
600821 -  ..
600822 - The doctor feels this record supports continuing current treatment, as
600823 - shown below. ref SDS 0 PF3O
600824 -
600825 -
600826 -
600827 -
6009 -

SUBJECTS
Esophagitis Continued Mild Refulx Treated with Tums Meeting Primary

6303 -
630401 -  ..
630402 - Esophagitis Not Compared in Current PET Test with Prior Report
630403 -
630404 - Follow up ref SDS F1 JP6K, ref SDS E7 JP6K.
630405 -
630406 - Background on imgaing tests finding "likely" esophagitis is cited in
630407 - the record on 060929, noting continued mild indigestion treated with
630408 - Tums, and occassional serious reflux. ref SDS F1 JP6K
630410 -  ..
630411 - There was no discussion of esophagitis today, shown by the doctor's
630412 - record. ref SDS 0 1248
630413 -
630414 -
630415 -
630416 -
630417 -
630418 -
6305 -

SUBJECTS
Left Axillary No Evidence Lymphadenopathy Lymphedema Left Arm Lump    2
Left Axillary Lymphadenopathy Patient No Complaint Swelling Discomfo

7404 -
740501 -  ..
740502 - Left Axillary No Evidence Lymphadenopathy CT Testing 060930
740503 - Lymphedema Left Arm Lump Complications Cellulitus Hospitalized
740504 - Cellulitus Hospitalized Lymphedema Left Arm Lump Complications
740505 - Post Operation Localized Edema Left Axillary Swelling Cellulitus
740506 -
740507 - Follow up ref SDS F1 MW8J, ref SDS E7 MW8J.
740509 -  ..
740510 - Patient history of left axillary lymphadenopathy and lymphedema is
740511 - reported on 060106. ref SDS 96 S164
740513 -  ..
740514 - Examination today again found no evidence of cancer in left axilla.
740515 - The patient made no complaint of lumps or discomfort from swelling
740516 - under the left arm.
740518 -  ..
740519 - CT scan imaging test ordered on 060929 was performed the next day on
740520 - 060930.  Review on 061012, ref SDS F6 0Y4N, shows testing found no
740521 - evidence of disease (NED) in the axilla and supraclavicular regions.
740522 - ref SDS F6 2967  This supports prior testing in April and May reviewed
740523 - during the meeting on 060623 that showed no findings of
740524 - lymphadenopathy. ref SDS C4 MW8J
740526 -  ..
740527 - Previously, on 060929 the doctor reviewed patient history on 060914
740528 - when Millie fell at the BART station as a result of fatigue, and
740529 - injured the middle index finger on her left hand; since this was the
740530 - side of mastectomy surgery on 051021, lymphedema increased causing the
740531 - left arm to swell. ref SDS F2 ZQ5I  Over the next week, swelling
740532 - increased, so on 060922 Millie notified Kaiser of significant
740533 - swelling. ref SDS F3 0D5Y  Examination on 060929 showed problem
740534 - persists on the left arm.  There was no change to treatment with home
740535 - massage and physical therapy at the Kaiser Lymphedema Clinic.
740536 - ref SDS F1 IW9J
740538 -  ..
740539 - Swelling in the left arm, and pain in the left finger worsened under
740540 - the prescribed regimen.
740542 -  ..
740543 - After physical therpay for rising lymphedema on 061016, Kaiser xrayed
740544 - the left hand and found Millie's finger was broken in the fall on
740545 - 060914.  Kaiser immobilized the left hand and finger with a soft-cast
740546 - to facilitate healing. ref SDS F8 IP5I  On 061019 orthopedic doctor
740547 - removed the cast, and prescribed continued exercise to maintain range
740548 - of motion; prognosis is long slow healing process. ref SDS F9 087I
740550 -  ..
740551 - The doctor examined Millie's left arm, hand, and finger.
740553 -  ..
740554 - Swelling was observed during the meeting today.  The doctor feels this
740555 - will decline, as the broken finger heals, and trauma to the left arm
740556 - subsides.  Prescribes further treatment in Kaiser Physical Therapy
740557 - Clinic, as shown in doctor's progress notes. ref SDS 0 1248
740559 -  ..
740560 - Measurements below elbow shows improvement 11.75" down slightly from
740561 - 12" reported during meeting with physical therapyst on 061016, and
740562 - shown in case study on 060509. ref SDS B4 HO7F
740564 -     ..
740565 -    [On 061027 Millie hospitalized temperature 102.6, ref SDS G3 HP52,
740566 -    severe red rash envelops left arm and shoulder; diagnosis
740567 -    cellulitis complications of lymphedema, reaction to tramua from
740568 -    fall and breaking finger on 060914. ref SDS G3 V759
740570 -     ..
740571 -    [On 061101 Millie was released from the hospital with home care
740572 -    administering antibiotis for 10 days to treat cellulitis.
740573 -    ref SDS G6 0001
740574 -
740575 -
740576 -
740577 -
740578 -
740579 -
7406 -

SUBJECTS
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom

7903 -
790401 -  ..
790402 - Right Axillary FDG SUV 2.5 Lump Discomfort Not Reported by Patient
790403 -
790404 - Follow up ref SDS F1 3D6K, ref SDS E7 3D6K.
790405 -
790406 - Background on patient history of testing for lymphedanopathy in the
790407 - right axilla is reported in the record on 060929. ref SDS F1 3D6K
790409 -  ..
790410 - Examination today again found no evidence of cancer in right axilla.
790411 - The patient made no complaint of lumps or discomfort from swelling
790412 - under the right arm.
790414 -  ..
790415 - CT scan imaging test ordered on 060929 was performed the next day on
790416 - 060930.  Review on 061012, ref SDS F6 0Y4N, shows testing found no
790417 - evidence of disease (NED) in the axilla and supraclavicular regions.
790418 - ref SDS F6 2967  This supports prior testing in April and May reviewed
790419 - during the meeting on 060623 that showed no findings of
790420 - lymphadenopathy. ref SDS C4 CZ8L
790421 -
790422 -
790423 -
790424 -
7905 -

SUBJECTS
Left Supraclavicular Neck Lymphadenopathy Patient No Complaint Swell

8703 -
870401 -  ..
870402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
870403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
870404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
870405 -
870406 - Follow up ref SDS F1 8R6M, ref SDS E7 8R6M.
870407 -
870408 - Background of image testing, and consideration for radiation treatment
870409 - of left supraclivicular is reported on 060623. ref SDS C4 8R6M
870411 -  ..
870412 - Examination today again found no evidence of lumpiness in the left
870413 - supraclavicular.  The patient made no complaint of lumps or discomfort
870414 - from swelling in this region.
870416 -  ..
870417 - On 060929 Doctor Benz 2nd opinion from examination on 060821 notes
870418 - that failure of CT test on 060505 to report findings in left
870419 - supraclavicular where PET test finds nodes progressing in size raises
870420 - concerns, ref SDS F2 WI4I, set out in previous analysis on 060523.
870421 - ref SDS B6 4R82
870423 -  ..
870424 - CT scan imaging test ordered on 060929 was performed the next day on
870425 - 060930.  Review on 061012, ref SDS F6 0Y4N, shows testing found no
870426 - evidence of disease (NED) in the axilla and supraclavicular regions.
870427 - ref SDS F6 2967  This supports prior testing in April and May reviewed
870428 - during the meeting on 060623 that showed no findings of
870429 - lymphadenopathy. ref SDS C4 K74Y
870430 -
870431 -
870432 -
870433 -
8705 -

