CONTACTS 

SUBJECTS
Meeting Doctor Examination 8th Review Prepare Changing Protocols aft

2003 -
2003 -    ..
2004 - Summary/Objective
2005 -
200501 - Follow up ref SDS H4 0000. ref SDS H1 0000.
200502 -
200503 - The doctor performed due diligence on UCSF proposals to treat Millie
200504 - in a clinical study with a new drug for breast cancer. ref SDS 0 P256
200505 - Kaiser therefore delayed starting treatment today with Navelbine to
200506 - replace Taxotere and capecitabine, which have become ineffective, so
200507 - that Millie qualifies for the clinical study. ref SDS 0 Y45G  Kaiser
200508 - and UCSF have agreed on arrangements for referral authorization and
200509 - payment of costs for Millie's treatment at UCSF. ref SDS 0 PK68  The
200510 - doctor advised that referral to UCSF is the best course for treating
200511 - Millie's IBC.  Clinical studies expand the list of chemotherapy drugs
200512 - for treating Millie, which is otherwise limited by a complex patient
200513 - profile. ref SDS 0 LU3J  Cetuximab and carboplatin in the UCSF drug
200514 - trial are powerful new drugs targeted to breast cancer cells, and so
200515 - do not cause general harm to the entire body and immune system, as do
200516 - conventional chemotherapies available for treating Millie. ref SDS 0
200517 - PK7L  Millie asked that UCSF be notified to expedite treatment to
200518 - avoid her cancer from cascading out of control, since her last
200519 - treatment was over a month ago, and examination and diagnostics today
200520 - show that IBC has been rising on her chest. ref SDS 0 Y46N  Kaiser has
200521 - not had time to perform trend analysis to determine increased risk
200522 - from pulmonary embolism and heart disorder of enlarged right
200523 - ventricle. ref SDS 0 CV5L  The recent PET/CT test failed to perform
200524 - comparisons ordered by the doctor to support diagnosis. ref SDS 0 XX8H
200525 - The doctor advised that Millie may have permanent lung damage, and may
200526 - not be able to recover her former level of fitness. ref SDS 0 MA9K
200527 - The doctor told Millie she can resume exercising in the gym.
200528 - ref SDS 0 G35K  Stethoscope examination and Sa02 diagnostic indicates
200529 - favorable cardio-pulmonary function. ref SDS 0 Q35O  Millie remains
200530 - concerned about diagnosis of enlarged right ventricle in the CT test
200531 - on 060930, and rising symptoms of fatigue, weakness, shortness of
200532 - breath.  She requested CT testing and examination by a heart
200533 - specialist to assess severity of heart disorder before resuming
200534 - vigorous exercise. ref SDS 0 SU4L  The doctor explained a practice of
200535 - ignoring irrelevant matters to save time focusing on immediate
200536 - problems, and emphasized the importance of context. ref SDS 0 MA8O
200537 - The doctor indicated that Cor Pulmonale is not an immediate problem
200538 - compared to the current crisis on making referral for treating
200539 - Millie's cancer. ref SDS 0 SG5M
200540 -
200541 -     [On 070329 review at Kaiser cites success of strategy making
200542 -     referral for targeted treatment of IBC. ref SDS K0 K36G
200543 -
200544 -
200545 -
200546 -
200548 -  ..
2006 -
2007 -
2008 - Progress
2009 -
200901 - Agenda Develop Work Plan Stage IV Breast Cancer 14 Mos after Mastectomy
200902 -
200903 - Follow up ref SDS H4 SM6M, ref SDS H1 SM6M.
200904 -
200905 - This is the 9th review meeting for the 7th chemotherapy cycle since
200906 - starting treatment on 060711, ref SDS C1 SM6M, for the 3rd relapse of
200907 - IBC. ref SDS C1 8Y8I  The meeting today plans changing treatment
200908 - protocols from Navelbine to a clinical study drug trial using
200909 - cetuximab and carboplatin.  The doctor had a hectic schedule today,
200910 - and so the meeting scheduled to start at 1200 actually started at
200911 - 1226.
200913 -  ..
200914 - Millie submitted a letter this morning, ref DIT 1 E06F, with an agenda
200915 - for the meeting today...
200916 -
200917 -    1.  CA 15-3 rising rapidly......................... ref SDS 0 GJ5M
200918 -    2.  Lymphedema/Cellulitis controlled............... ref SDS 0 MW8J
200919 -    3.  Breast exam IBC spreads measurable disease..... ref SDS 0 025H
200920 -    4.  IBC spread right breast or cellulitis.......... ref SDS 0 AX6G
200921 -    5.  PET/CT doctor's review......................... ref SDS 0 EY5O
200922 -    6.  Treatment plan change Navelbine or Other??..... ref SDS 0 K36G
200923 -    7.  Drug trials UCSF schedule meeting Doctor Rugo.. ref SDS 0 P256
200924 -    8.  Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
200925 -    9.  Symptoms cough clearing throat fatigue......... ref SDS 0 CV5L
200926 -   10.  Cor Pulmonale enlarged r ventricle heart doctor ref SDS 0 VJ4J
200927 -   11.  Esophagitis, heart burn PET test check......... ref SDS 0 JP6K
200929 -  ..
200930 - The doctor's Progress Notes in the Medical Chart list this agenda,
200931 - which the doctor displayed on the computer in the examination room to
200932 - guide discussions, ref SDS 0 684G, as was done on 061020, and 061110,
200933 - ref SDS G5 NO6O, but was missed for the meeting on 061208. ref SDS H4
200934 - K84N
200936 -  ..
200937 - Scheduled next meeting in 4 weeks on 070202 1420, to review effect of
200938 - new treatments. ref SDS 0 N96O
200940 -  ..
200941 - Millie's daughter, Pam, attended the meeting today, following up
200942 - previous support on 041130. ref SDS 51 SM6M
200943 -
200944 -
200945 -
200946 -
200947 -
2010 -

SUBJECTS
Complex Patient History 37 Issues Overwhelms Span of Attention Drive

2203 -
220401 -  ..
220402 - Complex Patient History Knowledge Management Dilemma Issues Grow 36
220403 -
220404 - Follow up ref SDS H4 LU3J, ref SDS H1 LU3J.
220405 -
220406 - Complexity overwhelms span of attention, cited below, ref SDS 0 EM5N,
220407 - from expanding issues of diagnosis and treatment...
220408 -
220409 -    1.  CA 15-3 monitors advance of cancer response to treatment
220410 -    2.  Lymphedema complicated by mastectomy surgery
220411 -    3.  Broken finger from minor fall complicates lymphedema
220412 -    4.  Esophagitis reflux digestion issues
220413 -    5.  Immune system chemotherapy increases risk of infection
220414 -    6.  Chemotherapy increase risk of infection
220415 -    7.  Cat bites increase risk of infection complicates lymphedema
220416 -    8.  Pneumonia chemotherapy increases risk of infection
220417 -    9.  Metastatic cancer increases risk pulmonary embolism
220418 -   10.  Lymphadenopathy left axilla local regional metastasis
220419 -   11.  Lymphadenopathy right axilla distant metastasis
220420 -   12.  Lymphadenopathy left supraclavicular diagnose metastatic cancer
220421 -   13.  Breast cancer secondary IBC 3rd relapse left breast
220422 -   14.  Cancer mutates slow response chemotherapy treatment
220423 -   15.  Mastectomy surgery impact on treatment IBC relapse
220424 -   16.  Blood vessels removed mastectomy slow chemotherapy treatments
220425 -   17.  Treatment options, strategy, planning, schedule
220426 -   18.  Drug trials increase declining pool chemotherapy agents
220427 -   19.  UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
220428 -   20.  Pulmonary embolism blood clots in lungs
220429 -   21.  INR weekly adjustments Coumadin treatment blood clots
220430 -   22.  Enlarged right ventricle heart problem cor pulmonale
220431 -   23.  Dizziness symptom enlarged right ventricle cor pulmonale
220432 -   24.  Fatigue shortness breath side effect chemotherapy loss fitness
220433 -   25.  Fatigue shortness breath symptom pulmonary embolism
220434 -   26.  Shortness breath fatigue dizzy symptoms pulmonary embolism
220435 -   27.  Coagulapathy hypercoagulable state work up genetic risks
220436 -   28.  Testing resolution of errors (see Benz 2nd opinion 060821)
220437 -   29.  Testing distant metastatic disease
220438 -   30.  Testing pulmonary embolism and heart disease
220439 -   31.  Communication hectic schedule not enough time to manage details
220440 -   32.  Emotional stress and well being
220441 -   33.  Cellulitis inflammation temperature 102.6 on chemotherapy
220442 -   34.  Urinary tract bladder infection
220443 -   35.  IBC rash spreads to right breast
220444 -   36.  Right breast rash may be "ring" infection, not cancer
220445 -   37.  Lung cancer seems to be diagnosed in the Medical Chart
220446 -   38.  Kaiser authorize treatment UCSF cetuximab clinical study
220447 -
220448 -
220449 -
220450 -
2205 -

SUBJECTS
Vitals Not Submitted Doctor Progress Note Medical Chart Meeting Doct

2403 -
240401 -  ..
240402 - Vitals Show Stable Medical Condition
240403 -
240404 - Follow up ref SDS H4 KB5L, ref SDS H1 KB5L.
240406 -                           ..
240407 -                          Bld Prssr   Pulse   Temp   Weight  SaO2
240408 -     ..
240409 - *  070105 1040............
240410 -    061208 1226............ 152 90     76     97.8    147     99%
240411 -    061201 1430............ 123 76     76     97.5
240412 -    061110................. 136 83     73     97.0    150     98%
240413 -    061020 1534............ 140 79     67     99.8    151     97
240414 -    060929 1452............ 141 78     66     98.3
240415 -    060908 1335............ 139 79     73     98.1
240416 -    060814 1610............ 139 80     59     98.2
240417 - *  060808.................
240418 -    060711................. 172 87     54     97.5    147
240419 -    060623................. 141 87     71     98.0    147     99%
240420 -    060428................. 129 73     80     99.4    149     99%
240421 -    060217................. 153 81     61     98.6    150     99%
240422 -
240423 - ...per the doctor's report in the Medical Chart shown below.
240424 - ref SDS 0 JQ4J
240425 -
240426 - *  For some reason, vitals not submitted.
240427 -
240428 -
2405 -

