CONTACTS 

SUBJECTS
Meeting Doctor Examination 10th Review Prepare Changing Protocols af

1203 -
1203 -    ..
1204 - Summary/Objective
1205 -
120501 - Follow up ref SDS B0 0000. ref SDS A3 0000.
120502 -
120503 - Excellent launch meeting for Millie's new medical team at UCSF aiding
120504 - primary care support at Kaiser.  Treatment was advanced today, rather
120505 - than further delayed, a welcome relief. ref SDS 0 SM6M  The doctor
120506 - made a thorough examination, which showed IBC disease seems less
120507 - intense than occurs with some patients, and in relation to recent
120508 - patient history, however, the rash is now advancing beyond prior left
120509 - breast region. ref SDS 0 M68J  Millie was relieved and heartened that
120510 - treatment with the clincial study trial drugs has a good chance of
120511 - being effective. ref SDS 0 M645  UCSF is coordinating with Kaiser to
120512 - advance CT testing so that Millie can get treatment on Thursday under
120513 - Doctor Rugo's supervision. ref SDS 0 EY5O  This test helps solve the
120514 - problem to distinguish side effects of cetuximab treatment, which
120515 - makes people weak and tired, from symptoms of pulmonary embolism by
120516 - evaluating whether PE findings on 060930 have improved, worsened or
120517 - stabilized. ref SDS 0 915J
120518 -
120519 -     [On 070130 the doctor submitted report to Kaiser on consultation
120520 -     today. ref SDS C6 795I
120522 -      ..
120523 -     [On 070131 Millie submitted the record to UCSF for review and
120524 -     comment. ref SDS C7 FT7G
120526 -      ..
120527 -     [On 070201 Jackie and Brigid received Millie's letter today, and
120528 -     seemed to indicate the record of the meeting today on 070130 is
120529 -     thorough and accurate, ref SDS C9 407N; feel there is not enough
120530 -     time for the doctor to provide feedback verifying accuracy of
120531 -     understandings on case management. ref SDS C9 NW9M
120533 -      ..
120534 -     [On 070204 UCSF notified no initial side effects of treatment,
120535 -     and energy has increased; planning for CT test to evaluate
120536 -     pulmonary embolism. ref SDS D1 JJ7O
120537 -
120538 -
120539 -
120541 -  ..
1206 -
1207 -
1208 - Progress
1209 -
120901 - Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
120902 -
120903 - Follow up ref SDS B0 SM6M, ref SDS A3 SM6M.
120904 -
120905 - The meeting today was scheduled by a call from Jackie this morning,
120906 - who coordinated to advance the work, originally scheduled for Friday.
120907 - ref SDS C4 DH9N
120909 -  ..
120910 - Millie asked about payments for seeing the doctor today?
120912 -  ..
120913 - The attendent checked Millie's file and said that since she is on a
120914 - clinical trial Millie is not charged for office visits because this is
120915 - paid as part of the cost of the clinical trial.
120916 -
120917 -     [On 070906 Millie's letter to UCSF reports not having been
120918 -     notified about coinsurance charges. ref SDS F3 KC8S
120920 -  ..
120921 - Doctor Rugo will meet with Millie for examination to approve starting
120922 - a new cycle of treatment every 4 weeks, following the practice at
120923 - Kaiser.  In addition, Millie will meet wtih Brigid and Jackie to
120924 - monitor progress prior to the 3rd weekly treatment in each cycle.
120926 -  ..
120927 - This is the 10th review meeting for the 8th chemotherapy cycle since
120928 - starting treatment on 060711, ref SDS 76 SM6M, for the 3rd relapse of
120929 - IBC. ref SDS 76 8Y8I  This is the first meeting with Doctor Rugo to
120930 - start a new treatment on a clinical study drug trial for cetuximab and
120931 - carboplatin.
120933 -  ..
120934 - Since this is the first meeting, an agenda was not submitted to UCSF.
120936 -  ..
120937 - The agenda for the meeting at Kaiser on 070105 provides a structure
120938 - for organizing results of the meeting.
120939 -
120940 -    1.  Breast exam IBC spreading...................... ref SDS 0 AX6G
120941 -    2.  Measurable disease pictures tape measure....... ref SDS 0 M652
120942 -    3.  PET/CT Jackie coordinating schedule............ ref SDS 0 EY5O
120943 -    4.  Patient work up develop strategy............... ref SDS 0 K36G
120944 -    5.  Treatment plan weekly clinical trial........... ref SDS 0 PF3O
120945 -    6.  Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
120947 -  ..
120948 - Scheduled next meeting for either Thursday or Friday when Millie will
120949 - have the first treatment with cetuximab and carboplatin. ref SDS 0
120950 - N96O
120952 -  ..
120953 - The doctor was assisted by two aides...
120954 -
120955 -        1.  Jackie, Clinical Research Coordinator, coordinating
120956 -        2.  Rosendo So-Rosillo, MD, assisting
120957 -
120958 -
120959 -
120960 -
120961 -
1210 -

SUBJECTS
Complex Patient History 36 Issues Overwhelms Span of Attention Drive

1603 -
160401 -  ..
160402 - Complex Patient History Knowledge Management Dilemma Issues Grow 36
160403 -
160404 - Follow up ref SDS B0 LU3J, ref SDS A3 LU3J.
160405 -
160406 - Sampling of issues patient history diagnosis and treatment...
160407 -
160408 -    1.  CA 15-3 monitors advance of cancer response to treatment
160409 -    2.  Lymphedema complicated by mastectomy surgery
160410 -    3.  Broken finger from minor fall complicates lymphedema
160411 -    4.  Esophagitis reflux digestion issues
160412 -    5.  Immune system chemotherapy increases risk of infection
160413 -        Chemotherapy increase risk of infection
160414 -    6.  Cat bites increase risk of infection complicates lymphedema
160415 -    7.  Pneumonia chemotherapy increases risk of infection
160416 -    8.  Metastatic cancer increases risk pulmonary embolism
160417 -    9.  Lymphadenopathy left axilla local regional metastasis
160418 -   10.  Lymphadenopathy right axilla distant metastasis
160419 -   11.  Lymphadenopathy left supraclavicular diagnose metastatic cancer
160420 -   12.  Breast cancer secondary IBC 3rd relapse left breast
160421 -   13.  Cancer mutates slow response chemotherapy treatment
160422 -   14.  Mastectomy surgery impact on treatment IBC relapse
160423 -   15.  Blood vessels removed mastectomy slow chemotherapy treatments
160424 -   16.  Treatment options, strategy, planning, schedule
160425 -   17.  Drug trials increase declining pool chemotherapy agents
160426 -   18.  UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
160427 -   19.  Pulmonary embolism blood clots in lungs
160428 -   20.  INR weekly adjustments Coumadin treatment blood clots
160429 -   21.  Enlarged right ventricle heart problem core pulmonale
160430 -   22.  Dizziness symptom enlarged right ventricle cor pulmonale
160431 -   23.  Fatigue shortness breath side effect chemotherapy loss fitness
160432 -   24.  Fatigue shortness breath symptom pulmonary embolism
160433 -   25.  Shortness breath fatigue dizzy symptoms pulmonary embolism
160434 -   26.  Coagulapathy hypercoagulable state work up genetic risks
160435 -   27.  Testing resolution of errors (see Benz 2nd opinion 060821)
160436 -   28.  Testing distant metastatic disease
160437 -   29.  Testing pulmonary emoblism and heart disease
160438 -   30.  Communication hectic schedule not enough time to manage details
160439 -   31.  Emotional stress and well being
160440 -   32.  Cellulitis inflammation temperature 102.6 on chemotherapy
160441 -   33.  Urinary tract bladder infection
160442 -   34.  IBC rash spreads to right breast
160443 -   35.  Right breast rash may be "ring" infection, not cancer
160444 -   36.  Lung cancer seems to be diagnosed in the Medical Chart
160445 -   37.  IBC rash spreads to stomach and toward back
160446 -
160447 -
160448 -
160449 -
160450 -
1605 -

SUBJECTS
Vitals Submitted by Doctor UCSF Blood Pressure Pulse High Demonstrat

1803 -
180401 -  ..
180402 - Vitals Show Stable Medical Condition
180403 -
180404 - Follow up ref SDS B0 KB5L, ref SDS A3 KB5L.
180406 -                           ..
180407 -                          Bld Prssr   Pulse   Temp   Weight  SaO2
180408 -     ..
180409 - *  070130 1300............ 140 83     87     98.???
180410 - *  070105 1040............
180411 -    061208 1226............ 152 90     76     97.8    147     99%
180412 -    061201 1430............ 123 76     76     97.5
180413 -    061110................. 136 83     73     97.0    150     98%
180414 -    061020 1534............ 140 79     67     99.8    151     97
180415 -    060929 1452............ 141 78     66     98.3
180416 -    060908 1335............ 139 79     73     98.1
180417 -    060814 1610............ 139 80     59     98.2
180418 - *  060808.................
180419 -    060711................. 172 87     54     97.5    147
180420 -    060623................. 141 87     71     98.0    147     99%
180421 -    060428................. 129 73     80     99.4    149     99%
180422 -    060217................. 153 81     61     98.6    150     99%
180423 -
180424 - *  For some reason, vitals not submitted.
180426 -  ..
180427 - High blood pressure reflects pressure on patient about effectivenss of
180428 - new treatment and arrangements between UCSF and Kaiser for timely
180429 - care, discussed below. ref SDS 0 Y642
180430 -
180431 -
180432 -
1805 -