SUBJECTS
Examination IBC Red Rash Left Breast Seems Stable Unchanged from 060

A403 -
A40401 -  ..
A40402 - Red Rash Stable Left Breast Slow Response to Treatment
A40403 - Examination Left Breast IBC Inflammation Red Rash Seems to Stable
A40404 - IBC Inflammation Left Breast Red Rash Stable Slow Response Treatment
A40405 - Response to Treatment Slow IBC Inflammation Left Breast Red Rash Stable
A40406 -
A40407 - Follow up ref SDS F1 025H, ref SDS E7 025H.
A40408 -
A40409 - Background on prior relapse examinations is listed on 060711.
A40410 - ref SDS C6 8Y7O
A40412 -  ..
A40413 - On 060929 the primary care physician submitted a copy of the 2nd
A40414 - opinion from UCSF, ref SDS F1 624L, following up the meeting with
A40415 - Doctor Benz on 060821. ref SDS E6 0001
A40417 -  ..
A40418 - Primary focus today is on pulmonary embolism, see below. ref SDS 0
A40419 - CV5L
A40421 -  ..
A40422 - As on 060929, the doctor looked briefly at the red rash on the left
A40423 - breast area, and noted stable to somewhat improved conditions with red
A40424 - rash possibly slightly less or slightly more spread out.  Without
A40425 - measurements this issue is indeterminate, because of slow change in
A40426 - the spread and severity of the rash. ref SDS F1 FQ6G
A40428 -  ..
A40429 - Observation today shows IBC rash occurs in various "pockets" with
A40430 - varying degrees of intensity above and below the incision line for
A40431 - mastectomy surgery on 051021.  Some pockets of rash seem stable,
A40432 - others seem slightly worse, and some may show improvement.  Overall
A40433 - there is little change since examination on 060825, ref SDS E7 025H,
A40434 - and including the 2nd opinion from UCSF received on 060929.
A40435 - ref SDS F2 WQ8V  After three (3) additional treatments there is no
A40436 - appreciable improvmement of the rash on the left breast from
A40437 - conditions found on 060821 by Doctor Benz. ref SDS E6 KR6I
A40438 -
A40439 -        [On 061208 primary care physician observes rash has spread
A40440 -        from the left breast to slightly onto the right breast for
A40441 -        the first time in 3 years, and so may establish measurable
A40442 -        disease to qualify for UCSF drug studies. ref SDS H2 AX6G
A40444 -  ..
A40445 - Doctor Benz raises the prospect in his 2nd opinion reviewed on 060929
A40446 - that the rash on the left breast might not be IBC, ref SDS F2 WQ8V,
A40447 - cited in Millie's letter to the primary care physician today.
A40448 - ref DIT 1 9I6O
A40450 -  ..
A40451 - During the examination on 060821 the doctor proposed getting a biopsy
A40452 - for "measurable" disease to qualify for drug trials. ref SDS E6 KT7J
A40453 - At that time, on 060821 Doctor Benz seemed to emphasize importance of
A40454 - establishing "measureable disease" to qualify for drug trials.
A40455 - ref SDS E6 W66J  Measureable disease was presented again in UCSF's
A40456 - written opinion, reviewed on 060929. ref SDS F2 WQ5T
A40458 -  ..
A40459 - Doctor Benz opinion on 060929 raises questions on "measurable
A40460 - disease." ref SDS F2 WQ5T   Do we need...
A40461 -
A40462 -        1.  biopsy.......................... 060929, ref SDS F2 WY79
A40463 -        2.  measurements.................... 060929, ref SDS F2 WQ5T
A40464 -        3.  photographs
A40465 -        4.  narrative
A40467 -  ..
A40468 - Millie's letter to Kaiser today alerted the doctor about these issues,
A40469 - saying in part...
A40471 -         ..
A40472 -        Conceivably CA 15-3 could be responding to cancer elsewhere
A40473 -        that is still too small for image testing to pickup, and the
A40474 -        rash is not IBC. That seems very remote. ref DIT 1 8J7K
A40476 -         ..
A40477 -        Measureable disease could be measuring spread of the rash.  You
A40478 -        used a tape measure for lymph nodes in my neck.  Maybe we can
A40479 -        take measurements of the rash.  What about photographs?
A40480 -        ref DIT 1 4K8F
A40482 -  ..
A40483 - The doctor decided not to take measurements, nor to take photographs
A40484 - to create a record of measureable disease.
A40486 -  ..
A40487 - Photographs were previously considered to capture a record for
A40488 - evaluating boundaries to perform mastectomy surgery, reported during
A40489 - examination by the surgeon on 050324. ref SDS 61 0347
A40490 -
A40491 -        [On 070130 photographs planned to determine measureable
A40492 -        disease treating Millie with drug trial in clinical
A40493 -        study at UCSF. ref SDS H6 M661
A40494 -
A40496 -  ..
A40497 - Distant Metastasis No Evidence Imaging Tests Conflicts Rising CA 15-3
A40498 -
A40499 - The doctor indicated that imaging tests, most recently on 060930, show
A40500 - no evidence of distant metastasis, which aligns with review on 061012.
A40501 - ref SDS F6 2967
A40503 -  ..
A40504 - One possibility is that sudden rise of CA 15-3 means that IBC is
A40505 - rising on the left breast area, though at this time not significantly
A40506 - enough to recognize by observation, per analysis of the cancer marker,
A40507 - shown above. ref SDS 0 GJ5M
A40508 -
A40509 -
A40510 -
A40511 -
A40512 -
A406 -

SUBJECTS
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea

AA03 -
AA0401 -  ..
AA0402 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
AA0403 - Slow Response to Treatment Mastectomy Removed Blood Vessels
AA0404 - Expectations Recovery Rate Tempered by Mastectomy Surgery
AA0405 - Mastectomy Removes Blood Vessels Slows Rate Recovery IBC Relapse
AA0406 -
AA0407 - Follow up ref SDS F1 EH3F, ref SDS E7 G57I.
AA0408 -
AA0409 - Background of mastectomy surgery performed on 051021 with impacts on
AA0410 - expectations for recovery from IBC red rash is reported on 060929,
AA0411 - ref SDS F1 EH3F  Case study on 041210 originally considered mastectomy
AA0412 - surgery for Millie. ref SDS 54 657F  Recent 2nd opinion meeting at
AA0413 - UCSF on 060821 requested review of effects from surgery that removed
AA0414 - blood vessels on effectiveness of systemic chemotherapy treatments
AA0415 - delivered through the blood system. ref SDS E6 NN3H
AA0417 -  ..
AA0418 - Analysis on 060922 cites mastectomy removing blood vessels as possible
AA0419 - reason for delayed response to treatment this year compared to much
AA0420 - faster response in 2005. ref SDS E9 ML3I
AA0422 -  ..
AA0423 - Sudden rise of CA 15-3 cancer marker, ref SDS 0 GJ5M, together with
AA0424 - stable to expanding IBC red rash on the left chest reported today,
AA0425 - ref SDS 0 XO5L, may relate to concerns presented by primary care
AA0426 - physician on 050311 that "pockets of resistance" to chemotherapy
AA0427 - treatment cause slow recovery, ref SDS 60 NT5O, supported later by 2nd
AA0428 - opinion consultation with Doctor Bailey on 051011. ref SDS 88 G65S
AA0429 - Additionally, cancer may be growing that is inherently resistant to
AA0430 - the current treatment using Taxotere and capecitabine (Xeloda), under
AA0431 - scenario #2 explained on 060808. ref SDS E0 HT5K
AA0432 -
AA0433 -        [On 051027 Millie asks about slow recovery from IBC caused by
AA0434 -        mastectomy surgery removing blood vessels needed to deliver
AA0435 -        treatment. ref SDS G2 MS3Y
AA0436 -
AA0437 -
AA0438 -
AA0439 -
AA0440 -
AA0441 -
AA05 -