SUBJECTS
CA 15-3 74 Rising Cancer Marker Aligns with IBC Rash Spreading Indic

4003 -
400401 -  ..
400402 - CA 15-3 Cancer Marker 74 Increase Aligns Rise IBC Rash
400403 -
400404 - Follow up ref SDS H4 087J, ref SDS H1 087J.
400405 -
400406 - Millie had two blood tests during the current period since the last
400407 - meeting with the doctor on 061208, ref SDS H4 087J, and since the last
400408 - report on CA 15-3 during the meeting on 061201. ref SDS H1 087J  On
400409 - 061227 the doctor submitted results of tests on 061214, and on 061218.
400410 - ref SDS H8 6P9F
400412 -           ..
400413 -         Test Date                         Date Received
400414 -          061218......... 74 H............. 061227, ref SDS H8 6P9F
400415 -          061214......... 63 H............. 061227, ref SDS H8 6P9F
400416 -          061130......... 67 H............. 061201, ref SDS H1 087J
400417 -          061116......... 66 H............. 061201, ref SDS H1 087J
400418 -          061110......... 56 H............. 061201, ref SDS H1 087J
400419 -          061109......... 61 H............. 061110, ref SDS G5 087J
400420 -          061026......... 57 H............. 061110, ref SDS G5 087J
400421 -          061019......... 56 H............. 061020, ref SDS F4 087J
400422 -          060928......... 51 H............. 060929, ref SDS E7 087J
400423 -          060907......... 68 H............. 060929, ref SDS E7 087J
400424 -          060813......... 73 H............. 060817, ref SDS E2 U24M
400425 -          060809......... 87 H............. 060810, ref SDS E0 2N5J
400426 -          060708......... 71 H............. 060711, ref SDS C1 087J
400427 -          060616......... 63 H............. 060623, ref SDS B9 UQ5Q
400428 -          060522......... 59 H............. 060605, ref SDS B4 UQ5Q
400429 -          060501......... 49 H............. 060522, ref SDS B1 MC4F
400430 -          060421......... 44 H............. 060428, ref SDS A4 087J
400431 -          060330......... 40 H............. 060428, ref SDS A4 087J
400432 -          060303......... 36............... 060428, ref SDS A4 087J
400433 -          060210......... 33............... 060217, ref SDS 94 087J
400434 -          060109......... 34............... 060126, ref SDS 93 KV59
400435 -          051223......... 34............... 060106, ref SDS 92 087J
400436 -          051202......... 28............... 060106, ref SDS 92 087J
400437 -          051116......... 31............... 051121, ref SDS 90 087J
400438 -          051109......... 30............... 051121, ref SDS 90 087J
400439 -          051102......... 34............... 051121, ref SDS 90 087J
400440 -          050909......... 45 H............. 051007, ref SDS 84 087J
400441 -          050826......... 45 H............. 050913, ref SDS 78 087J
400442 -          050819......... 45 H............. 050913, ref SDS 78 087J
400443 -          050812......... 39 .............. 050819, ref SDS 71 3K6L
400444 -          050729......... 45 H............. 050819, ref SDS 71 EA5G
400445 -          050708......... 46 H............. 050729, ref SDS 70 087J
400446 -          050701......... 37 .............. 050729, ref SDS 70 087J
400447 -          050617......... 45 H............. 050729, ref SDS 70 087J
400448 -          050527......... 56 H............. 050610, ref SDS 67 087J
400449 -          050512......... 67 H............. 050520, ref SDS 65 087J
400450 -          050506......... 80 H............. 050520, ref SDS 65 087J
400451 -  ..
400452 -          050415.........105 H............. 050422, ref SDS 62 087J
400453 -          050325.........100 H............. 050329, ref SDS 60 087J
400454 -          050318.........101 H............. 050325, ref SDS 59 2N5J
400455 -          050304......... 88 H............. 050311, ref SDS 57 087J
400456 -          050225......... 95 H............. 050308, ref SDS 56 0001
400457 -          050211......... 78 H............. 050214, ref SDS 55 02BB
400458 -          050128......... 67 H............. 050204, ref SDS 53 087J
400459 -          041228......... 56 H............. 041230, ref SDS 52 087J
400460 -          041204......... 43 H............. 041210, ref SDS 51 087J
400461 -          041007......... 39............... 041104, ref SDS 47 087J
400462 -          040923......... 49 H............. 041005, ref SDS 45 087J
400463 -          040908......... 44 H............. 040909, ref SDS 44 087J
400464 -          040825......... 47 H............. 040909, ref SDS 44 087J
400465 -          040811......... 42 H............. 040812, ref SDS 43 087J
400466 -          040728......... 43 H............. 040729, ref SDS 41 2N5J
400467 -          040712......... 47 H............. 040713, ref SDS 40 087J
400468 -          040614......... 55 H............. 040615, ref SDS 39 PX6X
400469 -          040517......... 78 H............. 040601, ref SDS 37 2N5J
400470 -          040311......... 70 H............. 040318, ref SDS 29 SM6M
400471 -          040205......... 60 H............. 040211, ref SDS 27 SM6M
400472 -          031201......... 62 H............. 031205, ref SDS 26 SM6M
400473 -          030912......... 66 H............. 030915, ref SDS 25 SM6M
400474 -          030708......... 68 H............. 030710, ref SDS 24 SM6M
400475 -          030503......... 54 H............. 030508, ref SDS 22 SM6M
400476 -          030403......... 45 H............. 030508, ref SDS 22 SM6M
400477 -          030215......... 46 H............. 030220, ref SDS 21 5E6L
400478 -          030106......... 37 H............. 030109, ref SDS 20 SM6M
400479 -          021202......... 41 H?............ 021204, ref SDS 19 SP5G
400480 -          021111......... 36 H?............ 021113, ref SDS 18 Y65I
400481 -          021023......... 33 H?............ 021023, ref SDS 17 SQ5I
400482 -          020930......... 33 H?..39........ 021002, ref SDS 16 SQ5I
400483 -          020917......... 36 H?............ 020924, ref SDS 15 SQ5I
400484 -          020717......... 59 H?............ 020726, ref SDS 14 YN5K
400485 -          020629......... 75 H ............ 020705, ref SDS 12 UX6I
400486 -          020608........  67 H ............ 020614, ref SDS 10 0001
400487 -          020603........ 108 H ............ 020607, ref SDS 9 X67F
400488 -          020511........ 117 H ............ 020603, ref SDS 8 PJ4J
400489 -          020419......... 81 H ............ 020430, ref SDS 6 7N5H
400490 -          020321......... 85 H ............ 020405, ref SDS 5 6T8K
400491 -
400492 -
400493 -
400494 -
400496 -  ..
4005 -
4006 -
4007 - Analysis
4008 -
400801 - CA 15-3 74 Cancer Marker Rises Significantly Aligns IBC Rash Increase
400802 -
400803 - Follow up ref SDS H4 GJ5M, ref SDS H1 GJ5M.
400804 -
400805 - On 061227 the doctor reported CA 15-3 74 significant rise from 67 to
400806 - 74. ref SDS H8 EE5T  Rising cancer marker aligns with IBC rash
400807 - spreading to the right breast, and increased severity reported, also,
400808 - on 061227. ref SDS H8 DY9T  Examination today shows IBC rash continues
400809 - spreading to the right breast. the doctor reported this probably
400810 - represents progression of metastatic disease, ref SDS 0 025H, which
400811 - requires changing treatments.  The doctor noted that rising CA 15-3 is
400812 - a common diagnostic for measurable disease to evaluate clinical study
400813 - drug trials.
400815 -         ..
400816 -        [On 070110 CA 15-3 56 dropped significantly, indicating
400817 -        possible delayed reaction to treatment. ref SDS I5 087J
400819 -         ..
400820 -        [On 070123 CA 15-3 68 rises significantly, indicating rising
400821 -        IBC from progression of disease. ref SDS J2 GK5B
400823 -         ..
400824 -        [On 070123 CA 15-3 rise indicating progression of metastatic
400825 -        cancer requires Kaiser authorization for treatment at UCSF to
400826 -        avoid IBC cascading out of control. ref SDS J2 SX5W
400827 -
400828 -
400829 -
400830 -
4009 -

SUBJECTS
Digestion Problems GERD PET Scan Test on 061227 Failed Perform Analy

4403 -
440401 -  ..
440402 - Digestion Problems Increasing Relatively Infrequent Mild
440403 - Esophagitis Not Compared in Current PET Test with Prior Report
440404 -
440405 - Follow up ref SDS H4 JP6K, ref SDS H1 JP6K.
440406 -
440407 - Background is reported in the meeting on 061201. ref SDS H1 JP6K
440409 -  ..
440410 - During the meeting at Kaiser on 061208, the doctor added a request to
440411 - compare the PET scan test ordered at that time, ref SDS H4 EY5O, and
440412 - later performed on 061227, with prior PET and CT tests to clarify
440413 - diagnosis for planning treatment of esophagitis or other malady that
440414 - may be causing increased digestion problems.  Requesting comparison
440415 - for trend analysis of esophagitis implemented planning on 061201,
440416 - ref SDS H1 5X40, and aligned with the doctor's progress report in the
440417 - medical chart on 061208 noting GERD worse. ref SDS H4 1248
440419 -  ..
440420 - Review on 070102 of PET scan test on 061227 shows the doctor's order
440421 - to compare with prior findings of esophagitis in the PET scan test on
440422 - 060106, and with the CT test on 060505, was not performed. ref SDS I2
440423 - AK9H
440425 -  ..
440426 - There was no discussion of this issue today.
440428 -  ..
440429 - The doctor's medical chart for today does not mention GERD.
440430 - ref SDS 0 1248, which is described as "worse," in prior reports,
440431 - raising a question on the basis of no review. ref SDS H4 1248
440432 -
440433 -
440434 -
440435 -
4405 -