SUBJECTS
Coordination Plan Kaiser UCSF Collaboration Clinical Study Drug Tria

3703 -
370401 -  ..
370402 - Collaboration Primary Care at Kaiser with UCSF Standard of Care
370403 -
370404 - Kaiser referral to UCSF for clinical study of drug trial treatment
370405 - with cetuximab for IBC creates divided responsibilities that increase
370406 - complexity of communications within a compound matrix management
370407 - model.
370409 -  ..
370410 - Coordination will be required to avoid "wicked problems" by providing
370411 - timely and comprehensive continuity of patient history for medical
370412 - tests, e.g., blood, CT, PET imaging.   Similarly, matrix management at
370413 - UCSF and Kaiser must distinguish side effects caused by chemotherapy
370414 - treatment for IBC, from symptoms that diagnose pulmonary embolism and
370415 - enlarged right ventricle, which present similarly, but significantly
370416 - increased risk, reported in research on 060722. ref SDS 78 346F  UCSF
370417 - and Kaiser coordination must further distinguish symptoms of IBC now
370418 - being treated at UCSF from symptoms of lymphedema and complications of
370419 - Cellulitis being treated at Kaiser.
370421 -  ..
370422 - Doctor Rugo related experience working with Kaiser shows everyone
370423 - benefits from taking time in the beginning, as done in this case, to
370424 - coordinate resolution of authorization and payment issues before
370425 - starting work in the clinical trial, reported on 070119. ref SDS B7
370426 - YF8U  She feels that resolution reported on 070126, ref SDS C2 F175,
370427 - will avoid the patient being presented with a big bill down the road
370428 - that gets everyone upset.
370429 -
370430 -     [On 070202 Millie examined by primary care physician at Kaiser
370431 -     performing oversight of work at UCSF, ref SDS D0 0001
370433 -      ..
370434 -     [On 070222 Jackie discussed having a meeting to develop a referral
370435 -     coordination plan, ref SDS D8 VK5N, to resolve issues with Kaiser
370436 -     on Millie's treatment in the clinical trial. ref SDS D8 KL5G
370438 -      ..
370439 -     [On 070830 Millie gets "big bill" of over $10K claimed by UCSF
370440 -     because Kaiser and UCSF failed to complete coordination for
370441 -     referral. ref SDS F1 W05N
370443 -      ..
370444 -     [On 070904 Millie requests assistance from the doctor to resolve
370445 -     evident error resulting in Millie getting a "big bill."
370446 -     ref SDS F2 6Q8W
370448 -      ..
370449 -     [On 070925 Kaiser primary care physician assigns staff to solve
370450 -     problems caused by failing to develop referral coordination plan
370451 -     for Millie's treatment at UCSF. ref SDS F4 G54J
370453 -      ..
370454 -     [On 071018 Doctor Rugo advised she gathered from communication
370455 -     with Kaiser after 070119 that Millie was "cut loose" from Kaiser
370456 -     failing to perform duties of insurance carrier to manage the work
370457 -     by UCSF. ref SDS F5 PY5F
370459 -  ..
370460 - Asked about meeting to develop a referral work plan care, rather than
370461 - leave coordination between Kaiser and UCSF to ad hoc calls, email, and
370462 - adjustments that caused delays with referral authorization this past
370463 - month, reported in another record today. ref SDS C5 RM4G
370465 -  ..
370466 - The medical team indicated UCSF typically does not issue referral
370467 - coordination plans.  Kaiser and UCSF have experienced professionals
370468 - using well established procedures from past and ongoing referrals for
370469 - other patients.  With so many medical issues to address, ref SDS 0
370470 - LU3J, coordination with Kaiser seems resolved.
370471 -
370472 -     [On 070215 example Kaiser refers diagnosis and treatment of new
370473 -     rash to UCSF for evaluation of side effects of cetuximab treatment
370474 -     for IBC, expanding IBC, or Cellulitis. ref SDS D4 HK5O
370476 -      ..
370477 -     [On 070330 example symptoms of Cellulitis difficult to distinguish
370478 -     from side effects of cetuximab, and/or symptoms of worsening IBC.
370479 -     ref SDS E6 T87G
370481 -      ..
370482 -     [On 070330 example doctor diagnosis Cellulitis and prescribes
370483 -     treatment rather than defer to UCSF for coordinated analysis, as
370484 -     occurred previously. ref SDS E6 F46F
370486 -      ..
370487 -     [On 070610 primary care physician advises channels of
370488 -     communication now established with UCSF for referral case
370489 -     management. ref SDS F0 GV9G
370491 -  ..
370492 - Case studies on Millie's treatment the past 6 years at Kaiser, show
370493 - excellent opportunities to support medical practice, reported 061018.
370494 - ref SDS 93 0001  Case study on Kaiser referral to UCSF illustrates
370495 - patient care can be strengthened through comprehensive coordination
370496 - performing divided responsibilities. ref SDS C5 RM4G  In some respects
370497 - this is a project management problem solved with proactive
370498 - coordination planning.
370499 -
370500 -     [On 070201 Jackie provides telephone number for patient to call
370501 -     for emergencies, and questions on the clinical study; case study
370502 -     on collaboration between Kaiser and UCSF indicates need for
370503 -     coordination plan. ref SDS C9 ST3G
370505 -      ..
370506 -     [On 070202 meeting at Kaiser with primary care physician cites
370507 -     requirement for written coordination plan between Kaiser and UCSF
370508 -     with respect to mediciation prescriptions and emergencies.
370509 -     ref SDS D0 2O5H
370511 -      ..
370512 -     [On 070215 letter to Kaiser illustrates confusion about handling
370513 -     coordination between Kaiser and UCSF with respect to mediciation
370514 -     prescriptions and emergencies. ref SDS D4 VW6U
370516 -      ..
370517 -     [On 070216 Jackie notifies Millie to call UCSF if fever and
370518 -     rash increase. ref SDS D5 AM4N
370520 -      ..
370521 -     [On 070217 Millie requests clarification of coordination
370522 -     planning on emergency treatment; notes that patient history
370523 -     shows treatment at Kaiser Emergency does not require
370524 -     calling a number, just show up; notes that driving to San
370525 -     Francisco for emergency treatment at UCSF might enocunter
370526 -     fatal traffic delays. ref SDS D6 4Q8O
370528 -      ..
370529 -     [On 070222 Jackie proposed UCSF and Kaiser develop coordination
370530 -     plan to facilitate collaboration on care for Millie's complex
370531 -     patient history. ref SDS D8 VK5N
370533 -      ..
370534 -     [On 070222 scope coordination planning developed. ref SDS D8 KL5G
370536 -      ..
370537 -     [On 070228 letter to UCSF requests draft of coordination
370538 -     plan for review during meeting on 070301. ref SDS D9 LQ6R
370540 -      ..
370541 -     [On 070301 there wasn't enough time to review draft coordination
370542 -     plan. ref SDS E0 HH7H
370544 -      ..
370545 -     [On 070301 UCSF asks patient to coordinate communications with
370546 -     Kaiser on integrated care and divided responsibilities.
370547 -     ref SDS E0 O67N
370549 -      ..
370550 -     [On 070330 example blood test problem failure maintain continuity
370551 -     of comprehensive data from UCSF transmitted to Kaiser, but not
370552 -     entered in Kaiser's Medical Chart records. ref SDS E6 128S
370554 -  ..
370555 - UCSF arranged to facilitate weekly treatments with reduced cost of
370556 - parking.
370557 -
370558 -        [On 070130 Millie asked about procedures for completing this
370559 -        task. ref SDS C7 FT6Q
370560 -
370561 -        [On 070201 Millie received signed form from Jackie.
370562 -        ref SDS C9 YY3F
370563 -
370564 -
370565 -
370566 -
370567 -
3706 -