SUBJECTS
Biopsy Left Breast Investigate for Mutated Cancer IBC Red Rash Statu

AG03 -
AG0401 -  ..
AG0402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
AG0403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
AG0404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
AG0405 -
AG0406 - Follow up ref SDS F1 KT7J, ref SDS E7 KT7J.
AG0407 -
AG0408 - Can a biopsy contribute to patient work up for developing a strategy
AG0409 - and treatment plan, discussed on 060711? ref SDS C6 K36G
AG0411 -  ..
AG0412 - Review on 060929 of UCSF 2nd opinion prepared by Doctor Benz from
AG0413 - examination on 060821 finds red rash on left breast area previously
AG0414 - found by biopsy on 040419 to be IBC, and later found to be clear of
AG0415 - IBC disease by biopsy on 051021 has, however, not established as
AG0416 - recurrent IBC by biopsy this year in 2006, ref SDS F2 WY79; caution
AG0417 - presented in the Benz examination resisting association of red rash
AG0418 - lesions and inflammation on the left breast area with IBC disease, and
AG0419 - in relation to rising CA 15-3 cancer marker, doctor indicates there
AG0420 - may be wide spread distant metastasis too small for recognition by
AG0421 - image testing and currently being treated systemcially with
AG0422 - chemotherapy. ref SDS F2 WQ8V
AG0424 -  ..
AG0425 - Slow response to treatment may warrant investigation with biopsy for
AG0426 - consideration of status change flowing from possible cancer mutation
AG0427 - that resists current treatment under scenario #2 developed on 060808,
AG0428 - ref SDS E0 HT5K, and citing analysis on 030606 presented by the
AG0429 - primary care physician. ref SDS 25 N27L
AG0431 -  ..
AG0432 - With a hectic schedule today, ref SDS 0 SM6M, the primary care
AG0433 - physician did not have time to review this issue.
AG0434 -
AG0435 -
AG0436 -
AG0437 -
AG0438 -
AG0439 -
AG05 -

SUBJECTS
IBC Imaging Tests CT Scan 060930 Investigate Symptoms Pulmonary Embo

AN03 -
AN0401 -  ..
AN0402 - CT Test 060930 Findings Pulmonary Emboli No Evidence Distant Metastasis
AN0403 - Distant Metastasis No Evidence PE Positive Findings CT Test 060930
AN0404 - Pulmonary Emboli Findings Distant Metastasis No Evidence CT Test 060930
AN0405 -
AN0406 - Follow up ref SDS F1 EY5O, ref SDS E7 EY5O.
AN0407 -
AN0408 - On 060929 the doctor ordered a CT test primarily to evaluate pulmonary
AN0409 - embolism. ref SDS F1 J446
AN0411 -  ..
AN0412 - The test was performed on an expedited basis the next day on 060930.
AN0413 - ref SDS F3 MI5I  A few days later, the doctor called on 061002 and
AN0414 - reported the test was positive for pulmonary embolism recurrence.  The
AN0415 - doctor prescirbed treatments with Coumadin to resume, ref SDS F4 MI5I,
AN0416 - which were previously stopped on 061007. ref SDS 87 GC6K
AN0418 -  ..
AN0419 - Review of test results on 061012 shows findings of pulmonary embolism,
AN0420 - ref SDS F6 294Q, with complications of enlarged right ventricle,
AN0421 - ref SDS F6 7E5L, discussed below. ref SDS 0 SM41
AN0423 -  ..
AN0424 - Review on 061012 further shows that the pathology report for the CT
AN0425 - test on 060930 does not compare with the prior test on 041103 that
AN0426 - originally diagnosed pulmonary embolism. ref SDS F6 2935  This
AN0427 - conflicts with the doctor's order for a comparison, reported on
AN0428 - 060929. ref SDS F1 DY5M  Millie's letter to Kaiser on 061013 asks how
AN0429 - to get the comparison ordered by the doctor for effective trend
AN0430 - analysis. ref SDS F7 I75V
AN0431 -
AN0432 -        [On 061208 doctor ordered PET scan test to set new baseline for
AN0433 -        changing chemotherapy to treat IBC; and added to the order
AN0434 -        request for analysis of pulmonary embolism, and enlarged right
AN0435 -        ventricle by comparing and contrasting with prior CT tests on
AN0436 -        041103 and on 060930, even though CT scan tests are a better
AN0437 -        diagnostic for this comparison. ref SDS H2 ZY5L
AN0439 -  ..
AN0440 - The doctor had a hectic schedule today, ref SDS 0 SM6M, so there was
AN0441 - not enough time during the meeting to compare findings between the
AN0442 - reports, as set out on 061012. ref SDS F6 7E7G
AN0443 -
AN0444 -        [...see below, pulmonary embolism review discusses comparing
AN0445 -        current condition with original diagnosis on 041103.
AN0446 -        ref SDS 0 385I
AN0448 -  ..
AN0449 - The primary care physician concurred with review on 061012 that the CT
AN0450 - test on 060930 found no evidence of distant metastasis, ref SDS F6
AN0451 - 1Y8G, also cited above. ref SDS 0 YQ6I
AN0453 -  ..
AN0454 - The doctor also noted today that the protocol for the test to evaluate
AN0455 - pulmonary embolism is different from CT tests normally done to
AN0456 - evaluate progression of metastatic cancer, as explained further below.
AN0457 - ref SDS 0 S56G
AN0458 -
AN0459 -        [On 061110 CT tests for pulmoanry embolism are more rigorous
AN0460 -        than tests normally performed to evaluate progression of
AN0461 -        metastatic cancer, ref SDS H0 MX4H, and so the test on 060930
AN0462 -        is nominally more reliable than normal in finding no evidence
AN0463 -        of distant metastasis, per above. ref SDS 0 NG6N
AN0464 -
AN0465 -
AN0466 -
AN0467 -
AN0468 -
AN0469 -
AN0470 -
AN05 -