SUBJECTS
Left Axillary Lymphadenopathy Patient No Complaint Swelling Discomfo

5703 -
570401 -  ..
570402 - Cellulitis Complications Lymphedema Recovering Improved
570403 - Left Axillary No Evidence Lymphadenopathy Lymphedema Improving
570404 - Post Operation Localized Edema Left Axillary No Evidence Lymphadenopathy
570405 - Lymphadenopathy Left Axillary No Evidence Lymphedema Improving Cellulitus Recovered
570406 -
570407 - Follow up ref SDS H4 MW8J, ref SDS H1 MW8J.
570409 -  ..
570410 - Patient history of left axillary lymphadenopathy and lymphedema is
570411 - reported on 060106. ref SDS 92 S164
570413 -  ..
570414 - There was no examination today for cancer in left axilla.  The patient
570415 - again made no complaint of lumps or discomfort from swelling under the
570416 - left arm.
570418 -  ..
570419 - Background on lymphedema and complications of Cellulitis when Millie
570420 - was hospitalized on 061027 is reported in the record for the meeting
570421 - on 061201. ref SDS H1 5Y5F  Cellulitis relapsed on 061203, ref SDS H2
570422 - MF9H, and on 061204, the doctor renewed the prescription for
570423 - antibiotics to treat Cellulitis. ref SDS H3 ZS5N   On 061208 patient
570424 - reported Cellulitis subsided and lymphedema seems controlled, though
570425 - swelling in the left arm remains significantly above prior norms,
570426 - ref SDS H4 CO7O, and citing examination on 061201. ref SDS H1 656L
570428 -  ..
570429 - Today, cellulitis appears controlled; no evident inflammation.
570430 - Swelling of left arm from lymphedema remains significant, and
570431 - continues to prevent routine exercise for fitness.
570433 -  ..
570434 - Below elbow measures 11.5" slightly increased from a month ago, shown
570435 - in case study on 060509. ref SDS A9 HO7F
570437 -  ..
570438 - Doctor Progress Notes in the Medical Chart for 061208 describe
570439 - lymphedema "improving." ref SDS H4 J59N   Similar description is
570440 - reported in the Medical Chart for today, per below. ref SDS 0 1248
570441 -
570442 -
570443 -
570444 -
570445 -
5705 -

SUBJECTS
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom

6403 -
640401 -  ..
640402 - Right Axillary No Evidence Cancer Red Rash Spreads Right Breast
640403 - Right Breast Red Rash Spreads No Evidence Disease Right Axillary
640404 - Red Rash Right Breast Spreads No Evidence Cancer Right Axillary
640405 -
640406 - Follow up ref SDS H4 3D6K, ref SDS H1 3D6K.
640407 -
640408 - Background on patient history of testing for lymphadenopathy in the
640409 - right axilla is reported in the record on 060929. ref SDS E7 3D6K
640411 -  ..
640412 - On 061204 patient notified Kaiser that inflammation spread from the
640413 - left chest area infected with IBC across the sternum and slightly onto
640414 - the right breast. ref SDS H3 AE5I  This was observed by the doctor
640415 - during examination on 061208. ref SDS H4 LG9I
640417 -  ..
640418 - Examination today yielded the following report in the Medical
640419 - Chart...
640420 -
640421 -            Chest wall: increased erythema on lower left chest wall and
640422 -            now extending to the right breast. ref SDS 0 ZL5W
640424 -  ..
640425 - The doctor determined from examination today that lack of improvement
640426 - from treatment with Diflucan prescribed on 061208, ref SDS H4 KW45,
640427 - and discussed below, ref SDS 0 KW45, rules out diagnosis of infection
640428 - treatable with antibiotics, and indicates more strongly progression of
640429 - IBC disease.
640431 -  ..
640432 - There was no examination today for cancer in the right axilla.  The
640433 - patient made no complaint of lumps or discomfort from swelling under
640434 - the right arm.  This work aligns with CT test on 061227.  Review of
640435 - test results on 070102 show no findings of disease in the right
640436 - axillary. ref SDS I2 9X4S
640438 -  ..
640439 - Efforts today are now focused on starting treatment for IBC on
640440 - clinical study with cetuximab that targets breast cancer, sponsored by
640441 - UCSF. ref SDS 0 PK7L
640442 -
640443 -
640444 -
640445 -
640446 -
640447 -
6405 -

SUBJECTS
Left Supraclavicular Neck CT Test Contrast Study on 060505 Finds No

7203 -
720401 -  ..
720402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
720403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
720404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
720405 -
720406 - Follow up ref SDS H4 8R6M, ref SDS H1 8R6M.
720407 -
720408 - Background of image testing, and consideration for radiation treatment
720409 - of left supraclavicular is reported on 060623. ref SDS B9 8R6M
720411 -  ..
720412 - Like the left and right axillary locations, there was no examination
720413 - today for cancer in left supraclavicular region.  The patient made no
720414 - complaint of lumps or discomfort from swelling in this area.  This
720415 - work aligns with CT test on 060930 that found no evidence of disease
720416 - in the left supraclavicular location, reported on 061020. ref SDS F4
720417 - LP5G
720418 -
720419 -
720420 -
720421 -
720422 -
7205 -

SUBJECTS
Examination IBC Red Rash Left Breast Spreads to Right Breast Aligns

7803 -
780401 -  ..
780402 - Pockets of Resistance to Treatment of IBC Red Rash Left Breast
780403 - IBC Red Rash Left Breast Extends Slightly onto the Right Breast
780404 - Examination Left Breast IBC Inflammation Spreads to Right Breast
780405 - Measurable Disease IBC Inflammation Spreading to Right Breast
780406 -
780407 - Follow up ref SDS H4 025H, ref SDS H1 025H.
780408 -
780409 - Background on prior relapse examinations is listed on 060711.
780410 - ref SDS C1 8Y7O
780412 -  ..
780413 - On 061204 Millie submitted a letter, ref DIP 1 I93X, notifying the
780414 - doctor that IBC spread from the left chest area to the right breast.
780415 - ref SDS H3 I93X   This was observed by the doctor during examination
780416 - on 061208. ref SDS H4 RU6J
780418 -  ..
780419 - On 061227 red rash on the left chest area worsens again, after seeming
780420 - improvement the week of 061218. ref SDS H8 ZT8H  On 061227 CA 15-3 74
780421 - significant rise, erratic change after slight decline, reflects IBC
780422 - rash wax and wane, cited by Doctor Benz in a 2nd opinion received on
780423 - 041117. ref SDS 48 OS6W  The primary care physician advised on 061227
780424 - that volatile changes in IBC rash probably represents progression of
780425 - metastatic disease. ref SDS H8 6P9F
780427 -  ..
780428 - The doctor's examination today shows no improvement; IBC rash seems to
780429 - be worsening with pockets of resistance to treatment, as reported in
780430 - the examination on 061208. ref SDS H4 RU6J  Worsening IBC spreading
780431 - from left to right breast, also, noted above, ref SDS 0 T99I, aligns
780432 - with rising CA 15-3 cancer marker, shown above. ref SDS 0 GJ5M  Slow
780433 - response to treatment due to loss of blood vessels removed by
780434 - mastectomy surgery last year on 051021 was reviewed in the record for
780435 - the meeting on 061208. ref SDS H4 EH3F
780437 -  ..
780438 - The doctor's Progress Notes in the Medical Chart today describe "Chest
780439 - wall: increased erythema on lower left chest wall and now extending to
780440 - the right breast," ref SDS 0 ZL5W, which is a significant change from
780441 - examination on 061201, and corrects the Medical Chart report on
780442 - 061208. ref SDS H4 ZL5W
780443 -
780444 -     [...below, doctor defers treatment today with Navelbine in order
780445 -     to qualify Millie for more effective treatment on clinical study
780446 -     sponsored by UCSF. ref SDS 0 PF3O
780448 -      ..
780449 -     [...below, discuss notifying UCSF to expedite start of treatment
780450 -     on clinical study. ref SDS 0 Y46N
780452 -      ..
780453 -     [On 070130 IBC progression spreads to stomach and wrapping toward
780454 -     back, examination at UCSF. ref SDS J4 M68J
780456 -      ..
780457 -     [On 070202 doctor's examination at Kaiser, and progress notes
780458 -     report cancer spreading toward the stomach, and around toward the
780459 -     back. ref SDS J6 368I
780461 -      ..
780462 -     [On 070222 examination at UCSF indicates rash on upper left arm
780463 -     likely expanding IBC. ref SDS J9 B64F
780464 -
780465 -
780466 -
7805 -

SUBJECTS
Diflucan Fluconazole Terminated Treatment Not Effective Red Rash Lef

8503 -
850401 -  ..
850402 - Diflucan Fluconazole 200 MG Prescription Not Effective Treatment Ends
850403 -
850404 - Follow up ref SDS H4 KW45.
850405 -
850406 - During the meeting on 061208, Diflucan was prescribed as a trial
850407 - treatment to diagnose "ring" rash ref SDS H4 WZ3N, spreading from
850408 - left to the right breast. ref SDS H4 KW45
850410 -  ..
850411 - On 061214 treatment for pulmonary embolism warfarin (Coumadin)
850412 - conflicted with prescription for Diflucan; blood test INR increased to
850413 - 6.4, which is a danger zone for hemorrhaging; blood clot coagulation
850414 - treatment was paused for 3 days, and the INR update blood test was
850415 - advanced. ref SDS H5 HF4O  On 061218 Millie notified the doctor that
850416 - INR increased on Diflucan. ref SDS H6 5M5Y  The doctor advised Millie
850417 - to stop taking Diflucan. ref SDS H6 NT6J
850418 -
850419 -
850420 -
850421 -
8505 -

SUBJECTS
Lung Cancer Metastatic Disease Lymph Nodes Doctor's Progress Notes M

9203 -
920401 -  ..
920402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
920403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
920404 -
920405 - Follow up ref SDS H4 G25K.
920406 -
920407 - The doctor's Progress Notes in the Medical Chart for 061208 shows
920408 - under Impressions...
920409 -
920410 -        Metastatic breast cancer (IBC)lung and lymph node; chest wall
920411 -        recurrence, ref SDS H4 1248
920413 -  ..
920414 - The same construction is shown again in the medical chart for today.
920415 - ref SDS 0 1248
920417 -  ..
920418 - Millie's letter to Kaiser on 061227 cited the doctor's note on lung
920419 - cancer to illustrate requirements for accuracy in medical practice.
920420 - ref SDS H8 Z89Y
920421 -
920422 -        [On 070112 Millie's letter asks the doctor to explain support
920423 -        for notation of lung cancer in Medical Chart. ref SDS I6 NM6G
920425 -         ..
920426 -        [On 070117 primary care physician cited several CT tests over
920427 -        the past few years report small pulmonary nodules involving the
920428 -        right lung, which are smaller than 5 mm, and so do not appear
920429 -        in PET scan tests. ref SDS I9 TS8G  Case study on patient
920430 -        history confirms that CT tests beginning in 2002 report nodules
920431 -        in the lungs; none are identified as cancer, and none show
920432 -        growth common to cancer. ref SDS I9 4Q46
920434 -  ..
920435 - There was no discussion of this issue, as reported previously on
920436 - 061208. ref SDS H4 G25K
920438 -  ..
920439 - The doctor advised today that Millie may have suffered permanent lung
920440 - damage from pulmonary embolism, reported below. ref SDS 0 MA9K  This
920441 - seems like a different issue from lung cancer.
920442 -
920443 -
920444 -
920445 -
920446 -
9205 -