SUBJECTS
CA 15-3 68 Rising After Falling to 56 from 74 Erratic Changes Cancer

4803 -
480401 -  ..
480402 - CA 15-3 Cancer Marker 68 Erratic Changes Since 060928
480403 -
480404 - Follow up ref SDS B0 087J, ref SDS A3 087J.
480405 -
480406 - On 070110, Millie received results for the blood test on 070104, which
480407 - shows CA 15-3 dropped to 56. ref SDS B1 087J  Millie had a blood test
480408 - 2 weeks later on 070118, and received the report on 070123 showing CA
480409 - 15-3 increased to 68. ref SDS B9 GK5B
480411 -           ..
480412 -         Test Date                         Date Received
480413 -          070118......... 68 H............. 070123, ref SDS B9 GK5B
480414 -          070104......... 56 H............. 070110, ref SDS B1 087J
480415 -          061218......... 74 H............. 061227, ref SDS A5 6P9F
480416 -          061214......... 63 H............. 061227, ref SDS A5 6P9F
480417 -          061130......... 67 H............. 061201, ref SDS A0 087J
480418 -          061116......... 66 H............. 061201, ref SDS A0 087J
480419 -          061110......... 56 H............. 061201, ref SDS A0 087J
480420 -          061109......... 61 H............. 061110, ref SDS 97 087J
480421 -          061026......... 57 H............. 061110, ref SDS 97 087J
480422 -          061019......... 56 H............. 061020, ref SDS 94 087J
480423 -          060928......... 51 H............. 060929, ref SDS 89 087J
480424 -          060907......... 68 H............. 060929, ref SDS 89 087J
480425 -          060813......... 73 H............. 060817, ref SDS 84 U24M
480426 -          060809......... 87 H............. 060810, ref SDS 83 2N5J
480427 -          060708......... 71 H............. 060711, ref SDS 76 087J
480428 -          060616......... 63 H............. 060623, ref SDS 75 UQ5Q
480429 -          060522......... 59 H............. 060605, ref SDS 74 UQ5Q
480430 -          060501......... 49 H............. 060522, ref SDS 73 MC4F
480431 -          060421......... 44 H............. 060428, ref SDS 70 087J
480432 -          060330......... 40 H............. 060428, ref SDS 70 087J
480433 -          060303......... 36............... 060428, ref SDS 70 087J
480434 -          060210......... 33............... 060217, ref SDS 66 087J
480435 -          060109......... 34............... 060126, ref SDS 65 KV59
480436 -          051223......... 34............... 060106, ref SDS 64 087J
480437 -          051202......... 28............... 060106, ref SDS 64 087J
480438 -          051116......... 31............... 051121, ref SDS 63 087J
480439 -          051109......... 30............... 051121, ref SDS 63 087J
480440 -          051102......... 34............... 051121, ref SDS 63 087J
480441 -          050909......... 45 H............. 051007, ref SDS 60 087J
480442 -          050826......... 45 H............. 050913, ref SDS 56 087J
480443 -          050819......... 45 H............. 050913, ref SDS 56 087J
480444 -          050812......... 39 .............. 050819, ref SDS 54 3K6L
480445 -          050729......... 45 H............. 050819, ref SDS 54 EA5G
480446 -          050708......... 46 H............. 050729, ref SDS 53 087J
480447 -          050701......... 37 .............. 050729, ref SDS 53 087J
480448 -          050617......... 45 H............. 050729, ref SDS 53 087J
480449 -          050527......... 56 H............. 050610, ref SDS 51 087J
480450 -          050512......... 67 H............. 050520, ref SDS 50 087J
480451 -          050506......... 80 H............. 050520, ref SDS 50 087J
480452 -  ..
480453 -          050415.........105 H............. 050422, ref SDS 48 087J
480454 -          050325.........100 H............. 050329, ref SDS 46 087J
480455 -          050318.........101 H............. 050325, ref SDS 45 2N5J
480456 -          050304......... 88 H............. 050311, ref SDS 43 087J
480457 -          050225......... 95 H............. 050308, ref SDS 42 0001
480458 -          050211......... 78 H............. 050214, ref SDS 41 02BB
480459 -          050128......... 67 H............. 050204, ref SDS 40 087J
480460 -          041228......... 56 H............. 041230, ref SDS 39 087J
480461 -          041204......... 43 H............. 041210, ref SDS 38 087J
480462 -          041007......... 39............... 041104, ref SDS 36 087J
480463 -          040923......... 49 H............. 041005, ref SDS 33 087J
480464 -          040908......... 44 H............. 040909, ref SDS 32 087J
480465 -          040825......... 47 H............. 040909, ref SDS 32 087J
480466 -          040811......... 42 H............. 040812, ref SDS 31 087J
480467 -          040728......... 43 H............. 040729, ref SDS 30 2N5J
480468 -          040712......... 47 H............. 040713, ref SDS 29 087J
480469 -          040614......... 55 H............. 040615, ref SDS 28 PX6X
480470 -          040517......... 78 H............. 040601, ref SDS 27 2N5J
480471 -          040311......... 70 H............. 040318, ref SDS 24 SM6M
480472 -          040205......... 60 H............. 040211, ref SDS 22 SM6M
480473 -          031201......... 62 H............. 031205, ref SDS 21 SM6M
480474 -          030912......... 66 H............. 030915, ref SDS 20 SM6M
480475 -          030708......... 68 H............. 030710, ref SDS 19 SM6M
480476 -          030503......... 54 H............. 030508, ref SDS 17 SM6M
480477 -          030403......... 45 H............. 030508, ref SDS 17 SM6M
480478 -          030215......... 46 H............. 030220, ref SDS 16 5E6L
480479 -          030106......... 37 H............. 030109, ref SDS 15 SM6M
480480 -          021202......... 41 H?............ 021204, ref SDS 14 SP5G
480481 -          021111......... 36 H?............ 021113, ref SDS 13 Y65I
480482 -          021023......... 33 H?............ 021023, ref SDS 12 SQ5I
480483 -          020930......... 33 H?..39........ 021002, ref SDS 11 SQ5I
480484 -          020917......... 36 H?............ 020924, ref SDS 10 SQ5I
480485 -          020717......... 59 H?............ 020726, ref SDS 9 YN5K
480486 -          020629......... 75 H ............ 020705, ref SDS 8 UX6I
480487 -          020608........  67 H ............ 020614, ref SDS 7 0001
480488 -          020603........ 108 H ............ 020607, ref SDS 6 X67F
480489 -          020511........ 117 H ............ 020603, ref SDS 5 PJ4J
480490 -          020419......... 81 H ............ 020430, ref SDS 4 7N5H
480491 -          020321......... 85 H ............ 020405, ref SDS 3 6T8K
480492 -
480493 -
480494 -
480495 -
480497 -  ..
4805 -
4806 -
4807 - Analysis
4808 -
480801 - CA 15-3 74 Cancer Marker Rises Significantly Aligns IBC Rash Increase
480802 -
480803 - Follow up ref SDS B0 GJ5M, ref SDS A3 GJ5M.
480804 -
480805 - There was no dicsussion of CA 15-3 today.  Consideration of measurable
480806 - disease focused on direct measurement with conventional tape measure,
480807 - and using photographic history. ref SDS 0 M652
480809 -  ..
480810 - Discussed erratic changes in intensity of IBC rash, ref SDS 0 025H,
480811 - which correlates with recent erratic changes in CA 15-3, per above.
480812 - ref SDS 0 087J
480813 -
480814 -
480815 -
480816 -
480817 -
4809 -

SUBJECTS
Blood Test 070123 for Clinical Study Cetuximab Carboplatin Drug Tria

5703 -
570401 -  ..
570402 - Blood Tests Ready for Treatment Tomorrow
570403 -
570404 - Follow up ref SDS B9 AS6M, ref SDS B8 AS6M.
570405 -
570406 - On 070105, the primary care physician ordered blood work required for
570407 - Millie to get treatment at UCSF on the cetuximab carboplatin clinical
570408 - study.  On 070118 Millie went to Kaiser and had blood drawn for the
570409 - test to start treatment scheduled on 070119. ref SDS B6 5S6L
570411 -  ..
570412 - UCSF reported on 070119 that Millie's lab work did not meet protocol
570413 - requirements. ref SDS B7 AS6M  Jackie coordinated with Arlette to
570414 - schedule Millie for a complete lab. ref SDS B7 Q95H  On 070122 the
570415 - primary care physician came into the office from vacation to order
570416 - another lab study for Millie to get treatment at UCSF. ref SDS B8 LX6V
570417 - The next day on 070123 Millie went to Kaiser for another blood test.
570418 - ref SDS B9 AS6M
570420 -  ..
570421 - Today, Millie was scheduled for treatment tomorrow based on the blood
570422 - test on 070123 that corrected past problems, and as planned during the
570423 - meeting today. ref SDS 0 LD59
570424 -
570425 -            [On 070131 UCSF requests another blood test before starting
570426 -            treatment on 070201. ref SDS C8 NZ4N
570428 -  ..
570429 - Key consideration will be avoiding trauma from needle penetrations by
570430 - using Millie's port for blood draws to test for ability to withstand
570431 - treatments.
570433 -  ..
570434 - Needle penetrations increase risk of bleeding from Coumadin (warfarin)
570435 - treatments for pulmonary embolism, discussed below. ref SDS 0 CV5L
570436 - Port catheter was installed on 040419 because Millie suffered severe
570437 - trauma to her arm from conventional needle applications for blood
570438 - draws and treatment IVs. ref SDS 25 XU5L
570440 -             ..
570441 -            [On 070131 technician warns about internal bleeding from
570442 -            needle penetration for blood draws; need plan to minimize
570443 -            using needles, use Millie's port to reduce risk of bleeding
570444 -            while on Coumadin (warfarin) for pulmonary embolism.
570445 -            ref SDS C8 E87I
570447 -             ..
570448 -            [On 070201 Millie was randomized to treatment on Cetuximab,
570449 -            and without Carboplatin, ref SDS C9 XR3M; Brigid advised
570450 -            that the protocol for Cetuximab alone requires only one (1)
570451 -            blood draw for each 4 week cycle, rather than weekly.
570452 -            ref SDS C9 XR40
570453 -
570454 -
570455 -
570456 -
570457 -
5705 -