SUBJECTS
Emotional Trauma Discovery Pulmonary Emboli Many Other Issues Cause

AW03 -
AW0401 -  ..
AW0402 - Emotional Trauma Rising Falling Cancer Symptoms
AW0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
AW0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
AW0405 -
AW0406 - Follow up ref SDS F1 Y642, ref SDS E7 Y642.
AW0407 -
AW0408 - Emotional roller coaster of good news mixed with concern from mounting
AW0409 - medical issues listed above, ref SDS 0 PB3H, increases stress because
AW0410 - limited time prevents timely consideration due a hectic schedule.
AW0411 - ref SDS 0 SM6M
AW0413 -  ..
AW0414 - The growing gap between problems and time for review increases trauma
AW0415 - from emotional stress, including...
AW0416 -
AW0417 -        1.  CT test showing no evidence distant metastasis, nor
AW0418 -            findings of cancer of any kind presents a big relief.
AW0419 -            ref SDS 0 EY5O  Conflict with slow recovery left breast
AW0420 -            IBC, ref SDS 0 XO5L, with rising CA 15-3 cancer marker,
AW0421 -            ref SDS 0 087J, causes doubt, worry, stress.
AW0423 -             ..
AW0424 -        2.  Knowledge Management dilemma of complexity from expanding
AW0425 -            medical issues, ref SDS 0 PB3H, that overwhelm span of
AW0426 -            attention, and give rise to desire to simplify analysis by
AW0427 -            ignoring issues that exceed span of attention. ref SDS 0
AW0428 -            MO4K
AW0430 -             ..
AW0431 -        3.  Pulmonary embolism recurrence diagnosed on 061002, after
AW0432 -            being removed from treatment on 061007, creates doubt and
AW0433 -            worry, reviewed below. ref SDS 0 SM41
AW0435 -             ..
AW0436 -        4.  Heart disorder discovered by accident complication of
AW0437 -            enlarged right ventricle without notice from Kaiser, and
AW0438 -            without assessment of severity. ref SDS 0 VD44
AW0440 -             ..
AW0441 -        5.  Slow response to treatment for IBC cancer left breast
AW0442 -            compared to prior rapid recovery with the same treatment in
AW0443 -            2005, reviewed above. ref SDS 0 XO5L
AW0445 -             ..
AW0446 -        6.  Challenge medical practice develop patient work up with
AW0447 -            pool of treatments, strategy, and planning for applying
AW0448 -            treatments creates stress about future prospects.
AW0449 -            ref SDS 0 K36G
AW0451 -             ..
AW0452 -        7.  Lymphedema rising left arm, pulmonary emboli, side effects
AW0453 -            chemotherapy prevent normal exercise to relieve stress and
AW0454 -            increase fitness. ref SDS 0 EP5N
AW0456 -             ..
AW0457 -        8.  Biopsy for IBC, 2nd opinion cites patient history using
AW0458 -            biopsy for diagnosis, and no biopsy to confirm current
AW0459 -            condition. ref SDS 0 KT7J
AW0461 -             ..
AW0462 -        9.  Communication problems within the team care model to verify
AW0463 -            medications are correctly coordinated for effectiveness and
AW0464 -            to prevent harmful conflicts in treatment, ref SDS 0 YQ7L
AW0466 -             ..
AW0467 -       10.  Discovery that CT tests require a special specification to
AW0468 -            examine pulmonary embolism. ref SDS 0 S56G
AW0470 -             ..
AW0471 -       11.  Failure of imaging tests to make correct comparisons
AW0472 -            ordered by the doctor. ref SDS 0 NG5O
AW0474 -  ..
AW0475 - All of these events during the past treatment cycle create emotional
AW0476 - sieches of hope, worry and stress about prospects of getting well to
AW0477 - restore fitness for emotional and physical strength to have a normal
AW0478 - life again.
AW0479 -
AW0480 -               [On 061027 Millie letter advises Kaiser that pulmonary
AW0481 -               embolism symptoms continue fatigue, shortness of breath;
AW0482 -               Millie asks about prognosis for getting back in the gym
AW0483 -               to improve fitness, which previously were attributed to
AW0484 -               symptoms for pulmonary embolism. ref SDS G2 K24K
AW0485 -
AW0486 -
AW0487 -
AW0488 -
AW0489 -
AW0490 -
AW0491 -
AW05 -

SUBJECTS
Strategy Treatment Plan IBC 3rd Relapse Scope Chemotherapy Drug Agen

B103 -
B10401 -  ..
B10402 - Pool Chemotherapy Drugs Available to Treat IBC
B10403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
B10404 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
B10405 -
B10406 - Follow up ref SDS F1 K36G, ref SDS E7 K36G.
B10407 -
B10408 - Background on requirements and challenge performing requirements for
B10409 - planning and proactive management in time for action to be effective
B10410 - is reported on 060825. ref SDS E7 K36G
B10411 -
B10412 -
B10413 -
B10414 -
B10415 -
B105 -

SUBJECTS
Treatment IBC 5th Cycle for 3rd Relapse Continue Chemotherapy Agents

B603 -
B60401 -  ..
B60402 - Treatment 5th Cycle Continue Taxotere and Capecitabine (Xeloda)
B60403 - 5th Cycle Taxotere and Capecitabine (Xeloda) Treatment Continue
B60404 - Taxotere and Capecitabine (Xeloda) 5th-Cycle Treatment Continue
B60405 -
B60406 - Follow up ref SDS F1 PF3O, ref SDS E7 PF3O.
B60407 -
B60408 - The doctor proposed continuing current treatment with Taxotere and
B60409 - capecitabine (Xeldoa).
B60411 -  ..
B60412 - No ideas and no research were presented for consideration to improve
B60413 - the rate of recovery for IBC on the left breast, which has shown no
B60414 - improvement for several cycles, per above, ref SDS 0 XO5L, and as
B60415 - noted in the doctor's treatment plan, see below. ref SDS 0 125V
B60416 -
B60417 -
B60418 -
B60419 -
B605 -

SUBJECTS
Schedule Treatment 061110 on Friday for 6th Cycle Taxotere Capecitab

B803 -
B80401 -  ..
B80402 - Schedule Treatment Continue Prescription Taxotere Capecitabine Xeloda
B80403 -
B80404 - Follow up ref SDS F1 N96O, ref SDS E7 N96O.
B80405 -
B80406 - The doctor scheduled the next meeting for 061110, after chemotherapy
B80407 - treatment.
B80408 -
B80409 -
B80410 -
B80411 -
B80412 -
B80413 -
B805 -

SUBJECTS
Pulmonary Emboli Diagnosis CT Test 060930 Blood Clots Lungs Treatmen

BM03 -
BM0401 -  ..
BM0402 - Fatigue Shortness Breath Normal Activity Pulmonary Emboli Symptoms
BM0403 - Coumadin Treatment Pulmonary Emboli Symptoms Less Severe Continue
BM0404 - Pulmonary Emboli Symptoms Continue Less Severe Coumadin Treatment
BM0405 -
BM0406 - Follow up ref SDS F1 CV5L, ref SDS E7 CV5L.
BM0407 -
BM0408 - On 060929 Millie reported side effects of chemotherapy to staff in the
BM0409 - Infusion Clinic, including shortness of breath, and fatigue doing
BM0410 - routine physicial tasks like climbing the stairs at home, and working
BM0411 - out at the gym. ref SDS F0 XP42  This was further reported to the
BM0412 - primary care physician in another meeting later that afternoon on
BM0413 - 060929. ref SDS F1 B56N
BM0415 -  ..
BM0416 - At that time, on 060929, the doctor ordered a CT test for pulmonary
BM0417 - embolism to compare with a prior test on 041103, that discovered
BM0418 - initial pulmonary emboli, reported on 041104. ref SDS F1 DY8L  The
BM0419 - test was scheduled for the next 10 days in time for review in the
BM0420 - meeting today. ref SDS F1 435I
BM0422 -  ..
BM0423 - The next day, on 040930 Millie was called and asked to come in for the
BM0424 - CT test later that same day on an expedited basis. ref SDS F3 MI5I
BM0426 -  ..
BM0427 - On 061002 the primary care physician called and left a message that CT
BM0428 - test findings show pulmonary emboli, ref SDS F4 MI5I; Millie resumed
BM0429 - treatment with coumadin, previously ended on 051007. ref SDS F4 GO3J
BM0431 -  ..
BM0432 - Millie now seems less fatigued and suffers less shortness of breath
BM0433 - after starting treatments for pulmonary emboli on 061002; however,
BM0434 - symptoms have continued.  The doctor feels continuing treatment with
BM0435 - coumadin (warfarin) will yield further improvement.
BM0436 -
BM0437 -        [On 061027 Millie letter advises Kaiser that pulmonary embolism
BM0438 -        symptoms continue fatigue, shortness of breath; Millie asks
BM0439 -        about prognosis for getting back in the gym to improve fitness,
BM0440 -        which previously were attributed to symptoms for pulmonary
BM0441 -        embolism. ref SDS G2 0C4I
BM0443 -  ..
BM0444 - Millie thanked the doctor for proactive management discovering
BM0445 - pulmonary embolism in time to avoid serious complications, reported on
BM0446 - 060722, ref SDS D1 346F, and as reported in her letter on 061002
BM0447 - notifying Kaiser that instructions for treatment were followed to
BM0448 - begin taking coumadin. ref SDS F4 HU6K
BM0449 -
BM0451 -  ..
BM0452 - Comparison CT Test 060930 with Test 041103 Original Diagnosis
BM0453 -
BM0454 - Millie asked about follow up with the Imaging department to perform
BM0455 - the comparison ordered by the doctor on 060929 for the CT test?
BM0457 -  ..
BM0458 - The doctor did not recall getting Millie's letter on 061013,
BM0459 - ref SDS F7 I75V, asking about failure of the CT test report to make
BM0460 - the comparison ordered by the doctor on 060929, ref SDS F1 DY8L, and
BM0461 - as reported on 061012 reviewing the CT test. ref SDS F6 2935
BM0463 -  ..
BM0464 - Since the doctor's schedule was hectic today, ref SDS 0 SM6M, there
BM0465 - was not enough time to review preliminary comparison begun on 061012
BM0466 - for diagnosis and treatment considerations. ref SDS F6 7E7G
BM0467 -
BM0468 -     [On 061110 hectic schedule again, doctor did not have time to
BM0469 -     review comparison of test reports. ref SDS H0 HB3K
BM0470 -
BM0471 -
BM0472 -
BM0473 -
BM05 -