SUBJECTS
Eyes Tearing Subsides Side Effect Taxotere Capecitabine (Xeloda) Che

9603 -
960401 -  ..
960402 - Eyes Tearing Side Effect Taxotere Capecitabine (Xeloda) Chemotherapy
960403 -
960404 - Follow up ref SDS H4 OH6I, ref SDS H1 OH6I.
960405 -
960406 - Millie met with the optometrist at Kaiser on 06122 for an eye
960407 - examination for prescription glasses.
960409 -  ..
960410 - Tearing eyes problem has largely ended since ending treatment with
960411 - Taxotere and capecitabine (Xeloda) on 061201.
960412 -
960413 -
960414 -
960415 -
960416 -
960417 -
9605 -

SUBJECTS
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea

A203 -
A20401 -  ..
A20402 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
A20403 - Slow Response to Treatment Mastectomy Removed Blood Vessels
A20404 - Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
A20405 - Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
A20406 -
A20407 - Follow up ref SDS H4 EH3F, ref SDS H1 EH3F.
A20408 -
A20409 - Background on slow response to treatment and impending progression of
A20410 - disease due to mastectomy surgery on 051021 was reviewed in the record
A20411 - for the meeting on 061020, ref SDS F4 EH3F, and again on 061110.
A20412 - ref SDS G5 EH3F
A20414 -  ..
A20415 - There was no discussion today on Millie's letter submitted 061027
A20416 - asking about expectations for recovery from IBC due to pockets of
A20417 - resistance to systemic chemotherapy treatments from mastectomy surgery
A20418 - on 051021 that removed blood vessels, which prevents delivering
A20419 - treatment, and cited on 061011. ref SDS G5 H53F
A20420 -
A20421 -
A20422 -
A20423 -
A20424 -
A205 -

SUBJECTS
Biopsy Right Breast Rash Spreads from Left Breast Evaluate IBC Simil

AF03 -
AF0401 -  ..
AF0402 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
AF0403 - Biopsy to Determine Biology of IBC and Guide Choice of Treatment
AF0404 - Status Change Did Not Occur Retest Biopsy 040419 Treatment Options
AF0405 -
AF0406 - Follow up ref SDS H4 KT7J, ref SDS H1 KT7J.
AF0407 -
AF0408 - Biopsy was not discussed today for patient work up to develop strategy
AF0409 - and treatment plan, discussed on 060711, ref SDS C1 K36G, and more
AF0410 - recently on 061020? ref SDS F4 KH6H  Further review on 061110 presents
AF0411 - objectives and rationale based on evidence of cancer mutating for
AF0412 - biopsy of IBC red rash on the left breast. ref SDS G5 448F
AF0414 -  ..
AF0415 - There was no discussion today of taking a biopsy to evaluate rash
AF0416 - spreading from the left to the right breast, as observed on 061208,
AF0417 - ref SDS H4 AX6G, and reported in the doctor's progress notes for
AF0418 - examination today, per above, ref SDS 0 YU4K  Patient history shows
AF0419 - IBC was originally diagnosed with a biopsy on 040419. ref SDS 33 789F
AF0420 - On 060821 Doctor Benz discussed during a 2nd opinion consultation
AF0421 - doing a biopsy to verify diagnosis of IBC recurrence on the left
AF0422 - breast. ref SDS E3 6Q6O  This was confirmed in the doctor's written
AF0423 - opinion letter received from Kaiser on 060929. ref SDS E8 WY79
AF0424 -
AF0425 -        [On 070116 consent documents for cetuximab carboplatin clinical
AF0426 -        study drug trial call for biopsy of cancer tumor. ref SDS I7
AF0427 -        5U7S  Additional tumor biopsies are also part of the, drug
AF0428 -        trial, but are optional based on patient history. ref SDS I7
AF0429 -        0348
AF0430 -
AF0431 -
AF0432 -
AF0433 -
AF0434 -
AF05 -

SUBJECTS
PET/CT Scan Test 061227 Baseline New Treatment Clinical Study Not Ev

AN03 -
AN0401 -  ..
AN0402 - PET/CT Test 061227 No Evidence Distant Metastatis
AN0403 - Distant Metastatis No Evidence PET/CT Test 061227
AN0404 - NED PET/CT Test 061227 Shows No Evidence Distant Metastasis
AN0405 -
AN0406 - Follow up ref SDS H4 EY5O, ref SDS H1 EY5O.
AN0407 -
AN0408 - PET/CT test on 061227 received on 070102. ref SDS I2 9X6O
AN0410 -  ..
AN0411 - The doctor seemed to indicate that the PET/CT test shows no evidence
AN0412 - of distant metastasis, as shown by review on 070102, ref SDS I2 RG4J,
AN0413 - continuing patient history having never been diagnosed with distant
AN0414 - metastasis. ref SDS I2 1Y8G
AN0416 -  ..
AN0417 - Kaiser did not make findings of pulmonary embolism and enlarged right
AN0418 - ventricle, which the doctor ordered on 061208, ref SDS H4 ZY5L,
AN0419 - because CT tests for pulmonary embolism, previously explained by the
AN0420 - doctor on 061020, ref SDS F4 S56G, cannot be accomplished with PET/CT
AN0421 - test equipment and procedures.
AN0423 -  ..
AN0424 - There was no discussion of Kaiser failing to make comparisons with
AN0425 - prior tests on 060120, and on 060505, which were ordered by the doctor
AN0426 - on 061208, ref SDS H4 LZ6J, as reported on 070102. ref SDS I2 AK9H
AN0428 -  ..
AN0429 - The doctor advised that the CT test on 061227 will support the new
AN0430 - treatment at UCSF, so there will not be a delay waiting to order
AN0431 - another test, per scheduling below. ref SDS 0 NX9N
AN0432 -
AN0433 -
AN0434 -
AN0435 -
AN0436 -
AN0437 -
AN05 -

SUBJECTS
Emotional Trauma Increases 36 Issues Drive Knowledge Management Dile

B103 -
B10401 -  ..
B10402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
B10403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
B10404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
B10405 -
B10406 - Follow up ref SDS H4 Y642, ref SDS H1 Y642.
B10407 -
B10408 - Medical issues create an emotional roller coaster that increase
B10409 - patient stress and trauma listed in the record on 061020. ref SDS F4
B10410 - Y642
B10412 -  ..
B10413 - Current issues that drive and help resolve anxiety....
B10414 -
B10415 -    1.  Worry rises from treatment the past 6 months with Taxotere and
B10416 -        capecitabine (Xeloda), which was very effective in 2005, and
B10417 -        evidently not effective to treat relapse, beginning on 070121,
B10418 -        and which recently spread from left to the right breast.
B10419 -        ref SDS 0 025H
B10421 -         ..
B10422 -    2.  Worry subsides with PET/CT test showing no evidence of distant
B10423 -        metastasis 5 years after diagnosis of breast cancer.
B10424 -        ref SDS 0 EY5O
B10426 -         ..
B10427 -    3.  Kaiser's progress reported on 061230, ref SDS I0 3X6K, and on
B10428 -        070101 collaborating with UCSF on referral authorization for
B10429 -        Millie to get treatment, ref SDS I1 E23W, helps relieve tension
B10430 -        and stress about the future, including IBC progressing from
B10431 -        left to the right breast. ref SDS 0 AX6G
B10433 -         ..
B10434 -    4.  Knowledge Management dilemma complexity from 32 medical issues,
B10435 -        reported on 061020, ref SDS F4 Z56M, now expands to 36, per
B10436 -        above. ref SDS 0 LU3J  Expanding complexity overwhelms span of
B10437 -        attention, and drives desire to simplify analysis by ignoring
B10438 -        issues, creating increased worry, stress, trauma for the
B10439 -        patient. ref SDS F4 MO4K
B10441 -         ..
B10442 -    5.  Worry about what will happen with the new treatment for IBC,
B10443 -        and when treatment will start at UCSF in the context of
B10444 -        dwindling treatments, and prolonged period since 061201 without
B10445 -        treatment. ref SDS 0 PK7L
B10447 -         ..
B10448 -    6.  Lung cancer reports in the Medical Chart create considerable
B10449 -        anxiety in the context of no explanation nor evident support in
B10450 -        the record. ref SDS 0 G25K
B10452 -         ..
B10453 -    7.  Prognosis today that there may be permanent lung damage, before
B10454 -        notice in extensive testing for 5 years, and before making
B10455 -        efforts to treat the lungs before damage became permenant.
B10456 -        ref SDS 0 WR4J,
B10458 -         ..
B10459 -    8.  Pulmonary embolism recurrence on 061002 slow recovery compared
B10460 -        to fast recovery with treatment for original diagnosis on
B10461 -        041104, reported on 041230.
B10463 -         ..
B10464 -    9.  Kaiser's failure to perform doctor's orders for diagnostic
B10465 -        testing to evalute progression of pulmonary embolism disease,
B10466 -        ref SDS 0 CV5L
B10468 -         ..
B10469 -   10.  Research on 060722 indicates 45% of patients die who suffer
B10470 -        recurrence of pulmonary embolism. ref SDS C7 BI5J
B10472 -         ..
B10473 -   11.  Symptoms are documented in the Medical Chart, but ignored
B10474 -        because other factors that cause the same symptoms present a
B10475 -        "wicked problem" of diagnosis that is not resolved until
B10476 -        autoposy after death discovers pulmonary embolism. ref SDS C7
B10477 -        7P9F
B10479 -         ..
B10480 -   12.  Cor Pulmonale from enlarged right ventricle compounds pulmonary
B10481 -        embolism increases emotional stress in the context of failure
B10482 -        to perform CT test to assess severity, and assurances from
B10483 -        clinical examination that starting exercise in the gym to
B10484 -        increase fitness, strengthen the immune system to fight cancer,
B10485 -        and help relieve emotional stress will be safe. ref SDS 0 MA9K
B10487 -         ..
B10488 -   13.  Context critical decision factor allocating time for referral
B10489 -        to get cancer treatment, makes spending time seem clinically
B10490 -        irrelevant making referral to a heart specialist to assess a
B10491 -        heart disorder that may take years, days, weeks or months to
B10492 -        become life threatening. ref SDS 0 MA8O
B10493 -
B10494 -
B10495 -
B10496 -
B10497 -
B105 -