SUBJECTS
Digestion Problems GERD Subside No Examination Nor Consideration PET

6103 -
610401 -  ..
610402 - Digestion Problems Increasing Relatively Infrequent Mild
610403 - Esophagitis Not Compared in Current PET Test with Prior Report
610404 -
610405 - Follow up ref SDS B0 JP6K, ref SDS A3 JP6K.
610406 -
610407 - Background is reported in the meeting on 061201. ref SDS A0 JP6K
610408 - During the meeting on 061208, the doctor requested comparison between
610409 - PET scan test scheduled for 061227, and prior PET test on 060120,
610410 - which was reviewed on 060126, ref SDS 65 DH4O, and CT test on 060505,
610411 - reviewed on 060523, ref SDS 73 4O8P, to clarify diagnosis and plan
610412 - treatment of esophagitis or other malady that may be causing increased
610413 - digestion problems.  Kaiser's medical chart for the meeting on 061208
610414 - shows GERD worse. ref SDS A3 1248  The medical chart for the meeting
610415 - on 070105 makes no reference to GERD. ref SDS B0 1248
610417 -  ..
610418 - There was no discussion of this issue today.
610419 -
610420 -
610421 -
610422 -
6105 -

SUBJECTS
Left Axillary Lymphadenopathy Patient No Complaint of Swelling Disco

7503 -
750401 -  ..
750402 - Cellulitis Complications Lymphedema Subsiding No Examination
750403 - Left Axillary No Evidence Lymphadenopathy Cellulitis Treatment Ends
750404 - Post Operation Localized Edema Left Axillary Swelling Reduced
750405 -
750406 - Follow up ref SDS B0 MW8J, ref SDS A3 MW8J.
750407 -
750408 - Patient has a long history of IBC on the left breast and associated
750409 - lymphadenopathy symptoms in the left axillary, see case study on
750410 - 040517. ref SDS 26 OW3I
750412 -  ..
750413 - The doctor examined the left axilla.  Clinical palpation made no
750414 - findings for lumps or other indications of cancer, swelled lymph nodes
750415 - that might indicate lymphadenopathy.  The patient made no complaint of
750416 - lumps or discomfort from swelling under the left arm.  These findings
750417 - are consistent with recent image testing listed on 070102. ref SDS A9
750418 - 1Y8G  Review of PET/CT test at that time shows no findings of
750419 - lymphadenopathy. ref SDS A9 RG4J
750421 -  ..
750422 - There was no examination of the left arm.  The patient wore a full arm
750423 - sleeve and hand glove for treating lymphedema.  There have been no
750424 - further relapses of Cellulitis, and lymphadema seems improved since
750425 - the last major episode reported on 061204. ref SDS A2 ZS5N
750427 -  ..
750428 - Prior to the meeting the left elbow measures 10.75" shown in case
750429 - study on 060509. ref SDS 71 HO7F
750430 -
750431 -     [On 070202 rash observed on upper left arm reported by primary
750432 -     care physician during examination at Kaiser, similar to symptoms
750433 -     for IBC and/or cellulitus. ref SDS D0 6H6L
750435 -      ..
750436 -     [On 070214 Millie notifies primary care physician rash continues
750437 -     on left arm, requests refill prescription antibiotic treatment for
750438 -     cellulitus, Keflex. ref SDS D3 R66P
750440 -      ..
750441 -     [On 070222 Brigid investigated effects of tennis on lymphedema and
750442 -     cellulitis in left arm, and determined that playing righ handed
750443 -     makes this a manageable risk for restoring fitness to strengthen
750444 -     the immune system. ref SDS D8 457F
750445 -
750446 -
750447 -
750448 -
750449 -
750450 -
7505 -

SUBJECTS
Case Study Lymphedema Cellulitis Patient History Symptoms Diagnosis
Cellulitis Keflex Antibiotics Treatment Prescription Cellulitis Rela

8004 -
800501 -  ..
800502 - Lymphedema Cellulitis Case Study on Possible Causation Factors
800503 -
800504 - Background on treatment for Cellulitis and lymphedema is shown in case
800505 - study on 061203. ref SDS A1 YT4M
800507 -  ..
800508 - Patient history on causation of lymphedema and cellulitis shows...
800509 -
800510 -        1.  Surgery left breast lumptectomy
800511 -            removeed tumor; lymph nodes left
800512 -            axillary removed.................. 020312, ref SDS 1 7V61
800514 -             ..
800515 -        2.  Pathology surgery on 020312; 3 of
800516 -            3 lymph nodes positive for
800517 -            metastatic disease left
800518 -            axillary.......................... 020321, ref SDS 2 5O5F
800520 -             ..
800521 -        3.  Meeting primary care physician
800522 -            recommends immediate surgery for
800523 -            local control, makes no disclosure
800524 -            risks lymphedema.................. 050913, ref SDS 56 5T4J
800526 -             ..
800527 -        4.  Meeting with surgeon to assess
800528 -            Kaiser's recommendations for left
800529 -            breast mastectomy makes no disclosure
800530 -            of risks for post operation side
800531 -            effects of lymphedema; surgon
800532 -            asks for patient's
800533 -            opinion........................... 050923, ref SDS 59 WI6K
800534 -            surgeon asks again what patient
800535 -            thinks about risks of approving
800536 -            mastectomy........................ 050923, ref SDS 59 7K3J
800537 -            surgeon warns mastectomy presents
800538 -            high risks, no disclosure that
800539 -            lymphedema and cellulitis will
800540 -            cause chronic medical problems
800541 -            with hospitalization.............. 050923, ref SDS 59 NT9G
800543 -             ..
800544 -        5.  Meeting primary care physician recommends
800545 -            patient approve mastectomy surgery
800546 -            for "palliation," no disclosure
800547 -            risks for lymphedema.............. 051007, ref SDS 60 IV4G
800549 -             ..
800550 -        6.  Surgery left breast mastectomy
800551 -            did not remove lymph nodes left
800552 -            axillary in order to reduce risk
800553 -            of lymphedema..................... 051021, ref SDS 61 QU5I
800555 -             ..
800556 -        7.  Surgeon confirms lymph nodes not
800557 -            removed left axillary for left
800558 -            breast mastectomy performed on
800559 -            051021............................ 051027, ref SDS 61 LI3K
800561 -             ..
800562 -        8.  Swelling, large bulge under left
800563 -            axillary; diagnosis is
800564 -            lymphadema........................ 060106, ref SDS 64 S164
800566 -             ..
800567 -        9.  Swelling reduced under left
800568 -            axillary, referral to lymphedema
800569 -            clinic............................ 060217, ref SDS 66 T56K
800571 -             ..
800572 -       10.  Lymphedema clinic examination finds
800573 -            worsening lymphedema.............. 060306, ref SDS 67 G26O
800575 -             ..
800576 -       11.  Lymphedema rises, begin physical
800577 -            therapy, and regimen of massage
800578 -            to reduce swelling on entire
800579 -            left arm and hand................. 060314, ref SDS 68 GE89
800581 -             ..
800582 -       12.  Therapyst finds improvement, says
800583 -            removal of lymph nodes during surgery
800584 -            on 051021 may have triggered
800585 -            increased symptoms of
800586 -            lymphedema........................ 060417, ref SDS 69 2Z9M
800588 -             ..
800589 -       13.  Measurements swelling patient
800590 -            history lymphedema................ 060509, ref SDS 71 HO7F
800592 -             ..
800593 -       14.  Swelling increases, then recedes
800594 -            somewhat; therapyst recommends
800595 -            resuming using bandage on
800596 -            entire left arm during
800597 -            exercise.......................... 060515, ref SDS 72 Q05H
800599 -             ..
800600 -       15.  Lymphedema seems under
800601 -            control........................... 060623, ref SDS 75 K75S
800603 -             ..
800604 -       16.  Physical therapyst ends treatment
800605 -            for lymphedema.................... 060711, ref SDS 76 MW8J
800607 -             ..
800608 -       17.  Millie falls at BART breaks finger
800609 -            left hand, left arm swells
800610 -            complications from
800611 -            lymphedema........................ 060914, ref SDS 87 ZQ5I
800613 -             ..
800614 -       18.  Lymphedema swelling left arm
800615 -            suddenly increases................ 060922, ref SDS 88 0D5Y
800617 -             ..
800618 -       19.  Millie hospitalized 5 days temperature
800619 -            102.6 severe red rash envelops left
800620 -            arm and shoulder; diagnosis cellulitis
800621 -            complications of lymphedema, reaction
800622 -            to tramua from fall and breaking
800623 -            finger on 060914.................. 061027, ref SDS 96 V759
800625 -             ..
800626 -       20.  Cellulitis relapse left arm,
800627 -            prescription Keflex
800628 -            renewed........................... 061112, ref SDS 98 5K5G
800630 -             ..
800631 -       21.  Case study Cellulitis and lymphedema
800632 -            indicates risks increase with exercise
800633 -            after surgery removes lymph
800634 -            nodes............................. 061203, ref SDS A1 YT4M
800636 -             ..
800637 -       22.  Cellulitis recurrence again, possibly
800638 -            caused by cat bite, doctor renews
800639 -            prescription for
800640 -            Keflex............................ 061204, ref SDS A2 ZS5N
800642 -             ..
800643 -       23.  Cellulitis inflammation subsides,
800644 -            swelling of lymphedema in left arm
800645 -            remains significantly above
800646 -            norms............................. 061208, ref SDS A3 CO7O
800648 -             ..
800649 -       24.  Cellulitis no evidence; lymphedema
800650 -            swelling left arm and hand still
800651 -            significant, preventing routine
800652 -            exercise for
800653 -            fitness........................... 070105, ref SDS B0 3Z9H
800655 -             ..
800656 -       25.  Rash left breast 2 scenarios,
800657 -            erratic changes severity, expanding
800658 -            from left breast toward stomach,
800659 -            wrapping toward back expanding
800660 -            to right breast could be
800661 -            IBC compounded by
800662 -            cellulitis........................ 070130, ref SDS 0 M68J
800664 -             ..
800665 -       26.  Rash upper left arm cited by primary
800666 -            care physician similar to previous
800667 -            condition diagnosed as
800668 -            cellulitis........................ 070202, ref SDS D0 JP6F
800670 -             ..
800671 -       27.  Exercise case study correlation causing
800672 -            Cellulitis and lymphedema after surgery
800673 -            removed lymph nodes, reduces
800674 -            capacity lymphatic
800675 -            system............................ 070218, ref SDS D7 3M3J
800677 -             ..
800678 -       28.  Examination at UCSF indicates rash
800679 -            on upper left arm more likely
800680 -            expanding IBC, rather than
800681 -            cellulitis........................ 070222, ref SDS D8 B64F
800683 -             ..
800684 -       29.  Exerecise tennis using right arm
800685 -            minimizes harm compounding
800686 -            lymphedema complications to
800687 -            left arm.......................... 070222, ref SDS D8 IS5K
800689 -             ..
800690 -       30.  Lymphedema swelling left arm increases
800691 -            significantly raising concerns about
800692 -            exercising to strengthen immune system
800693 -            that resists cancer and helps
800694 -            manage emotional
800695 -            stress............................ 070329, ref SDS E5 T87G
800697 -             ..
800698 -       31.  Cellulitis lymphedema recurrence during
800699 -            treatment for cancer at UCSF; evident
800700 -            cause increased exercise to stimulate
800701 -            bone marrow that produces new blood
800702 -            that maintains immune system essential
800703 -            for chemotherapy treatments; exercise
800704 -            further maintains physicial fitness
800705 -            essential for aggressive chemotherapy
800706 -            treatments to recover from
800707 -            cancer............................ 070607, ref SDS E9 ZH6I
800709 -             ..
800710 -       32.  Cellulitis and lymphedema causation
800711 -            discussed with UCSF; no evident
800712 -            correlations that can help reduce
800713 -            recurrence........................ 080501, ref SDS F6 9U5M
800715 -             ..
800716 -       33.  Lymphedema and Cellulitis risk declines
800717 -            gradually after surgery remove cancerous
800718 -            lymph nodes; lymphatic system gradually
800719 -            becomes more robust because remaining
800720 -            lymph nodes increase capacity so that
800721 -            exercise can continue to maintain fitness
800722 -            essential for aggressive chemotherapy
800723 -            treatment to recover from cancer
800724 -            reported by surgeon at
800725 -            Kaiser............................ 080606, ref SDS F7 4P7L
800726 -
800727 -
800728 -
800729 -
800730 -
8008 -