SUBJECTS
Coumadin Medication Notification Mistakes Computer Access Pulmonary

C903 -
C90401 -  ..
C90402 - Notification Patient Medications Coumadin Balance with Xeloda
C90403 - Patient Medications Coumadin Balance with Xeloda Notification
C90404 - Coumadin Balance with Capecitabine (Xeloda) Patient Medications
C90405 -
C90406 - Millie reported discussions earlier today with the Oncology pharmacist
C90407 - about notifying the Coagulation Control Clinic that she is being
C90408 - treated with capecitabine (Xeloda). ref SDS G0 S69H  The pharmacist
C90409 - was concerned that capecitiabine treatments prescribed for cancer by
C90410 - the doctor on 060711, ref SDS C6 PF3O, require adjustments to Coumadin
C90411 - treatments for pulmonary emboli, prescribed by the doctor a few weeks
C90412 - ago on 061002. ref SDS F4 MI5I
C90414 -  ..
C90415 - Millie asked if the the Coagulation Treatment Clinic was notified that
C90416 - current medications include capecitabine (Xeloda), when Coumadin was
C90417 - prescribed on 061002?
C90418 -
C90419 -        [On 061208 doctor prescribes Diflucan antibiotics and expects
C90420 -        this will be entered in Kaiser's computer to notify everyone to
C90421 -        avoid conflicts in treatments. ref SDS H2 C75F
C90423 -         ..
C90424 -        [On 061214 treatment mistake pulmonary embolism warfarin
C90425 -        (Coumadin) conflicts with Doflucan; blood test INR rises 6.4
C90426 -        danger zone for hemoraging; blood clot coagulation treatment
C90427 -        paused for 3 days; INR update test advanced. ref SDS H3 HF4O
C90429 -  ..
C90430 - The doctor explained that he helped develop a system about 10 years
C90431 - ago for patient medications to be accessible on Kaiser's computers.
C90432 - He was therefore surprised to hear today that the Oncology Pharmacy
C90433 - here in Kaiser's Walunt Creek hospital, and the Coagulation Control
C90434 - Clinic in Martinez were not aware of Millie's treatments, since they
C90435 - all have access to the same data on Kaiser's computer system.
C90436 -
C90437 -     [On 061112 Doctor Seier found patient history on 061027 prepared
C90438 -     by lead ER physician, and this assisted diagnosis and treatment
C90439 -     for cellulitis relapse on 061112 ref SDS H1 XS5J; patient history
C90440 -     of other doctors treating Millie for cellulitis beginning on
C90441 -     061027 under Kaiser's team care practice was not available.
C90442 -     ref SDS H1 5L6H
C90444 -      ..
C90445 -     [On 061024 case study medical practice computer access limited
C90446 -     even with everything on the computer, people can't find details
C90447 -     stored in parts of the computer (software modules) that are not
C90448 -     frequently used. ref SDS G1 JD9L
C90450 -  ..
C90451 - While we talked, the doctor displayed Millie's medications on the
C90452 - computer screen to demonstrate that access is fast and easy.  This
C90453 - took about 10 seconds or so.  He feels it should not be necessary for
C90454 - the patient to notify the Coagulation Treatment Clinic to make
C90455 - adjustments for Coumadin treatments with capecitiabine (Xeloda).  The
C90456 - doctor also feels that the Oncology Pharmacy down the hall from the
C90457 - examination room should equally be aware of Millie's treatments.  He
C90458 - was pleased to learn the Pharmacist took proactive action to notify
C90459 - the Coagulation Treatment Clinic, and that the Clinic updated Millie's
C90460 - records in time to make the proper adjustments in her treatments,
C90461 - reported earlier today, as well. ref SDS G0 VE57  The doctor was
C90462 - frustrated that the pharmacist had to expressly notify the Coagulation
C90463 - Clinic, since balancing treatments is the responsibility of the
C90464 - attending physician, and, when the prescription for coumadin was made
C90465 - on 061002, ref SDS F4 MI5I, the doctor was counting on fast and easy
C90466 - access to medications using Kaiser's computer system, for the
C90467 - Coagulation Treatment Clinic to make adjustments, without express
C90468 - notice from the doctor, the patient, or the Oncology Pharmacy
C90469 - department.
C90471 -  ..
C90472 - Since the doctor was behind schedule, ref SDS 0 SM6M, there was not
C90473 - enough time today to review comments by the pharmacist, ref SDS G0
C90474 - RS6H, and by Debbie in the Infusion Clinic on weaknesses in Kaiser's
C90475 - computer system, ref SDS G0 TR53, which can be corrected with feedback
C90476 - loops to verify accuracy of daily communications.  Feedback is part of
C90477 - "intelligence" support explained in POIMS, ref OF 3 0367, and is
C90478 - further explained in NWO. ref OF 10 0936  Even though people resist
C90479 - investing time for feedback, in part because feedback sometimes
C90480 - creates controversy, also explained in NWO, ref OF 14 2670, accuracy
C90481 - is critical in medical practice, noted on 040402, ref SDS 33 6E4K, as
C90482 - well as engineering, law, and most other fields, shown by reporting on
C90483 - 990912. ref SDS 5 0001
C90485 -  ..
C90486 - The fact that access to part of Kaiser's computer system is fast and
C90487 - easy for one practitioner, does not make this so for others who mostly
C90488 - use different parts of the software, as Debbie noted earlier today.
C90489 - ref SDS G0 P18K  The history of difficult access to computers delaying
C90490 - case management and reducing productivity is reported on 060711.
C90491 - ref SDS C6 5Y5J
C90492 -
C90493 -        [...below, doctor's progress notes list of current medications
C90494 -        is incorrect, omits Coumadin prescribed on 061002. ref SDS 0
C90495 -        SE86
C90497 -         ..
C90498 -        [On 061024 Coagulation Treatment Clinic uses software that
C90499 -        requires accessing another part of Kaiser's computer system to
C90500 -        coordinate patient treatments; such access requires training,
C90501 -        and time for performance; therefore direct notice from the
C90502 -        doctor and support staff in Oncology Pharmacy, as occurred
C90503 -        today, reported in another record, ref SDS G0 VE57, and also by
C90504 -        the patient, as encouraged by the pharmacist, also, in another
C90505 -        record, ref SDS G0 S69H, assists the Coagulation Treatment
C90506 -        Clinic in making an accurate and effective balance of
C90507 -        treatments for pulmonary embolism with chemotherapy treatments
C90508 -        for cancer using capecitabine (Xeloda) in this case.
C90509 -        ref SDS G1 TZ4I
C90511 -         ..
C90512 -        [On 061024 case study medical practice computer access limited
C90513 -        even with everything on the computer, people can't find details
C90514 -        stored in parts of the computer (software modules) that are not
C90515 -        frequently used. ref SDS G1 JD9L
C90517 -         ..
C90518 -        [On 061110 doctor's list of current medications incorrect not
C90519 -        listing Coumadin, and also does not list antibiotics for
C90520 -        cellulitis, Lovenox, also, for PE, Procrit is not listed for
C90521 -        anemia (low energy) to redress low blood counts for hemoglobin,
C90522 -        Tums is not listed for GERD. ref SDS H0 SE86
C90524 -         ..
C90525 -        [On 061208 doctor prescribes Diflucan antibiotics and expects
C90526 -        this will be entered in Kaiser's computer to notify everyone to
C90527 -        avoid conflicts in treatments. ref SDS H2 C75F
C90529 -         ..
C90530 -        [On 061214 treatment mistake pulmonary embolism warfarin
C90531 -        (Coumadin) conflicts with Doflucan; blood test INR rises 6.4
C90532 -        danger zone for hemoraging; blood clot coagulation treatment
C90533 -        paused for 3 days; INR update test advanced. ref SDS H3 HF4O
C90534 -
C90535 -
C90536 -
C90537 -
C906 -