SUBJECTS
Strategy Treatment Plan IBC 3rd Relapse Referral UCSF Clinical Study

B903 -
B90401 -  ..
B90402 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
B90403 - Work Up Patient History Kaiser Summary Avoids Treatment Strategy Options
B90404 - Tumor Board Review on Changing Treatment Expansion of Disease
B90405 -
B90406 - Follow up ref SDS H4 K36G, ref SDS H1 K36G.
B90407 -
B90408 - Background on requirements and challenge performing requirements for
B90409 - planning and proactive management in time for action to be effective
B90410 - is reported on 060825. ref SDS E4 K36G
B90412 -  ..
B90413 - Discussion today of using "context" to avoid "irrelevant" issues
B90414 - illustrates crisis management that resists proactive medical
B90415 - management. ref SDS 0 MA8O
B90417 -  ..
B90418 - Review of strategy issues was reported on 061208, ref SDS H4 5Q5I,
B90419 - including consideration of Tumor Board support to address slow
B90420 - response to treatment, ref SDS H4 P69G, and erratic changes in CA 15-3
B90421 - cancer marker and severity of IBC rash. ref SDS H4 ZZ9H
B90423 -  ..
B90424 - On 061218 Millie's letter to Kaiser confirmed request for Tumor Board
B90425 - with panel that has experience treating secondary IBC relapse, post
B90426 - mastectomy surgery. ref SDS H6 OT5I  On 061228 doctor submitted a copy
B90427 - of a summary of patient history submitted to UCSF for participation in
B90428 - clinical drug trial.  The doctor indicated this summary provided a "5
B90429 - year review" of complex patient history in place of Tumor Board
B90430 - support for analysis of diagnosis and treatment planning. ref SDS H9
B90431 - 086H
B90433 -  ..
B90434 - There was no discussion today of Tumor Board review to develop opinion
B90435 - on strategy that leverages expertise with diversity of experience to
B90436 - complement analysis by primary care physician, considered on 061228.
B90437 - ref SDS H9 NP8G
B90439 -  ..
B90440 - The doctor commented that his research on the clinical study at UCSF
B90441 - for cetuximab and carboplatin offers a better solution for Millie,
B90442 - because these drugs are targeted to her patient profile, having triple
B90443 - negative breast cancer, rather than general chemotherapy that attacks
B90444 - all body cells while attempting to also attack cancer cells, discussed
B90445 - further below. ref SDS 0 PK7L
B90446 -
B90447 -        [On 070329 review at Kaiser cites success of strategy making
B90448 -        referral for targeted treatment of IBC. ref SDS K0 K36G
B90450 -         ..
B90451 -        [On 070921 doctor advises that cetuximab is a very expensive
B90452 -        drug so referral to UCSF where the drug company pays the cost
B90453 -        of treatment was good financial strategy to save Kaiser money.
B90454 -        ref SDS K4 QY58
B90455 -
B90456 -
B90457 -
B90458 -
B90459 -
B90460 -
B905 -

SUBJECTS
Navelbine Treatment Deferred Pending Results Clinical Study Cetuxima

BE03 -
BE0401 -  ..
BE0402 - Navelbine Treatment Deferred Pending Results Clinical Study Cetuximab
BE0403 -
BE0404 - Follow up ref SDS H4 Q74O, ref SDS E8 WR3Y.
BE0405 -
BE0406 - On 061218 doctor reviewed plans to use use single agent treatments to
BE0407 - avoid exhausting drugs to treat Millie, without listing available drugs
BE0408 - for IBC, and conflicting with patient history prescribing double-agent
BE0409 - treatments. ref SDS H6 JU7J
BE0411 -  ..
BE0412 - Navelbine pharmacology was reviewed on 061208. ref SDS H4 3B4N
BE0414 -  ..
BE0415 - At this time consideration of Navelbine has been deferred pending
BE0416 - results of treatment at UCSF on clinical study, per below. ref SDS 0
BE0417 - PK68
BE0418 -
BE0419 -
BE0420 -
BE05 -

SUBJECTS
Strategy Treatment Plan Surgery Remove Pockets of Resistance to Chem

BK03 -
BK0401 -  ..
BK0402 - Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
BK0403 -
BK0404 - Follow up ref SDS H4 ZZ5F, ref SDS E4 WE8K.
BK0405 -
BK0406 - Surgery to treat "pockets of resistance" to chemotherapy was discussed
BK0407 - only briefly on 061208. ref SDS H4 ZZ5F
BK0409 -  ..
BK0410 - Patient history on considerations for surgery in this case are
BK0411 - reported on 040416. ref SDS 51 657F
BK0413 -  ..
BK0414 - There was no discussion of surgery today, pending results of treatment
BK0415 - on the cetuximab and carboplatin clinical study drug trial, which has
BK0416 - not yet been scheduled by UCSF.
BK0417 -
BK0418 -
BK0419 -
BK05 -

SUBJECTS
Treatment 8th Cycle IBC 3rd Relapse 1st Cycle 1st Treatment Cetuxima

BR03 -
BR0401 -  ..
BR0402 - Treatment Complete 7th Cycle Taxotere and Capecitabine (Xeloda)
BR0403 - 7th Cycle Taxotere and Capecitabine (Xeloda) Treatment Concludes
BR0404 - Taxotere and Capecitabine (Xeloda) 7th-Cycle Treatment Concludes
BR0405 - Cetuximab Clinical Study Drug Trial Start Treatment at UCSF Pending
BR0406 -
BR0407 - Follow up ref SDS H4 PF3O, ref SDS H1 PF3O.
BR0408 -
BR0409 - Treatment with Navelbine planned on 061208, ref SDS H4 PF3O, has been
BR0410 - deferred by the doctor's letter on 061230. ref SDS I0 OU5K  The doctor
BR0411 - clarified his letter explaining that he intended to say defer
BR0412 - treatment with both Navelbine and Gemzar.
BR0414 -  ..
BR0415 - No treatment is scheduled at this time, pending implementation of
BR0416 - considerations on 061208 of switching Millie from Taxotere and
BR0417 - capecitabine, to treatment with cetuximab and carboplatin on clinical
BR0418 - study, ref SDS H4 P27L, and as discussed further below. ref SDS 0 P256
BR0420 -  ..
BR0421 - Primary consideration is to expedite starting treatment on the
BR0422 - clinical trial to prevent cancer from cascading beyond control,
BR0423 - discussed below on drug trials. ref SDS 0 PK7L
BR0424 -
BR0425 -
BR0426 -
BR0427 -
BR0428 -
BR0429 -
BR0430 -
BR0431 -
BR05 -