SUBJECTS
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom

8603 -
860401 -  ..
860402 - Right Axillary Possible Involvement Red Rash Spreads Right Breast
860403 - Right Breast Red Rash Spreads Possible Involvement Right Axillary
860404 - Red Rash Right Breast Spreads Possible Involvement Right Axillary
860405 -
860406 - Follow up ref SDS B0 3D6K, ref SDS A3 3D6K.
860407 -
860408 - Background on patient history of testing for lymphadenopathy in the
860409 - right axilla is reported in the record on 060929. ref SDS 89 3D6K
860411 -  ..
860412 - On 061204 patient notifies Kaiser that IBC inflammation spread from
860413 - the left chest area infected with IBC across the sternum and slightly
860414 - onto the right breast. ref SDS A2 AE5I
860416 -  ..
860417 - Patient has a long medical history of cancer associated with IBC rash
860418 - on the left breast and lymphadenopathy symptoms in the left axillary,
860419 - see case study on 040517. ref SDS 26 OW3I
860421 -  ..
860422 - The doctor made careful and thorough examination of the left and right
860423 - breast areas.
860425 -  ..
860426 - Examination of the right axillary yielded same results from examining
860427 - the left axilla, per above. ref SDS 0 VU6O
860428 -
860429 -
860430 -
860431 -
860432 -
8605 -

SUBJECTS
Left Supraclavicular Neck Lymphadenopathy Patient No Complaint Swell

9403 -
940401 -  ..
940402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
940403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
940404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
940405 -
940406 - Follow up ref SDS B0 8R6M, ref SDS A3 8R6M.
940407 -
940408 - During examination, the doctor asked about history of radiation to the
940409 - neck, and sequence of finding recurrence from Doctor Laio's biopsy
940410 - reported on 040309. ref SDS 23 0001
940412 -  ..
940413 - Background of image testing, and consideration for radiation treatment
940414 - of left supraclavicular is reported on 060623. ref SDS 75 8R6M
940416 -  ..
940417 - Like the left and right axillary locations, the doctor examined for
940418 - cancer in left supraclavicular region.  There were no findings of
940419 - lumps which could indicate lymphadenopathy, as reported above.
940420 - ref SDS 0 VU6O
940421 -
940422 -
940423 -
940424 -
940425 -
9405 -