SUBJECTS
CT Test Pulmonary Embolism Different from CT Tests for Cancer Explai

CI03 -
CI0401 -  ..
CI0402 - CT Tests for Pulmonary Emboli Different from CT Tests for Cancer
CI0403 -
CI0404 - The letter submitting the agenda for the meeting today, also asked the
CI0405 - doctor whether CT tests are different for pulmonary embolism?
CI0406 - ref DIT 1 WI8L
CI0408 -  ..
CI0409 - During the meeting this afternoon, the doctor explained that CT scan
CI0410 - tests for pulmonary emboli are different from CT tests for other
CI0411 - issues, for example in Millie's case evauating distant metastasis.  He
CI0412 - described thin slice CT scans find pulmonary embolism.  This helps
CI0413 - explain why CT scan tests did not identify pulmonary embolism from
CI0414 - 040517 and until 041104. ref SDS 50 RZ4I
CI0415 -
CI0416 -        [On 061110 CT tests for pulmoanry embolism are more rigorous
CI0417 -        than tests normally performed to evaluate progression of
CI0418 -        metastatic cancer, ref SDS H0 MX4H, and so the test on 060930
CI0419 -        is nominally more reliable than normal in finding no evidence
CI0420 -        of distant metastasis, per above. ref SDS 0 NG6N
CI0422 -  ..
CI0423 - Using tests with similar names that have different performance, and
CI0424 - require additional steps and commands to order using the computer
CI0425 - system, compounds the "wicked problem" diagnosing pulmonary embolism
CI0426 - for professionals and patients alike, reviewed on 060722. ref SDS D1
CI0427 - 346F  When some parts of the computer system are used frequently, and
CI0428 - other parts are used only rarely, people forget the commands, and
CI0429 - forget to invest time performing rarely used functions.  Limited time
CI0430 - drives people to believe the lessor test that is fast and easy to
CI0431 - order with familiar skills is satisfactory, especially since there is
CI0432 - an explanation for symptoms other than pulmonary embolism.
CI0434 -  ..
CI0435 - Disclosure today that the computer system requires different ordering
CI0436 - steps for CT scans to test for pulmonary embolism explains why 2 tests
CI0437 - in 2004 failed to report blood clots until 041104, ref SDS 50 Q54K,
CI0438 - and again this year in 2006 multiple CT scans did not report pulmonary
CI0439 - embolism, which leads practitioners to diagnose rising clincial
CI0440 - symptoms as loss of fitness from accumulation of chemotherapy side
CI0441 - effects, as reviewed on 060722. ref SDS D1 WF5H
CI0443 -  ..
CI0444 - The dilemma discussed with the primary care physician on 040909 seems
CI0445 - resolved by new information today.  At that time, persistant symptoms
CI0446 - escaped correct diagnosis because numerous CT scan tests failed to
CI0447 - diagnose pulmonary embolism. ref SDS 47 RZ4I  This problem was
CI0448 - repeated a month later at Kaiser on 041005. ref SDS 48 OG3I
CI0450 -         ..
CI0451 -        [On 061024 case study medical practice computer access limited
CI0452 -        even with everything on the computer, people can't find details
CI0453 -        stored in parts of the computer (software modules) that are not
CI0454 -        frequently used. ref SDS G1 JD9L
CI0455 -
CI0456 -
CI0457 -
CI0458 -
CI0459 -
CI0460 -
CI05 -

SUBJECTS
Enlarged Right Ventricle CT Test 060930 Doctor Does Not Remember See

DF03 -
DF0401 -  ..
DF0402 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
DF0403 -
DF0404 - Follow up ref SDS F6 7E5L.
DF0405 -
DF0406 - Millie asked how serious is her pulmonary emobli condition, and cited
DF0407 - her letter to Kaiser on 061013, ref SDS F7 US6H, commenting on the CT
DF0408 - test on 060930, which was reviewed on 061012, ref SDS F6 7E5L, and
DF0409 - Millie further asked about resuming routine exercise at the gym.
DF0411 -  ..
DF0412 - The doctor did not recall the letter on 061013, and did not offer an
DF0413 - estimate on when Millie can be return to the gym to restore physical
DF0414 - and emotional fitness, also, reviewed above. ref SDS 0 Y642
DF0415 -
DF0416 -            [On 061027 Millie letter advises Kaiser that pulmonary
DF0417 -            embolism symptoms continue fatigue, shortness of breath;
DF0418 -            Millie asks about prognosis for getting back in the gym to
DF0419 -            improve fitness, which previously were attributed to
DF0420 -            symptoms for pulmonary embolism. ref SDS G2 MS5P
DF0422 -  ..
DF0423 - The doctor requested clarification of "serious"?
DF0425 -  ..
DF0426 - Millie cited the pathology report that the right ventrical is enlarged
DF0427 - compared to the left ventrical, but does not say how much larger, nor
DF0428 - otherwise present severity, as shown in the record on 061012.
DF0429 - ref SDS F6 7E5L  For example, the report does say that the main
DF0430 - pulmonary artery is near the upper limit of normal, which suggests
DF0431 - prospective problems. ref SDS F6 294V
DF0432 -
DF0433 -        [On 061108 Millie experiences continued symptoms pulmonary
DF0434 -        embolism, shortness of breath, fatigue, cough clearing throat.
DF0435 -        ref SDS G9 VR6F
DF0437 -  ..
DF0438 - The doctor did not remember reading the CT test finding of enlarged
DF0439 - right ventricle.  He asked where the issue is presented in the CT test
DF0440 - findings?
DF0442 -  ..
DF0443 - Case study on 060428 indicates difficulty doctors have with a hectic
DF0444 - schedule, as occurred today, per above, ref SDS 0 SM6M, allocating
DF0445 - time to read complex medical test findings.  Limited time prevents
DF0446 - doctors from performing test analyst's recommendations to correlate
DF0447 - clinically with patient history for discovering symptomatic trends
DF0448 - that enable proactive case management; there is only enough time to
DF0449 - read summaries that present the gist of findings. ref SDS A9 VG5L
DF0450 - Reflects more recent study on 060809 demonstrating Kaiser's strong
DF0451 - reputation for doctor patient partnership through effective
DF0452 - communications. ref SDS E2 K65G
DF0454 -  ..
DF0455 - Millie asked the doctor to display the report on the computer screen
DF0456 - there in the examination room.  She scrolled through the report to the
DF0457 - paragraph on right ventrical enlargement, reported on 061012.
DF0458 - ref SDS F6 7E5L
DF0459 -
DF0460 -        [On 061024 case study medical practice computer access limited
DF0461 -        even with everything on the computer, people can't find details
DF0462 -        stored in parts of the computer (software modules) that are not
DF0463 -        frequently used. ref SDS G1 JD9L
DF0465 -  ..
DF0466 - Millie asked that Kaiser submit actual measurements?  Is the right
DF0467 - ventrical 10% larger, 50%, 100% larger, as an indication of
DF0468 - seriousness of the problem reported by Kaiser?  The analyst should
DF0469 - further comment on seriousness of pulmonary embolism, for example,
DF0470 - compared to the prior problem reported on 041103, and in compliance
DF0471 - with the doctor's order for the CT test, as reviewed on 061012.
DF0472 - ref SDS F6 2935
DF0473 -
DF0474 -     [On 061110 hectic schedule Kaiser has not had enough time to
DF0475 -     determine how much the right ventricle is enlarged. ref SDS H0
DF0476 -     WT5N
DF0477 -
DF0478 -
DF0479 -
DF0480 -
DF05 -