SUBJECTS
Drug Trials Kaiser Due Diligence UCSF Proposal Clinical Study Advise

C703 -
C70401 -  ..
C70402 - Cetuximab Carboplatin UCSF Clinical Study Expedite Treatment
C70403 - UCSF Clinical Studies Kaiser Authorizes Referral Schedule Treatment
C70404 - Drug Trials Kaiser Authorizes Referral to UCSF Expedite Treatment Schedule
C70405 - Expedite Treatment UCSF Cetuximab Carboplatin Clinical Study Drug Trial
C70406 -
C70407 - Follow up ref SDS H4 P256.
C70408 -
C70409 - On 061201 the doctor discussed plans to change Millie's chemotherapy
C70410 - treatments for IBC because Taxotere and capecitabine (Xeloda) have
C70411 - become increasingly less effective, shown by progression of Millie's
C70412 - cancer. ref SDS H1 GJ5M,  The following week on 061208 the doctor
C70413 - proposed switching to older technology, because Millie's complex
C70414 - medical profile limits drugs available for treating her cancer.
C70415 - ref SDS H4 P24L  At that time, on 061208 Millie asked about Kaiser's
C70416 - progress finding drug trials to expand treatment options, as the
C70417 - doctor presented on 040318, ref SDS 29 DG4J, and again on on 041130?
C70418 - ref SDS 49 028N
C70420 -  ..
C70421 - The doctor reported today that Kaiser cannot find drug trials to treat
C70422 - Millie at Kaiser, because her complex patient history prevents
C70423 - qualifying for clinical study protocols. ref SDS H4 VT7F
C70425 -  ..
C70426 - We reviewed the record showing Millie asked Kaiser to perform due
C70427 - diligence on treatment proposals in a 2nd opinion prepared by Doctor
C70428 - Benz at UCSF, and submitted to Kaiser, reported on 060929. ref SDS E8
C70429 - 6L9O  The UCSF 2nd opinion states that Millie qualifies for two (2)
C70430 - drug trials sponsored by UCSF. ref SDS E8 UI9K  At that time, on
C70431 - 061208, the primary care physician requested help finding the UCSF 2nd
C70432 - opinion proposals submitted to Kaiser. ref SDS H4 P27L
C70434 -  ..
C70435 - On 061218 Millie submitted a letter to Kaiser with a link to the
C70436 - record on 060929 reviewing the UCSF proposal on treating Millie with
C70437 - drug trials. ref SDS H6 YV38  On 061226 Kaiser reported performing due
C70438 - diligence collaborating with Doctor Rugo at UCSF to consider drug
C70439 - trial protocols for Millie's patient profile. ref SDS H7 086H
C70441 -  ..
C70442 - On 061230 the primary care physician wrote to Millie proposing that
C70443 - Kaiser delay starting treatment with Gemzar or Navelbine chemotherapy
C70444 - drugs so that Millie can qualify for clinical studies. ref SDS I0 OU5K
C70446 -  ..
C70447 - At that time on 061230, the doctor also submitted correspondence
C70448 - between Kaiser and UCSF on Millie satisfying protocol requirements for
C70449 - the cetuximab and carboplatin clinical study, which is limited to
C70450 - patients who have been previously treated with no more than three (3)
C70451 - drugs. ref SDS I0 PN5X  The doctor also reported Millie's treatments
C70452 - for pulmonary embolism, ref SDS I0 PN6R, and her "triple negative"
C70453 - status. ref SDS I0 PO3Q
C70455 -         ..
C70456 -        [On 070116 consent documentation for cetuximab and carboplatin
C70457 -        clinical study shows this drug trial is targeted for "triple
C70458 -        negative" patients, which means ER PR HER2 negative.
C70459 -        ref SDS I7 0Q7I
C70461 -         ..
C70462 -        [On 070201 the cetuximab clinical study only counts treatments
C70463 -        that were used until ineffective; Avastin was stopped because
C70464 -        Millie developed PE, and so was not counted against her
C70465 -        qualifying for the study. ref SDS J5 1N6N
C70467 -  ..
C70468 - The doctor made arrangements on 061230 with Doctor Rugo authorizing
C70469 - UCSF to treat Millie on referral from Kaiser. ref SDS I0 3X6K  Two
C70470 - days later on 070101, Doctor Rugo proposed plans to Kaiser on
C70471 - scheduling a meeting with Millie to start treatment at UCSF.
C70472 - ref SDS I1 086H
C70474 -  ..
C70475 - The primary care physician advised today that Navelbine chemotherapy
C70476 - prescribed on 061208 for starting Millie's treatment today,
C70477 - ref SDS H4 P24L, has been changed.
C70479 -  ..
C70480 - Doctor Johnson indicated that his research, which was requested in the
C70481 - meeting on 061208, ref SDS H4 P27L, shows treatment at UCSF with
C70482 - cetuximab and carboplatin proposed in the Benz 2nd opinion received
C70483 - from UCSF on 060929, ref SDS E8 UI9K, has a better chance of stopping
C70484 - progression of Millie's cancer than treatment with chemotherapy using
C70485 - Navelbine or Gemzar, per above, ref SDS 0 VQ5K, because Millie's
C70486 - cancer has been medicated repeatedly with chemotherapy, causing her
C70487 - cancer to mutate into cells that now resist chemotherapy, explained
C70488 - previously on 030606. ref SDS 23 N27L  However, cetuximab is a newer
C70489 - drug "targeted" to Millie's patient profile of ER, PR, HER2 (triple)
C70490 - negative; and further cetuximab is designed to "target" only cancer.
C70491 - This significantly reduces torturous pain and suffering from killing
C70492 - non-cancerous, healthy cells throughout the body causing people to
C70493 - feel so horrible that death brings welcome relief, as occurs with
C70494 - chemotherapy technology, like AC, Taxotere, Taxol, Navelbine, Gemzar,
C70495 - and capecitabine.
C70497 -  ..
C70498 - Doctor Johnson feels that this new class of "targeted" drugs
C70499 - significantly improve chemotherapy giving patients better outcomes for
C70500 - survival and quality of life.  This helps solve problems Doctor
C70501 - Johnson presented on 030606, that discourage patients from living
C70502 - while getting chemotherapy. ref SDS 23 ED8H
C70504 -  ..
C70505 - The doctor explained that "targeted" drugs do not impair bone marrow
C70506 - producing new blood cells, so blood counts are maintained that in turn
C70507 - maintain patient imunity.  Additionally, "targeted" drugs are often
C70508 - more easily tolerated than conventional chemotherapy like
C70509 - capecitabine, Navelbine, Gemzar, and Taxotere.   On 050516 the doctor
C70510 - had to reduce the dose of capecitabine to relieve horrible feelings
C70511 - like the "walking dead." ref SDS 64 AQ6G  The same problem would occur
C70512 - with Navelbine and Gemzar.  Switching to cetuximab "targeted" drug
C70513 - technology enables maintaining a full dose.  Maintaining high dose
C70514 - levels with good blood counts creates synergy between steady treatment
C70515 - and high immunity from normal good health to fight cancer, rather than
C70516 - having to pause conventional chemotherapy to allow blood counts to
C70517 - recover for protection against fatal infection.
C70518 -
C70519 -        [On 090529 1109 Millie letter to medical team cites Doctor
C70520 -        Rugo's opinion that MPA will have less side effects that Millie
C70521 -        had from cetuximab; Millie asks if UCSF prescription to treat
C70522 -        Millie's 8th relapse of cancer can be expected to have similar
C70523 -        sucess that Millie had with cetuximab. ref SDS K9 0N3X
C70525 -  ..
C70526 - Additionally, the UCSF study for triple negative patients, like
C70527 - Millie, reported on 020321, ref SDS 4 LA7O, makes her status an
C70528 - advantage that expands treatments (i.e., increases the doctor's "tool
C70529 - kit," explained on 040318, ref SDS 29 DG4J), rather than a negative
C70530 - that limits her options, since most of the newer more powerful cancer
C70531 - drugs are for patients who are ER PR HER2 positive, indicated by
C70532 - Doctor Benz in a 2nd opinion on 041117. ref SDS 48 OU6W
C70534 -  ..
C70535 - The doctor will monitor progress of treatment at UCSF with
C70536 - examinations every 2 months, so that Kaiser retains responsibility for
C70537 - case management, per planning on 061208. ref SDS H4 P270
C70539 -         ..
C70540 -        [On 070830 UCSF and Kaiser working on billing issues for
C70541 -        Millie's treatment with clinical trial at UCSF ordered by her
C70542 -        doctor at Kaiser. ref SDS K3 T259
C70544 -         ..
C70545 -        [On 070921 doctor advises that cetuximab is a very expensive
C70546 -        drug so referral to UCSF where the drug company pays the cost
C70547 -        of treatment for clinical trial was good financial strategy to
C70548 -        save Kaiser money. ref SDS K4 QY58
C70550 -         ..
C70551 -        [On 070925 Kaiser primary care physician assigns staff to
C70552 -        solve problems caused by failing to develop referral
C70553 -        coordination plan for Millie's treatment at UCSF.
C70554 -        ref SDS K5 G54J
C70556 -         ..
C70557 -        [On 071006 Paula in Kaiser's MCRC unit asks why the doctor
C70558 -        prescribed treatment with cetuximab and carboplatin at UCSF.
C70559 -        ref SDS K6 Q969
C70561 -         ..
C70562 -        [On 071128 Kaiser Appeals Committee approved payment for
C70563 -        Millie's care on referral to UCSF. ref SDS K7 JZ5R
C70565 -         ..
C70566 -        [On 071203 Paula advised that Kaiser Appeals Committee ordered
C70567 -        examinations every 3 months. ref SDS K8 QF9I
C70569 -  ..
C70570 - The doctor said that UCSF has not notified Kaiser when Millie will
C70571 - start treatment.  Since Millie's last treatment was 061201, delay
C70572 - risks losing local control of Millie's cancer, which is expanding,
C70573 - shown by examination today, per above. ref SDS 0 555O  On 050913 the
C70574 - doctor emphasized the importance of timely treatment for local control
C70575 - of cancer. ref SDS 78 5T4N
C70577 -  ..
C70578 - Millie asked the doctor to contact UCSF on expediting referral to
C70579 - start the new treatment, since Millie's last treatment was on 061201,
C70580 - about 6 weeks ago, and to report results of examination today, showing
C70581 - IBC is expanding along with rising cancer marker, per above.
C70582 - ref SDS 0 J44H
C70583 -
C70584 -     [On 070202 doctor's examination at Kaiser, and progress notes
C70585 -     report cancer spreading toward the stomach, and around toward the
C70586 -     back. ref SDS J6 368I
C70588 -      ..
C70589 -     [On 070329 review at Kaiser cites success of strategy making
C70590 -     referral for targeted treatment of IBC. ref SDS K0 K36G
C70592 -  ..
C70593 - The doctor feels that sending a letter or calling to expedite the work
C70594 - would be unprofessional and insulting, because UCSF knows Millie has
C70595 - IBC, and, also, knows that IBC is an aggressive metastatic disease
C70596 - that requires urgent care to avoid losing control, cited for example
C70597 - on 060807, ref SDS D5 Q65G, and previous research on 040517.
C70598 - ref SDS 36 TO7L  He indicated that, since Doctor Rugo said in a letter
C70599 - on 061231 that arrangements would be made for Millie, ref SDS I1 E23W,
C70600 - Kaiser should not submit a reminder, like telling a cement contractor
C70601 - when to pour the foundation.  On 050913 the doctor previously used a
C70602 - construction management analogy to illustrate medical management
C70603 - practices. ref SDS 78 5T4N
C70604 -
C70605 -        [...below, the doctor indicated that spending time on referral
C70606 -        to UCSF for cancer treatments leaves not enough time for making
C70607 -        another referral to a heart specialist to examine heart
C70608 -        disorder Cor Pulmonale because symptoms may take years to
C70609 -        become life threatening. ref SDS 0 SG5M
C70611 -  ..
C70612 - There was discussion that people get busy.  There isn't enough time to
C70613 - study at the moment and write up a plan of action for later.  Nobody
C70614 - can remember pending action items when time comes for changing course.
C70615 - As a result, everyone needs reminders to follow up in time to be
C70616 - effective.
C70617 -
C70618 -        [...below, the doctor indicated there is not enough time for
C70619 -        referral to investigate heart disorder because time is focused
C70620 -        on referral to UCSF for treating Millie's cancer. ref SDS 0
C70621 -        794K
C70623 -         ..
C70624 -        [On 070109 Millie asks Kaiser again to request that UCSF
C70625 -        schedule Millie for treatment of rising symptoms. ref SDS I4
C70626 -        WZ4L
C70628 -         ..
C70629 -        [On 070110 Kaiser contacted UCSF about Millie starting
C70630 -        treatment. ref SDS I5 9R3K
C70632 -         ..
C70633 -        [On 070116 Millie received consent forms on the Cetuximab
C70634 -        and Carboplatin clinical study; UCSF proposes she start
C70635 -        treatment on 070124; agreement to this protocol rests on
C70636 -        understandings from the meeting at Kaiser on 070105.
C70637 -        ref SDS I7 I65I
C70639 -         ..
C70640 -        [On 070119 UCSF had to delay treatment, because Kaiser delayed
C70641 -        referral authorization. ref SDS J1 AS96
C70643 -         ..
C70644 -        [On 070123 treatment delayed again because referral
C70645 -        authorization still delayed. ref SDS J2 0001
C70647 -         ..
C70648 -        [On 070124 Millie expedites referral authorization. ref SDS J3
C70649 -        0001
C70651 -         ..
C70652 -        [On 070130 Millie meeting at UCSF with Doctor Rugo to plan
C70653 -        starting treatment. ref SDS J4 0001
C70655 -         ..
C70656 -        [On 070201 Millie was randomized to get only Cetuximab,
C70657 -        ref SDS J5 XR3M, and started treatment. ref SDS J5 G68I
C70658 -
C70659 -
C70660 -
C70661 -
C70662 -
C707 -