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

A303 -
A30401 -  ..
A30402 - Erratic Rash IBC Aligns Erratic CA 15-3 Results Case Study
A30403 - Case Study Erratic Changes IBC Rash Aligns Changes CA 15-3
A30404 - IBC Red Rash Left Breast Expands Toward Stomach Wraps Toward Back
A30405 - Examination Left Breast IBC Inflammation Expanding Stomach Back
A30406 -
A30407 - Follow up ref SDS B0 025H, ref SDS A3 025H.
A30408 -
A30409 - Background on prior relapse examinations is listed on 060711.
A30410 - ref SDS 76 8Y7O
A30412 -  ..
A30413 - On 061204 Millie submitted a letter, ref DIP 1 I93X, notifying Kaiser
A30414 - that IBC spread from the left chest area to the right breast,
A30415 - ref SDS A2 I93X  This was observed by the doctor during examination on
A30416 - 061208. ref SDS A3 RU6J  Doctor's notes for examination on 070105
A30417 - describe erythema extending to the right breast. ref SDS B0 925L
A30419 -  ..
A30420 - There has been steady expansion of rash beginning on the left chest
A30421 - area near the sternum since examination on 060623, ref SDS 75 025H,
A30422 - and since starting treatment with Taxotere and capecitabine on 060721.
A30423 - ref SDS 77 0001
A30425 -  ..
A30426 - Erratic changes in severity/intensity and spreading of IBC rash are
A30427 - shown by case study in the record on 040517. ref SDS 26 2F4G  Patient
A30428 - history since June of last year show changing severity of IBC rash
A30429 - during 3rd relapse. ref SDS 26 KR8O
A30431 -  ..
A30432 - Changing intensity of rash generally tracks changes in CA 15-3 during
A30433 - treatment of 3rd relapse, shown above. ref SDS 0 087J  This was cited
A30434 - by the primary care physician during a meeting on 061201 to discuss
A30435 - changing treatments. ref SDS A0 GJ5M  The doctor further cited CA 15-3
A30436 - as a primary diagnostic for measurable disease in a letter to Doctor
A30437 - Rugo on 061230, ref SDS A7 PO3V, reflecting that IBC does not appear
A30438 - in image tests with PET and CT scan technology, unless there is
A30439 - related lymphadenopathy, which is not present at this time, reported
A30440 - above. ref SDS 0 VU6O
A30441 -
A30443 -  ..
A30444 - Stomach Back IBC Rash Spreading
A30445 - IBC Progression Spreads Stomach and Back
A30446 - Progression IBC Disease Spreads Stomach and Back
A30447 -
A30448 - Examination today shows rash expanding on the left chest, and onto the
A30449 - right breast, as previously reported.  Intensity of the rash seems
A30450 - much less severe today than prior examinations, based on patient
A30451 - comments.  However, there is new and significant expansion of rash to
A30452 - the lower abdomen (stomach), and beginning to wrap toward the side and
A30453 - back.  At this time, extension of rash toward the stomach and side,
A30454 - are light sprinkles of red dots, similar to when IBC relapse was
A30455 - observed near the sternum, above and below the mastectomy incision,
A30456 - reported on 060623. ref SDS 75 NE6G
A30457 -
A30458 -     [On 070131 primary care physician at Kaiser notified examination
A30459 -     today indicates rash has spread to stomach, and toward the back.
A30460 -     ref SDS C8 6K6V
A30462 -      ..
A30463 -     [On 070201 rash severity continues to subside, shown by
A30464 -     examination at UCSF to start treatment on 070201. ref SDS C9 6T6M
A30466 -      ..
A30467 -     [On 070202 rash observed on upper left arm reported by primary
A30468 -     care physician during examination at Kaiser, similar to symptoms
A30469 -     for IBC and/or cellulitus. ref SDS D0 6H6L
A30471 -      ..
A30472 -     [On 070216 UCSF schedules meeting to examine report new rash on
A30473 -     left arm; proactive management may be spread of IBC. ref SDS D5
A30474 -     VE3K
A30476 -      ..
A30477 -     [On 070222 examination at UCSF indicates rash on upper left arm
A30478 -     likely expanding IBC. ref SDS D8 B64F
A30480 -      ..
A30481 -     [On 070301 new rash on upper right arm similar to IBC, but not
A30482 -     diagnosed as IBC. ref SDS E0 H15M
A30484 -  ..
A30485 - The doctor described rash and skin seems smooth to the touch, rather
A30486 - than rigid and pitted, as may occur with advanced IBC.  The skin does
A30487 - not seem warm or hot, as also occurs when IBC becomes severe.  Millie
A30488 - has previously noticed this area has been "hot" to the touch on
A30489 - occassion, but this has not occurred for a month or so.
A30491 -  ..
A30492 - Biopsy has not been performed to affirmatively diagnose these new rash
A30493 - sites, and changes in intensity, per above, ref SDS 0 SE9O, and
A30494 - discussed again below. ref SDS 0 KT7J
A30495 -
A30496 -     [On 070201 examination Brigid, Nurse Practitioner, prior to
A30497 -     treatment, rash described similarly. ref SDS C9 LH5H
A30499 -  ..
A30500 - This record indicates some response to treatment with Taxotere and
A30501 - capecitabine (Xeloda) having restrained and controlled advance of
A30502 - disease.
A30504 -  ..
A30505 - May fit 2 scenario analysis on 060808, ref SDS 81 J16O, possibility
A30506 - expanding rash observed today is cellulitis which previously presented
A30507 - as initial light sprinkes of red dots, reported on 061027. ref SDS 95
A30508 - MS3Q   This was reported in another record the same day. ref SDS 96
A30509 - HP52  In that case of cellulitis, Millie had elevated temperature,
A30510 - ref SDS 96 EX9L, reaching a high of 102.4. ref SDS 96 Q265  Physical
A30511 - correlation of connection between cellulitis on left arm, and IBC rash
A30512 - area on left chest was directly observed on 061027. ref SDS 96 V79M
A30514 -  ..
A30515 - Since there is no temperature today, this may indicate the rash is not
A30516 - cellulitis, but IBC.  Diagnosis seems indeterminate without a biopsy.
A30518 -      ..
A30519 -     [On 070202 doctor's examination at Kaiser, and progress notes,
A30520 -     report cancer spreading toward the stomach, and around toward the
A30521 -     back, ref SDS D0 368I, similar inflammation also occurred on the
A30522 -     upper left arm, diagnosed as possible cellulitis; expanding rash
A30523 -     beyond the left breast area could therefore be cellulitis from
A30524 -     lymphedema. ref SDS D0 YK8O
A30525 -
A30526 -
A30528 -  ..
A30529 - Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
A30530 -
A30531 - The doctor commented today that there is a good chance treatment with
A30532 - Cetuximab and Carboplatin will clear inflammation and rash observed
A30533 - today, as previously occurred in 2005 when Taxotere and capecitabine
A30534 - (Xeloda) were started to treat Millie for 2nd recurrence, illustrated
A30535 - by the report on 050520. ref SDS 50 025H
A30536 -
A30537 -     [On 070301 subsiding rash and dramatic drop in CA 15-3 cancer
A30538 -     marker after 4 treatments with cetuximab on clinical study at UCSF
A30539 -     shows improving prospects. ref SDS E0 M645
A30540 -
A30542 -  ..
A30543 - Local IBC Infection No Record Distant Metastasis Improves Chances
A30544 - Prognosis Favorable No Lymphadenopathy 2006 No Distant Metastasis 5 Years
A30545 -
A30546 - The doctor feels Millie is fortunate that 5 years of patient history
A30547 - image testing, listed recently on 070102, ref SDS A9 1Y8G, has not
A30548 - found distant metastatis.  During all of 2006, there were no findings
A30549 - of swelled lymph nodes in the axillary regions, nor in the left
A30550 - supraclavicular where biopsy on 040309 reported a single incidence of
A30551 - cancer, which is is a symptom of IBC, reported on 040517. ref SDS 26
A30552 - N23J  This gives Millie a good chance of arresting growth of cancer,
A30553 - if treatment accomplishes local control.
A30554 -
A30555 -
A30556 -
A30557 -
A30558 -
A306 -

SUBJECTS
Measurable Disease IBC Spreads from Left to Right Breast Photographs

A503 -
A50401 -  ..
A50402 - Measurable Disease IBC Spreads from Left to Right Breast
A50403 - Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
A50404 - Measurable Disease IBC Observed with Tape Measure Photograph Pictures
A50405 - CA 15-3 Diagnostic Measurable Disease IBC Not Meaured by Image Testing
A50406 -
A50407 - Follow up ref SDS A8 4Q6K.
A50408 -
A50409 - On 061230 Doctor Rugo asked in a letter to Kaiser about measurable
A50410 - disease in Millie's case.  The primary care physician cited rising CA
A50411 - 15-3, ref SDS A7 PO3V, which has tracked expanding IBC rash and
A50412 - intensity, discussed above. ref SDS 0 SE5J  Measurable disease was
A50413 - cited again in follow up correspondence reviewed on 070101, At that
A50414 - time, a case study lists patient history considering use of diagrams
A50415 - and photographs to measure advance and improvement treating IBC,
A50416 - because image testing with CT and PET scan technologies are not
A50417 - effective for IBC. ref SDS A8 4Q6K
A50419 -  ..
A50420 - Today, the doctor used a tape measure to obtain dimensions of the
A50421 - current rash.  This is a little difficult because the rash spreads
A50422 - unevenly in all directions.  Seemed like the doctor used the stermun
A50423 - as a base point, where IBC was initially concentrated following
A50424 - relapse, reported on 060711. ref SDS 76 T86N  Infected skin tissue
A50425 - measures 1 - 2 inches from the sternum onto the right breast.
A50426 - Measurement was also made of rash extending approximately 5 inches
A50427 - from the sternum on the left side above and below the mastectomy
A50428 - incision wound.  The doctor also measured vertically about 4 inches
A50429 - left of the sternum from above and and extending below the incision
A50430 - line, toward the stomach to a location which the doctor described as
A50431 - significant rash.
A50433 -  ..
A50434 - Jackie plans to take pictures of IBC infected area on the first day of
A50435 - treatment, to compare with subsequent pictures taken every 4 weeks
A50436 - starting a new cycle, as discussed on 070116 for determining
A50437 - measurable disease. ref SDS B3 JS5G   Background considering
A50438 - photographic records for diagnostics to assess progress of "measurable
A50439 - disease" treating IBC was reviewed in a case study on 070101, when
A50440 - this issue was raised in correspondence between UCSF and Kaiser.
A50441 - ref SDS A8 4Q6K
A50442 -
A50443 -     [On 070201 Jackie took pictures of infected IBC tissue with a tape
A50444 -     measure held in various angles to assess measurable disease.
A50445 -     ref SDS C9 6T6M
A50446 -
A50447 -
A50448 -
A50449 -
A50450 -
A505 -