SUBJECTS
Heart Disorder Cor Pulmonale From Pulmonary Hypertension Article Mer

DO03 -
DO0401 -  ..
DO0402 - Heart Disorder Enlarged Right Ventricle Cor Pulmonale How Serious
DO0403 - Cor Pulmonale: Heart Disorder From Pulmonary Hypertension How Serious
DO0404 -
DO0405 - Follow up ref SDS F6 IM5J.
DO0406 -
DO0407 - Research on 061012 associates enlarged right ventricle with Cor
DO0408 - Pulmonale that can lead to heart failure and death. ref SDS F6 IM5J
DO0410 -  ..
DO0411 - The doctor seemed to indicate that the enlarged right ventrical is not
DO0412 - a factor in Millie's diagnosis for pulmonary embolism.  He cited
DO0413 - language in the report that describes
DO0414 -
DO0415 -            There are filling defects within the subsegemental branches
DO0416 -            of the right lower lobe pulmonary arteries. ref SDS F6 M435
DO0417 -
DO0418 - ...as the controlling conditions for pulmonary embolism.  There seemed
DO0419 - to be reluctance about contacting the Medical Imaging Department for
DO0420 - clarification of the CT test report.
DO0421 -
DO0422 -                [On 061228 letter from doctor says Cor Pulmonale
DO0423 -                enlarged right ventricle most likely due to pulmonary
DO0424 -                embolism, clarifying understandings today. ref SDS H4
DO0425 -                JU7L
DO0427 -  ..
DO0428 - Millie's patient history over many months of slight dizziness and
DO0429 - lightheadedness showing in the record on 061012 correlation with
DO0430 - symptoms of enlarged right ventricle, ref SDS F6 IR46, was not
DO0431 - discussed today.
DO0433 -  ..
DO0434 - The doctor said that patients with severe pulmonary embolism have
DO0435 - symptoms of severe distress, such as pain in the lower legs, and
DO0436 - swelled veins, which demonstrate severe pulmonary embolism.
DO0437 - Thankfully, Millie has not had these conditions.
DO0438 -
DO0439 -        [On 061110 doctor cites So2 blood test 98% shows good cardio
DO0440 -        pulmonary performance, indicating enlarged right ventricle not
DO0441 -        impacting patient health. ref SDS H0 HT3M
DO0443 -  ..
DO0444 - Since the doctor's schedule was hectic today, there was not enough
DO0445 - time to review research on 061012 that seems to indicate an enlarged
DO0446 - right ventrical can cause heart failure and is associated with
DO0447 - pulmonary embolism. ref SDS F6 L35J
DO0449 -  ..
DO0450 - As well, there no review of experience in the Oncology Department
DO0451 - working with heart disorders.
DO0453 -  ..
DO0454 - Kaiser's team care practice may support review by a heart specialist
DO0455 - for heart disorders, including enlarged right ventricle.
DO0456 -
DO0457 -
DO0458 -
DO0459 -
DO05 -

SUBJECTS
Examination Clinical Findings Correlate with Research Stethoscope No

E003 -
E00401 -  ..
E00402 - Clincial Examination Stethoscope No Findings Enlarged Right Ventricle
E00403 -
E00404 - The doctor examined Millie with a stethescope, as called out in
E00405 - research for clinical assesment, also, reported 061012, ref SDS F6
E00406 - IR5T, and he seemed satisfied that the enlarged right ventricle does
E00407 - not present a serious enough problem to consider directed treatment,
E00408 - or further investigation, and that continuing with coumadin is the
E00409 - best course.  The doctor did not report hearing characteristic heart
E00410 - sounds for enlarged right ventricle, possibly indicating a moderate to
E00411 - minimal problem, or that sounds for this problem are unfamiliar.
E00413 -         ..
E00414 -        [On 061108 Millie experiencing symptoms that may be related to
E00415 -        enlarged right ventricle. ref SDS G9 VR6F
E00416 -
E00417 -
E00418 -
E00419 -
E00420 -
E00421 -
E00422 -
E005 -

SUBJECTS
Pulmonary Emboli Coagulapathy Report Family History Blood Clots Gene

E503 -
E50401 -  ..
E50402 - Coagulapathy Report Family Genetic Disposition Pulmonary Emboli
E50403 - Hypercoabulable State Work Up Risk Assessment Treatment Guidance
E50404 -
E50405 - The doctor advised that he received a document faxed from the doctor
E50406 - treating Millie's family member; however, it listed only medications
E50407 - prescribed for pulmonary emboli, and did not present the coagulapathy
E50408 - study that describes underlying family genetic disposition, as
E50409 - requested during the meeting on 060929. ref SDS F1 QT6N
E50411 -  ..
E50412 - Millie asked if Kaiser still needs the coagulapathy study in light of
E50413 - her diagnosis and treatment for pulmonary embolism, reported by the
E50414 - doctor on 061002? ref SDS F4 0001
E50416 -  ..
E50417 - The primary care physician indicated he would like to have the study,
E50418 - if it is not too much trouble.  Previously, on 050922 Doctor Bailey
E50419 - recommended in a 2nd opinion that Kaiser perform a hypercoagulable
E50420 - state work up.  Millie's family history of blood clot issues, and now
E50421 - her own recurrence increases risks of blood related treatment which
E50422 - can be aided with full understanding of family history for
E50423 - hypercoagulable state, as reviewed on 060929. ref SDS F1 9U4G
E50424 -
E50425 -     [On 061027 Millie hospitalized 102.6 temperature, cellulitis
E50426 -     complications from lymphedema, and pulmonary emboli. ref SDS G3
E50427 -     PP9Q
E50429 -      ..
E50430 -     [On 061030 called and confirmed request for coagulapathey report.
E50431 -     ref SDS G4 IM90
E50433 -      ..
E50434 -     [On 061031 letter requesting coagulapathy report. ref SDS G5 FW8M
E50436 -      ..
E50437 -     [On 061102 coagulapathy report received on family history;
E50438 -     indicates possible finding Millie has increased genetic risk
E50439 -     for blood clots, including pulmonary embolism. ref SDS G7
E50440 -     KJ3H
E50442 -      ..
E50443 -     [On 061103 coagulapathy report submitted to doctor at Kaiser
E50444 -     through the advice nurse. ref SDS G8 VR6F
E50446 -      ..
E50447 -     [On 061110 primary care physician received the coagulapathy
E50448 -     report on first-degree relative submitted today on 061103,
E50449 -     ref SDS G8 VR6F; the paragraph on risks and follow up to
E50450 -     treat pulmonary emboli, ref SDS G8 N18S, was highlighted in
E50451 -     the doctor's printed version, ref SDS H0 N18S; the doctor
E50452 -     advised that the report shows positive findings for
E50453 -     acquired rather than inherited DNA genetic risk for blood
E50454 -     clots, and in this case pulmonary emboli, ref SDS H0 626L;
E50455 -     the doctor recommended against further measures to evaluate
E50456 -     patient profile, including defer hypercoagulable state work
E50457 -     up, and indicated no adjustments required in diagnosis and
E50458 -     treatment. ref SDS H0 JT6N
E50459 -
E50460 -
E50461 -
E505 -