SUBJECTS
Schedule Meeting 070202 Review Effectiveness Side Effects Treatment

C903 -
C90401 -  ..
C90402 - Schedule Treatment Pending Start Clinical Study Cetuximab at UCSF
C90403 - Chemotherapy Holiday Treatment Delayed Pending Start Drug Trial at UCSF
C90404 -
C90405 - Follow up ref SDS H4 N96O, ref SDS H1 N96O.
C90406 -
C90407 - During the meeting today, the doctor scheduled the next meeting in
C90408 - four (4) weeks on 070202 to assess treatment for IBC with a clinical
C90409 - study at UCSF, as reported above. ref SDS 0 PK68
C90411 -  ..
C90412 - The doctor will monitor progress with treatment at UCSF with
C90413 - examinations every 60 days.
C90415 -  ..
C90416 - Millie will continue without treatment until arrangements are made
C90417 - with UCSF to start treatment with cetuximab and possibly carboplatin,
C90418 - as planned, per above. ref SDS 0 PF3O
C90420 -  ..
C90421 - The doctor advised that the CT test on 061227, which was discussed
C90422 - during the meeting today, per above, ref SDS 0 EY5O, will support the
C90423 - new treatment at UCSF, so there will not be a delay scheduling another
C90424 - test.
C90426 -  ..
C90427 - The doctor used the computer in the examination room to order a blood
C90428 - test required for Millie to treatment at UCSF with the cetuximab and
C90429 - Carboplatin protocol.  This issue is further explained on 060810.
C90430 - ref SDS E0 NH8T  Millie can get the test done at any Kaiser facility,
C90431 - when UCSF notifies they have scheduled treatment to start.
C90432 -
C90433 -        [On 070116 Jackie advised that the CT test on 061227 will
C90434 -        expedite starting treatment before 070124. ref SDS I7 RT7K
C90436 -         ..
C90437 -        [On 070117 UCSF expedites treatment advances schedule to start
C90438 -        on 070119. ref SDS I8 5S85
C90440 -         ..
C90441 -        [On 070118 UCSF asks Millie to get blood test ordered by
C90442 -        primary care physician today, on 070105. ref SDS J0 5S6L
C90444 -         ..
C90445 -        [On 070119 UCSF requires another lab because the scope of the
C90446 -        test at Kaiser on 070118 does not meet requirements for the
C90447 -        cetuximab Carboplatin protocol. ref SDS J1 AS6M
C90448 -
C90449 -
C90450 -
C90451 -
C90452 -
C905 -

SUBJECTS
Pulmonary Emboli Blood Clots Lungs Symptoms Continue Fatigue Weaknes

CM03 -
CM0401 -  ..
CM0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
CM0403 - Lung Damage Permanent Cannot Resume Exercise to Build Immune System
CM0404 - Pulmonary Emboli PET/CT Test Failed Perform Doctor's Order Comparison
CM0405 - Immune System Cancer Recovery Exercise Prevented Permanent Lung Damage
CM0406 -
CM0407 - Follow up ref SDS H4 CV5L, ref SDS H1 CV5L.
CM0408 -
CM0409 - Background on pulmonary embolism recurrence is reported in the record
CM0410 - for the meeting on 061020. ref SDS F4 CV5L  On 061201 symptoms of
CM0411 - chronic fatigue, cough, shortness of breath, clearing of throat
CM0412 - continue under a Coumadin regimen. ref SDS H1 CV5L
CM0414 -  ..
CM0415 - Kaiser has not reviewed differences in pulmonary embolism findings for
CM0416 - trend analysis, as reported on 061208. ref SDS H4 HB3K  At that time,
CM0417 - the doctor modified the order for the PET/CT scan test by adding scope
CM0418 - for the analyst to compare prior tests on 041103, and on 060930, with
CM0419 - the new test to assess trends (i.e., worsening, improving, or stable)
CM0420 - in Millie's condition of pulmonary embolism, per above. ref SDS H4
CM0421 - ZY5L
CM0423 -  ..
CM0424 - On 061227 Millie was concerned the doctor is not aware of how severely
CM0425 - her symptoms of pulmonary embolism were affecting her life.
CM0426 - ref SDS H8 645I  She therefore reported in a letter to Kaiser at that
CM0427 - time on 061227 continuing symptoms of chronic fatigue, shortness of
CM0428 - breath, cough, and heavy chest. ref SDS H8 KX6N  This complements case
CM0429 - study on pulmonary embolism, listed on 060722, ref SDS C7 6G6O, which
CM0430 - shows patient history of rising symptoms. ref SDS C7 ZV41
CM0432 -  ..
CM0433 - The PET/CT was performed on 061227, and the report was received on
CM0434 - 070102, and showed that comparisons ordered by the doctor on 061208
CM0435 - were again not performed. ref SDS I2 AK9H  This may reflect Kaiser's
CM0436 - decision to prescribe PET/CT, and this form of test does not support
CM0437 - analysis of pulmonary embolism, as discussed above. ref SDS 0 5D6F  As
CM0438 - a result, there is no affirmative evidence in the record that Coumadin
CM0439 - treatments have improved Millie's condition, as occurred after
CM0440 - treatment when Millie was first diagnosed with pulmonary embolism,
CM0441 - reported on 041230. ref SDS 52 RZ4I
CM0443 -  ..
CM0444 - Changes in lung scans from original diagnosis of pulmonary embolism on
CM0445 - 041103 and the more recent test on 060930 need professional review for
CM0446 - trend analysis, as shown on 061012. ref SDS F1 7E7G
CM0448 -  ..
CM0449 - Millie asked the doctor today about getting professional review of
CM0450 - differences in pulmonary embolism diagnosed on 041103 and on 060930,
CM0451 - in order to make an assessment about when she can resume vigorous work
CM0452 - outs in the gym and hiking to restore physical and emotional fitness,
CM0453 - as previously raised on 061027? ref SDS C7 B28F
CM0455 -  ..
CM0456 - Millie commented that she would like a CT test that reports there is
CM0457 - no visualization of pulmonary embolism, like the CT test on 041217,
CM0458 - and reported on 041230, which aligned with relief from symptoms of
CM0459 - fatigue, weakness, shortness of breath, serious cough, associated with
CM0460 - pulmonary embolism. ref SDS 52 PW3K
CM0462 -  ..
CM0463 - The doctor advised that Millie has likely, or may likely have,
CM0464 - suffered permanent lung damage, which prevents reaching prior levels
CM0465 - of physical exercise.  The doctor seemed emotional saying with
CM0466 - emphasis that he understands Millie's objective to regain health to
CM0467 - work out in the gym.  Vigorous exercise to test and increase strength
CM0468 - and endurance helps dissipates emotional stress, discussed above,
CM0469 - ref SDS 0 Y642, and improves Millie's life prospects by strengthening
CM0470 - the immune system, which aids recovery from cancer, including
CM0471 - withstanding debilitating chemotherapy treatments, as previously
CM0472 - discussed on 030606. ref SDS 23 ED8H
CM0474 -  ..
CM0475 - The doctor indicated that Millie should go ahead and try working out
CM0476 - in the gym, and start within limits that feel comfortable.
CM0477 -
CM0478 -     [On 070204 Millie reports exercising in the gym twice on
CM0479 -     consecutive days following treatment with cetuximag on clinical
CM0480 -     study at UCSF on 070201. ref SDS J7 JJ7O
CM0482 -      ..
CM0483 -     [On 070218 energy increases, shortness of breath, fatigue,
CM0484 -     weakness subside 10 weeks after ending treatment for 3rd relapse
CM0485 -     of IBC with Taxotere and cacecitabine; Millie is exercising in the
CM0486 -     gym again, playing tennis 2 days her pulse reached 144.
CM0487 -     ref SDS J8 N05H
CM0489 -      ..
CM0490 -     [On 070516 Millie reports to Kaiser training hard in the gym,
CM0491 -     feeling well. ref SDS K1 UH4S
CM0493 -      ..
CM0494 -     [On 070607 Millie suffers recurrence Cellulitis inflammation
CM0495 -     envelopes left arm trauma complications lymphedema, high fever
CM0496 -     possibly from working out and training too hard in the gym.
CM0497 -     ref SDS K2 ZH6I
CM0499 -  ..
CM0500 - This seems conflicting with the doctor's report today of permanent
CM0501 - lung damage.  There is nothing in the Medical Cart for today that
CM0502 - diagnoses lung damage, and that patient is released for normal,
CM0503 - vigorous exercise in the gym, and cautions to be careful. ref SDS 0
CM0504 - ZL5W
CM0506 -  ..
CM0507 - Millie explained that her emotional state, reported above. ref SDS 0
CM0508 - 2T6H, will be calmed after the next CT test for pulmonary embolism and
CM0509 - hopefully reports there is no visualization of former conditions that
CM0510 - diagnosed pulmonary embolism, like the report for the test on 041217,
CM0511 - received from the doctor on 041230. ref SDS 52 PW3K
CM0512 -
CM0513 -     [...above the doctor does not discuss comment in Medical Chart for
CM0514 -     061208 that seems to report lung cancer. ref SDS 0 M26F
CM0515 -
CM0516 -
CM0517 -
CM0518 -
CM0519 -
CM0520 -
CM06 -

SUBJECTS
Examination Clinical Findings Correlate with Stethoscope No Findings

CY03 -
CY0401 -  ..
CY0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
CY0403 -
CY0404 - Follow up ref SDS H4 Q35O, ref SDS H1 Q35O.
CY0405 -
CY0406 - The doctor examined Millie with a stethoscope again today.  This
CY0407 - included multiple locations on her her back, and on her chest.  He
CY0408 - reported finding no evidence of cardio pulmonary issues from clinical
CY0409 - examination.  The doctor's Progress Notes in the Medical Chart report
CY0410 - Lung:  Clear to A & P. ref SDS 0 ZL5W
CY0412 -  ..
CY0413 - For some reason, Kaiser did not report Sa02 diagnostic for oxygenated
CY0414 - blood.  The test on 061208 was very good at 99%, ref SDS H4 KB5L,
CY0415 - indicating Millie was not suffering at that time from loss of
CY0416 - cardio-pulmonary functioning due to pulmonary embolism, including
CY0417 - enlarged right ventricle.
CY0418 -
CY0419 -
CY0420 -
CY0421 -
CY0422 -
CY05 -