SUBJECTS
Lung Cancer No Discussion Metastatic Disease Lymph Nodes Doctor's Pr

A903 -
A90401 -  ..
A90402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
A90403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
A90404 -
A90405 - Follow up ref SDS B0 G25K, ref SDS A3 G25K.
A90406 -
A90407 - Primary care physician Progress Notes in the Medical Chart for 070105
A90408 - shows under Impressions...
A90409 -
A90410 -        Metastatic breast cancer (IBC)lung and lymph node; chest wall
A90411 -        recurrence. ref SDS B0 1248
A90412 -
A90413 - ...which repeats an entry in the Medical Chart for the meeting on
A90414 - 061208. ref SDS A3 1248  Review on 061208 notes there is no record of
A90415 - disclosure to the patient on lung cancer, and nothing in patient
A90416 - history over the past 5 years that hints nor diagnoses lung cancer.
A90417 - ref SDS A3 LP6K
A90419 -  ..
A90420 - There was no discussion at Kaiser on 061208, because the Medical Chart
A90421 - was received after the meeting.  This matter was not reviewed with the
A90422 - doctor during the meeting on 070105 because at that time, the doctor
A90423 - was focused on getting Millie started with treatment at UCSF.
A90424 - ref SDS B0 PK7L and ref SDS B0 MA8O
A90426 -  ..
A90427 - Lung cancer seems like a matter that could effect clinical study
A90428 - issues, and so may warrant review by UCSF.
A90430 -  ..
A90431 - On 070112 Millie asked Kaiser to explain support for notation of lung
A90432 - cancer in the Medical Chart. ref SDS B2 NM6G  On 070117 the primary
A90433 - care physician cited several CT tests over the past few years report
A90434 - small pulmonary nodules involving the right lung, which are smaller
A90435 - than 5 mm, and so do not appear in PET scan tests. ref SDS B5 TS8G
A90436 - Case study on patient history confirms that CT tests beginning in 2002
A90437 - report nodules in the both right and left lungs; none are identified
A90438 - as cancer, and none show growth common to cancer. ref SDS B5 4Q46
A90439 - Unless Kaiser pathology reports have been audited with further review
A90440 - of scan files, and changed to reflect further findings, there is no
A90441 - evident basis for diagnosis of lung cancer.
A90443 -  ..
A90444 - On 070105 the primary care physician further indicated that Millie may
A90445 - have suffered permanent lung damage from pulmonary embolism, which
A90446 - seems related, but different from lung cancer. ref SDS B0 3Q5J
A90448 -  ..
A90449 - There was no discussion of this issue today, so that attention could
A90450 - be focused on starting Millie's treatment to stop progression of IBC
A90451 - metastatic disease.
A90452 -
A90453 -
A90454 -
A90455 -
A90456 -
A90457 -
A905 -

SUBJECTS
Mastectomy Removes Blood Vessels Prevents Delivery Chemotherapy Trea

AG03 -
AG0401 -  ..
AG0402 - Pockets of Resistance to Treatment of IBC Red Rash Left Breast
AG0403 - Blood Vessels Removed Mastectomy Create Pockets that Resist Treatment
AG0404 - Expectations Recovery Rate Reduced Mastectomy Remove Blood Vessels
AG0405 - Alternate Treatment Method Blood Vessels Cannot Deliver Chemotherapy
AG0406 -
AG0407 - Follow up ref SDS B0 EH3F, ref SDS A3 EH3F.
AG0408 -
AG0409 - Background on slow response to treatment and impending progression of
AG0410 - disease due to mastectomy surgery on 051021 was reviewed in the record
AG0411 - for the meeting on 061020, ref SDS 94 EH3F, and again on 061110.
AG0412 - ref SDS 97 EH3F  Case study considering mastectomy surgery for Millie
AG0413 - is reported on 041210. ref SDS 38 657F
AG0415 -  ..
AG0416 - On 041117 Doctor Benz recommended there is no role for surgery in
AG0417 - Millie's case. ref SDS 37 OU4U  On 050311 Kaiser oncology ordered
AG0418 - examination by the surgery department for mastectomey to remove
AG0419 - "pockets of resistance" to chemotherapy in the left breast.
AG0420 - ref SDS 43 XQ41  On 050324 the surgeon observed IBC spreading toward
AG0421 - the neck provided, which prevented surgery because there was no
AG0422 - evident boundary for surgery. ref SDS 44 YY7F  On 050329 oncology
AG0423 - changed treatment to Taxotere and capecitabine, which started on
AG0424 - 050415. ref SDS 47 407N  On 050727 surgeon observed IBC rash was no
AG0425 - longer visible. ref SDS 52 YY7F  On 050729 Kaiser oncology recommended
AG0426 - mastectomy surgery. ref SDS 53 BZ56  On 050811 Millie asked UCSF about
AG0427 - Kaiser's proposal for surgery, and on 050823 UCSF referred the issue
AG0428 - to Doctors Bailey and Grissom. ref SDS 55 AI8N
AG0430 -  ..
AG0431 - Doctor Grissom recommended on 050922 continuing chemotherapy for local
AG0432 - control, and that mastectomy could be considered, but that risks of
AG0433 - distant metastasis are high. ref SDS 57 XL6S  Similarly, 2nd opinion
AG0434 - from Doctor Bailey received on 050922, cautioned against surgery,
AG0435 - ref SDS 58 XD6U, and that, if mastectomy was performed, then Millie's
AG0436 - patient history of no distant metastasis and IBC spreading toward the
AG0437 - neck, indicated that breast reconstruction of a very wide mastectomy
AG0438 - should be considered to avoid recurrence by removing previously
AG0439 - infected tissue. ref SDS 58 XD8P
AG0441 -  ..
AG0442 - On 051007 Kaiser proposed deferring breast replacement, ref SDS 60
AG0443 - 635M, explaining that tissue harvested for reconstruction may have
AG0444 - poor blood vessels due to prior surgery, and this could reduce
AG0445 - delivery and therefore effectiveness of chemotherapy drugs in the
AG0446 - event of relapse. ref SDS 60 KO49
AG0448 -  ..
AG0449 - Today, the doctor seemed to comment that slow, and erratic response to
AG0450 - treatment the past several months, including evident progression of
AG0451 - disease, cited in the study above, ref SDS 0 SE9O, is not likely
AG0452 - caused by "pockets of resistance" to treatment because mastectomy
AG0453 - surgery interrupted the blood vessel system slowing delivery of
AG0454 - chemotherapy drug agents to this region, as considered in the record
AG0455 - on 061110. ref SDS 97 5E5I  The doctor described this theory as new to
AG0456 - oncology practice at the UCSF Cancer Center.
AG0458 -  ..
AG0459 - The doctor further indicated today that mastectomy was reasonable
AG0460 - treatment with a 20% chance of long term success for Millie's patient
AG0461 - history, but that IBC presents an aggressive disease that is difficult
AG0462 - to treat.  There was no discussion of palliation, i.e., how mastectomy
AG0463 - aided patient comfort from failing treatment.  Case study on 051027
AG0464 - reviews mastectomy for palliation in relation to increasing local
AG0465 - control. ref SDS 62 F25H
AG0467 -  ..
AG0468 - The doctor indicated today that breast reconstruction has not been an
AG0469 - effective solution at UCSF for IBC patients.  UCSF has seen the worst
AG0470 - IBC relapse occur with breast reconstruction.
AG0471 -
AG0472 -
AG0473 -
AG0474 -
AG0475 -
AG05 -

SUBJECTS
Biopsy Left Right Breasts Start Clinical Study Treatment IBC Cetuxim

AU03 -
AU0401 -  ..
AU0402 - Clinical Study Benefits from Biopsy of IBC Targeted Tissue
AU0403 - Biopsy Determine Biology of IBC and Guide Choice of Treatment
AU0404 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
AU0405 -
AU0406 - Follow up ref SDS B0 KT7J, ref SDS A3 KT7J.
AU0408 -  ..
AU0409 - Biopsy for patient work up to treat 3rd IBC relapse was originally
AU0410 - discussed on 060711, ref SDS 76 K36G, and more recently on 061020?
AU0411 - ref SDS 94 KH6H  Further review on 061110 presents objectives and
AU0412 - rationale based on evidence of cancer mutating. ref SDS 97 448F
AU0413 - Biopsy was reviewed at Kaiser on 070105 to evaluate rash spreading
AU0414 - from left to the right breast, ref SDS B0 WZ5J, and based on patient
AU0415 - history discovering IBC with a biopsy on 040419. ref SDS 25 789F
AU0417 -  ..
AU0418 - Status change can be reviewed with biopsy, which could increase
AU0419 - treatment options for Millie.
AU0421 -  ..
AU0422 - During the meeting today, Millie agreed to several biopsy samples of
AU0423 - rash infected areas observed during examination, per above,
AU0424 - ref SDS 0 M68J, in order to support clinical study objectives, set out
AU0425 - in the consent form reviewed on 070116. ref SDS B3 0348
AU0427 -  ..
AU0428 - Consent form was signed and initialed during the meeting today
AU0429 - authorizing UCSF to share patient health care data on biopsy tissue
AU0430 - with clinical study personnel.  This supplements consent documents
AU0431 - signed on 070119 authorizing UCSF to share blood, test, and other
AU0432 - data. ref SDS B7 1G3K
AU0434 -  ..
AU0435 - Biopsy can provide more definitive diagnosis of new rash sites and
AU0436 - erratic changes in rash intensity, reported in case study today, also,
AU0437 - per above. ref SDS 0 5N6L
AU0439 -  ..
AU0440 - The doctor identified several locations where biopsy would cause
AU0441 - least discomfort.
AU0442 -
AU0443 -     [On 070131 doctor consults with surgeon and decides Millie's
AU0444 -     treatment with Coumadin for pulmonary embolism presents elevated
AU0445 -     risk of bleeding (hemoraging); decides not to do biopsies.
AU0446 -     ref SDS C8 6E3J
AU0448 -      ..
AU0449 -     [On 070201 Jackie explains that biopsy diagnostics and pathology
AU0450 -     are not reported to the doctor for patient diagnosis and
AU0451 -     treatment; therefore, even though Millie has experienced minimal
AU0452 -     bleeding while on Coumadin the past few months, there is no
AU0453 -     benefit to balance risk to the patient for performing biopsies
AU0454 -     that only support research. ref SDS C9 IH6H
AU0455 -
AU0456 -
AU0457 -
AU05 -