SUBJECTS
Work Plan Doctor Submits Doctor/Patient Partnership Communications I

EA03 -
EA0401 -  ..
EA0402 - Work Plan Received Communications Doctor/Patient Partnership
EA0403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
EA0404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
EA0405 -
EA0406 - Follow up ref SDS F1 FE4I, ref SDS E7 FE4I.
EA0408 -  ..
EA0409 - The doctor's initiative today incorporating the agenda from Millie's
EA0410 - letter into Kaiser's electronic Medical Chart, per above, ref SDS 0
EA0411 - NO6O, facilitated discussions for comprehensive care. ref SDS 0 684G
EA0412 - Collaboration to save time and avoid mistakes applies Kaiser's policy
EA0413 - of leveraging medical capabilities with a doctor/patient partnership
EA0414 - model, reported on 990625. ref SDS 4 4185
EA0416 -           ..
EA0417 -          [On 061110 doctor worked from agenda transferred into
EA0418 -          Kaiser's electronic Medical Chart, so Millie does not write
EA0419 -          the list on the marking board. ref SDS H0 K84N
EA0421 -  ..
EA0422 - Doctor's Progress Notes in the medical chart were submitted at the
EA0423 - conclusion of the meeting, and received via email, continuing
EA0424 - efficiencies begun on 060711. ref SDS C6 FE4I  Kaiser's email
EA0425 - correspondence system can be transferred with cut and paste into SDS
EA0426 - for intelligence support, explained in NWO. ref OF 13 A56M  This is a
EA0427 - big improvement on prior practice of not getting any feedback, or
EA0428 - getting printed documents that require typing everything for command
EA0429 - and control of the record with precision access using connections to
EA0430 - chronology in the organic structure of context required for effective
EA0431 - case management.
EA0433 -  ..
EA0434 - Vitals and other aspects of the medical chart were again omitted from
EA0435 - the Kaiser's letter submitted to the patient, continuing the problem
EA0436 - reported on 060929. ref SDS F1 1153  This was discussed today.  The
EA0437 - problem is lack of experience using Kaiser's computer system.  Getting
EA0438 - certain technical details from paragraphs 1 - 6, which were provided
EA0439 - in the record for meeting with the backup doctor on 060808,
EA0440 - ref SDS E0 D64Q, requires using other parts of Kaiser's computer
EA0441 - program.  This takes training and assistance from another doctor, a
EA0442 - technician, or nurse.  Since the doctor was already 30 minutes late to
EA0443 - the meeting, ref SDS 0 SM6M, adding time into the work flow for
EA0444 - technical support disrupts the doctor's meeting, disrupts the train of
EA0445 - thought, and dialog, and for an unknown amount of time.  Finding
EA0446 - someone who is skilled and available for technical assistance where
EA0447 - there are a lot patients waiting for medical attention, therefore,
EA0448 - makes Knowledge Management seem like unnecessary overkill.
EA0449 -
EA0450 -            [On 061024 case study medical practice computer access
EA0451 -            limited even with everything on the computer, people can't
EA0452 -            find details stored in parts of the computer (software
EA0453 -            modules) that are not frequently used. ref SDS G1 JD9L
EA0455 -             ..
EA0456 -            [On 061214 treatment mistake pulmonary embolism warfarin
EA0457 -            (Coumadin) conflicts with prescription for Diflucan; blood
EA0458 -            test INR rises 6.4 danger zone for hemoraging; blood clot
EA0459 -            coagulation treatment paused for 3 days; INR update test
EA0460 -            advanced. ref SDS H3 HF4O
EA0462 -  ..
EA0463 - Lack of familiarity with different parts of Kaiser's medical chart
EA0464 - computer system was discussed by...
EA0465 -
EA0466 -    Infusion Clinic........................... 061020, ref SDS G0 TR53
EA0467 -    Oncology Pharmacy......................... 061020, ref SDS G0 RS6H
EA0468 -    Oncology Clinic........................... 061020, ref SDS 0 YQ7L
EA0469 -    Coagulation Treatment Clinic.............. 061026, ref SDS G1 TZ4I
EA0471 -  ..
EA0472 - A work around for vitals is drawing the data from the report created
EA0473 - for chemotherapy treatment in the Infusion clinic that is captured
EA0474 - just prior to meeting with the doctor.
EA0475 -
EA0477 -  ..
EA0478 - Patient Correspondence No Record Document Management in Medical Chart
EA0479 -
EA0480 - The doctor does not mention in the Progress Note receiving patient's
EA0481 - correspondence into the medical chart...
EA0482 -
EA0483 -    1.  Letter commending Kaiser and Arlette
EA0484 -        for saving time and money assembling
EA0485 -        thorough and orderly packet of patient
EA0486 -        medical history to facilitate 2nd
EA0487 -        opinion review by UCSF which earned
EA0488 -        $200 credit (30% reduction) on
EA0489 -        cost for 2nd opinion.................. 061011, ref SDS F5 WW4Q
EA0491 -         ..
EA0492 -    2.  Letter asking about severity of
EA0493 -        pulmonary embolism, and other
EA0494 -        issues from CT test on 060930
EA0495 -        submitted on 061012 and received
EA0496 -        by the patient........................ 061013, ref SDS F7 UR7K
EA0498 -         ..
EA0499 -    3.  Letter submitting agenda, and with
EA0500 -        context on critical issues............ 061020, ref SDS 0 NO6O
EA0502 -  ..
EA0503 - Progress continues toward good management using the doctor patient
EA0504 - partnership for timely review of patient history, called out in
EA0505 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 4 TD5S, and
EA0506 - recently reported on 060106. ref SDS 96 FE4I
EA0507 -
EA0508 -    1.  10/20/2006     04:40 PM
EA0509 -
EA0510 -            Wcr-ONnc2 > Main Campus
EA0513 -         ..
EA0514 -    2.  Your primary care clinician is listed as...
EA0515 -
EA0517 -
EA0831 -
EA0832 -
EA0833 -
EA0834 -
EA0835 -
EA0836 -
EA0837 -
EA09 -