SUBJECTS
Enlarged Right Ventricle Heart Examination Not Ordered Kaiser Not En

DW03 -
DW0401 -  ..
DW0402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
DW0403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
DW0404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
DW0405 -
DW0406 - Follow up ref SDS H4 VJ4J, ref SDS H1 VJ4J.
DW0407 -
DW0408 - The CT scan on 060930 reported findings of enlarged right ventricle.
DW0409 - This was not reported by Kaiser when pulmonary embolism was disclosed
DW0410 - on 061002, ref SDS F0 MI5I  Enlarged right ventricle findings were
DW0411 - noticed during review of test findings after receiving the report from
DW0412 - Kaiser on 061012. ref SDS F1 7E5L  Research indicates enlarged right
DW0413 - ventricle is a heart disorder, called Cor Pulmonale, that compounds
DW0414 - pulmonary embolism. ref SDS F1 L35J  On 061020 Millie asked the doctor
DW0415 - how much the right ventricle is enlarged?  Kaiser has not had time to
DW0416 - make this determination, reported on 061110. ref SDS G5 VJ4J
DW0418 -  ..
DW0419 - On 061208 the doctor advised that Kaiser has diagnosed Cor Pulmonale.
DW0420 - ref SDS H4 J14I  The doctor did not report findings in Progress Notes
DW0421 - for the Medical Chart on 061208, ref SDS H4 ZL5W, nor again today, per
DW0422 - below, ref SDS 0 ZL5W  This seems like an additional medical problem
DW0423 - that prolongs recovery from pulmonary embolism, discussed today, per
DW0424 - above. ref SDS 0 3Q5J
DW0426 -  ..
DW0427 - On 061208 Millie requested examination by a heart specialist to assess
DW0428 - rising symptoms of fatigue, weakness, shortness of breath, and heavy
DW0429 - chest with routine activities that prevent regular exercise in the gym
DW0430 - to restore fitness, strengthen the immune system to recover from
DW0431 - cancer, ref SDS H4 HZ39, and build emotional stability.  The doctor
DW0432 - deferred referral until symptoms become more severe, ref SDS H4 HZ3O,
DW0433 - and cited favorable Sa02 diagnostics. ref SDS H4 VV4H
DW0435 -  ..
DW0436 - The doctor amended the orger for a CT test on 061227 to compare with
DW0437 - the test on 060930 for trend analysis of enlarged right ventricle.
DW0438 - ref SDS H4 Y77J
DW0440 -  ..
DW0441 - On 061218 Millie requested examination by heart specialist for
DW0442 - clearance to resume exercise in the gym and restore fitness while
DW0443 - symptoms of fatigue, weakness, cough, shortness of breath increase.
DW0444 - ref SDS H6 HX6V  The doctor responded that enlarged right ventricle
DW0445 - most likely not clinically relevant because symptoms Cor Pulmonale
DW0446 - take years to become life threatening. ref SDS H6 XQ5H
DW0448 -  ..
DW0449 - On 061227 Millie requested examination by a heart specialist to backup
DW0450 - up the doctor's first impression that Cor Pulmonale is not clinically
DW0451 - relevant; and further reported continuing symptoms of chronic fatigue,
DW0452 - shortness of breath, and heavy chest. ref SDS H8 VC4M  The next day,
DW0453 - on 061228 the primary care physician Kaiser advises enlarged right
DW0454 - ventricle heart disorder Cor Pulmonale most likely due to pulmonary
DW0455 - embolism, ref SDS H9 0M6O, after treatment ended a year earlier on
DW0456 - 051007. ref SDS 84 RZ4I
DW0458 -  ..
DW0459 - On 070102 review showed that Kaiser failed to make comparison in the
DW0460 - CT test on 061227 ordered by the doctor on 061028 for trend analysis
DW0461 - on the enlarged right ventricle initially reported in the test on
DW0462 - 060930. ref SDS I2 AK9H
DW0464 -  ..
DW0465 - With this context, Millie requested examination by a heart specialist
DW0466 - to investigate findings in the CT test on 060930 of enlarged right
DW0467 - ventricle.
DW0468 -
DW0469 -
DW0470 -
DW05 -

SUBJECTS
Patient History Agenda 2 Referrals Too Many Complexity Overwhelms Me

EK03 -
EK0401 -  ..
EK0402 - Crisis Management Defers Investigation Until Time Runs Out for Analysis
EK0403 - Context Management Complements Chronology and Connection Working Intelligently
EK0404 - Information Management Prevents Understanding Chronology Context Connections
EK0405 - Proactive Management Chronology Context Connections Prevents Constant Crises
EK0406 -
EK0407 - Follow up ref SDS H8 VC4M.
EK0408 -
EK0409 - The doctor drew a diagram on the marking board in the examination room
EK0410 - to illustrate medical practice making complex decisions based on
EK0411 - context.  The diagram showed three (3) branchs...
EK0412 -
EK0413 -                               /
EK0414 -                              /
EK0415 -                             /-------- Issue 1
EK0416 -                      /
EK0417 -           Issue 2 --------/
EK0418 -                          /
EK0419 -                         /
EK0420 -                        /--------Issue 3
EK0421 -                       /
EK0422 -                      /
EK0424 -  ..
EK0425 - The doctor explained frustrations making sense of multiple issues,
EK0426 - discussed previously on 061020. ref SDS F4 MO4K  Good practice saves
EK0427 - time and money by eliminating irrelevant options to focus on one issue
EK0428 - that seems most urgent based on the context at the time.  The doctor
EK0429 - noted that Millie has a complex patient profile, listed above.
EK0430 - ref SDS 0 LU3J  In this context, limited time should focus on making
EK0431 - sense of referral to UCSF for Millie to start treatment on a clinical
EK0432 - trial to stop the spread of IBC, discussed above. ref SDS 0 P256
EK0433 -
EK0434 -        [...above, Millie asks doctor to expedite referral to UCSF.
EK0435 -        ref SDS 0 Y46N
EK0437 -         ..
EK0438 -        [On 070119 treatment at UCSF was delayed because referral
EK0439 -        authorization was not performed, following agreement on 061230.
EK0440 -        ref SDS J1 AS96
EK0442 -         ..
EK0443 -        [On 070105 doctor frustrated that multiple issues are hard to
EK0444 -        manage; describes focusing on immediate problems rather than
EK0445 -        spending time on issues that are irrelevant to the current
EK0446 -        context. ref SDS I3 794K
EK0448 -  ..
EK0449 - The doctor seemed to indicate today that spending time making referral
EK0450 - for cancer treatment, per above, ref SDS 0 Y47J, leaves no time for,
EK0451 - also, making referral to a heart doctor to investigate heart disorder
EK0452 - diagnosed three (3) months ago on 061012. ref SDS F1 7E5L  Kaiser
EK0453 - seems to propose today waiting address findings in the CT test until
EK0454 - symptoms of edemya occur in the lower extremeties, as discussed on
EK0455 - 061208. ref SDS H4 HZ3O, and further notes that Cor Pulmonale make
EK0456 - take years to become life threatening, see above. ref SDS 0 MA49
EK0458 -  ..
EK0459 - "Life threatening" disease is a critical "context."  Proactive action
EK0460 - may be warranted in the context of Cor Pulmonale identified in CT test
EK0461 - on 060930, reviewed on 061012. ref SDS F1 7E5L  Research indicates
EK0462 - this condition compounds pulmonary embolism which is known to cause
EK0463 - sudden death without evidence of clinical symptoms, reported on
EK0464 - 061012. ref SDS F1 IN3H, and citing prior reseach on 060722 presenting
EK0465 - high risk mortality; 45% of patients die who suffer recurrance.
EK0466 - ref SDS C7 BI5J  Kaiser diagnosed Millie with recurrance on 061002.
EK0467 - ref SDS F0 MI5I
EK0468 -
EK0469 -     [On 070202 context missing from CT test on 070131; history cites
EK0470 -     breast cancer, does not present pulmonary embolism and enlarged
EK0471 -     right ventrical, Cor Pulmonale heart disorder. ref SDS J6 4I3N
EK0473 -  ..
EK0474 - Context plays a critical role getting medical advice to resume working
EK0475 - out in the gym that seems relevant to rising symptoms of enlarged
EK0476 - right ventricle, discussed above. ref SDS 0 2T6H
EK0478 -  ..
EK0479 - Millie requested timely review of Cor Pulmonale by a heart specialist
EK0480 - to prevent crisis management from discovering problems after prolonged
EK0481 - exposure that complicates recovery, illustrated by case studies on...
EK0482 -
EK0483 -        IBC.......................... 040517, ref SDS 36 S66O
EK0484 -        Pulmonary embolism........... 060722, ref SDS C7 6G6O
EK0485 -        Diflucan INR 6.4............. 061217, ref SDS 0 KW45
EK0486 -        UCSF drug trials............. 061208, ref SDS H4 P256
EK0487 -        UCSF referral authorization.. 061230, ref SDS I0 3X6K
EK0488 -        Cor Pulmonale................ 070105, ref SDS 0 2T6H
EK0489 -        Lung cancer.................. 070117, ref SDS I9 NM6G
EK0491 -  ..
EK0492 - Rather than jumping from one crisis to another, proactive management
EK0493 - enables investigation that increases time for finding solutions that
EK0494 - save lives, time, and money.  Background on resistance to planning and
EK0495 - proactive management in time for action to be effective was reviewed
EK0496 - previously on 060825. ref SDS E4 K36G
EK0497 -
EK0498 -
EK0499 -
EK0500 -
EK0501 -
EK06 -

SUBJECTS
Work Plan Doctor Submits Doctor/Patient Partnership Communications I

FB03 -
FB0401 -  ..
FB0402 - Work Plan Received Communications Doctor/Patient Partnership
FB0403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
FB0404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
FB0405 -
FB0406 - Follow up ref SDS H4 FE4I, ref SDS H1 FE4I.
FB0412 -  ..
FB0413 - Issues from Kaiser's Progress Notes continue from prior review on
FB0414 - 061110, ref SDS G5 EN4K, and listed again on 061208. ref SDS H4 EN4K
FB0416 -  ..
FB0417 - New issues inclued...
FB0418 -
FB0419 -    1.  Current medications shows Xeloda, which was ended on 061201.
FB0420 -        ref SDS 0 SE86
FB0421 -
FB0422 -    2.  Coumadin treatment are not listed, which began on 061002.
FB0423 -        ref SDS 0 SE86,  Coumadin is listed in the doctor's "Plan"
FB0424 -        section. ref SDS 0 125V
FB0426 -         ..
FB0427 -    3.  Patient request for examination by heart specialist to evaluate
FB0428 -        Cor Pulmonale enlarged right ventricle not reported in the
FB0429 -        Medical Chart. ref SDS 0 125V
FB0431 -  ..
FB0432 - Progress continues toward good management using the doctor patient
FB0433 - partnership model for timely review of patient history, called out in
FB0434 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 2 TD5S, and
FB0435 - reported on 060106. ref SDS 92 FE4I
FB0437 -  ..
FB0438 - Using the patient's agenda transferred into Kaiser's electronic
FB0439 - Medical Chart following procedures set out in the record on 061020,
FB0440 - ref SDS F4 K84N, demonstrates commitment to good management, essential
FB0441 - to sustain transformation.  This helps overcome lapses, as occurred
FB0442 - last month on 061208. ref SDS H4 114J
FB0443 -
FB0444 -    1.  1/5/2007     11:30 AM
FB0445 -
FB0446 -            Wcr-ONnc2 > Main Campus
FB0449 -         ..
FB0450 -    2.  Your primary care clinician is listed as...
FB0451 -
FB0453 -
FB0718 -
FB0719 -
FB0720 -
FB0721 -
FB0722 -
FB0723 -
FB0724 -
FB08 -