SUBJECTS
CT Scan Test Ordered 070131 Baseline New Treatment Clinical Study Dr

B903 -
B90401 -  ..
B90402 - CT Test Baseline Clinical Trial PE Expedite Collaborate with Kaiser
B90403 -
B90404 - Follow up ref SDS B0 EY5O, ref SDS A3 EY5O.
B90405 -
B90406 - PET/CT test on 061227 received on 070102. ref SDS A9 XT4M
B90408 -  ..
B90409 - Test history listed in the same record on 070102, shows no evidenece
B90410 - of regional nor distant metastasis. ref SDS A9 1Y8G
B90412 -  ..
B90413 - On 070125 Jackie advised that UCSF wants another CT test because delay
B90414 - on referral authorization issues, delayed start of clinical trial
B90415 - beyond the protocol period for using the last test on 061227.
B90416 - ref SDS C1 Z24H
B90418 -  ..
B90419 - Jackie reported today during the meeting that UCSF has requested
B90420 - Kaiser advance the CT test one day, from 070201 to 070131, i.e., from
B90421 - Thursday to Wednesday, as discussed earlier this morning, when Jackie
B90422 - called. ref SDS C4 JM4J  Advancing the test enables Millie's treatment
B90423 - to start on 070201, rather than on Friday, 070202, so that Doctor Rugo
B90424 - can supervise Millie's first day of treatment.  Apparently, Doctor
B90425 - Rugo will not be available on Friday, so advancing treatment is
B90426 - critical to avoid scheduling conflicts, and revises UCSF planning from
B90427 - yesterday. ref SDS C3 TD3O
B90428 -
B90429 -     [On 070201 Doctor Rugo was consulted on issues to support start of
B90430 -     treatment. ref SDS C9 7835
B90432 -  ..
B90433 - Jackie seemed to indicate that discussion today with Arlette at Kaiser
B90434 - showed that the original order for the CT test prepared by a
B90435 - substitute doctor on 070126, while Millie's primary care physician was
B90436 - on vacation, ref SDS C2 G29I, did not include specified scope to
B90437 - evaluate pulmonary embolism and enlarged right ventricle, in order to
B90438 - help the doctor distinguish side effects of Cetuximab, which are
B90439 - similar to symptoms of pulmonary embolism, reported below. ref SDS 0
B90440 - MO7K
B90442 -  ..
B90443 - Evidently, today the primary care physician was on site at Kaiser,
B90444 - back from vacation.  Jackie relayed something along the lines that
B90445 - Millie can only get a "regular" CT test tomorrow at Kaiser's
B90446 - Pleasanton facility, because they do not have the equipment to perform
B90447 - CT tests that detect pulmonary embolism.  Jackie said there are two
B90448 - time slots available for Millie to be tested in Pleasenton:  OA 1030
B90449 - and OA 1130.
B90451 -  ..
B90452 - Jackie further indicated that the primary care physician may be able
B90453 - to order the form of the CT test that evaluates pulmonary embolism, at
B90454 - Kaiser's Walnut Creek offices, but the earliest this can be done is on
B90455 - 070201.  Under this scenario, treatment cannot start until the
B90456 - following day, and, as noted, this would prevent Doctor Rugo from
B90457 - supervising Millie's first treatment, due to a prior schedule
B90458 - commitment on 070202, as noted above. ref SDS 0 M882
B90459 -
B90460 -     [On 070131 technician giving Millie CT test at Pleasenton seemed
B90461 -     to indicate that testing for pulmonary embolism and enlarged right
B90462 -     ventricle is supported. ref SDS C8 KM4F
B90464 -  ..
B90465 - Jackie will ask Kaiser later today to consider performing the CT test
B90466 - at Walnut Creek tomorrow, rather than waiting until Thursday, so that
B90467 - the scope can include analysis of pulmonary embolism, and will also
B90468 - fit Doctor Rugo's schedule.
B90470 -  ..
B90471 - If this cannot be accomplished, then Kaiser will be asked to give the
B90472 - CT test in Pleasanton tomorrow without scope to evalate pulmonary
B90473 - embolims and enlarged right ventricle.  The primary goal at this time
B90474 - is to perform the CT test tomorrow so that Doctor Rugo can monitor
B90475 - Millie's first treatment on Thursday, rather than delay treatment to
B90476 - Friday, when the doctor will not be available to manage the work.
B90477 -
B90478 -
B90479 -
B90480 -
B90481 -
B905 -

SUBJECTS
Emotional Trauma Increases Stress Pulse 87 Complex Medical Profile 3

BE03 -
BE0401 -  ..
BE0402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
BE0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
BE0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
BE0405 -
BE0406 - Follow up ref SDS B0 Y642, ref SDS A3 Y642.
BE0407 -
BE0408 - Medical issues create an emotional roller coaster that increase
BE0409 - patient stress and trauma listed in the record on 070105. ref SDS B0
BE0410 - Y642
BE0412 -  ..
BE0413 - Millie's vitals were very high today, e.g., pulse 87, ref SDS 0 KB5L,
BE0414 - where normally her resting heart beat is plus or minus 60, reported on
BE0415 - 061201. ref SDS 99 AW4L
BE0417 -  ..
BE0418 - Millie related during the meeting being very concerned about how the
BE0419 - meeting today would go, and whether there would even be a meeting,
BE0420 - which caused her to leave town last Wednesday on 070124. ref SDS C0
BE0421 - KX9H
BE0423 -  ..
BE0424 - Recent progress through collaboration between Kaiser and UCSF relieves
BE0425 - stress and anxiety, reported by Jackie this morning scheduling the
BE0426 - meeting with Doctor Rugo today, and expediting required testing so
BE0427 - that Doctor Rugo can supervise the work, per above. ref SDS 0 M85Q
BE0429 -  ..
BE0430 - There was reassurance during the meeting that proposed treatment has a
BE0431 - good chance of stopping advance of disease, and possibly clearing the
BE0432 - rash currently spreading from the left chest area.  There was further
BE0433 - reassurance that side effects that cause acne-like face rash will most
BE0434 - likely be controlled with medication.
BE0436 -     ..
BE0437 -    [On 070204 Kaiser and UCSF notified no initial side effects of 1st
BE0438 -    treatment with cetuximab; energy has increased, Millie worked out
BE0439 -    in the gym 2 days in a row, and for the first time in 6 months;
BE0440 -    planning for CT test to evaluate pulmonary embolism. ref SDS D1
BE0441 -    JJ7O
BE0442 -
BE0443 -
BE0444 -
BE0445 -
BE05 -

SUBJECTS
Strategy IBC 3rd Relapse Treatment Plan UCSF Clinical Study Drug Tri
Strategy CT Test Evaluate Aggressive Treatment IBC Cetuximab Clinica

BR04 -
BR0501 -  ..
BR0502 - Patient History Presented for Profile Work Up Planning and Strategy
BR0503 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
BR0504 - Strategy Treatment Options Scenarios Planning Patient Work Up Deferred
BR0505 -
BR0506 - Follow up ref SDS B0 K36G, ref SDS A3 K36G.
BR0507 -
BR0508 - Background on requirements and obstacles to planning and proactive
BR0509 - management in time for action to be effective is reported on 060825.
BR0510 - ref SDS 86 K36G
BR0512 -  ..
BR0513 - Review of treatment history is listed on 061208. ref SDS A3 5Q5I
BR0515 -  ..
BR0516 - There was no discussion today on the role of the Tumor Board process
BR0517 - to support strategy and planning, considered on 061208. ref SDS A3
BR0518 - P69G
BR0520 -  ..
BR0521 - Doctor Rugo's assistant, Doctor So-Rosillo, developed a summary of
BR0522 - patient history from reviewing the record, aided by Millie's primary
BR0523 - care physician at Kaiser submitting a summary of the case to UCSF on
BR0524 - 061228. ref SDS A6 NP8G
BR0526 -  ..
BR0527 - Jackie advised that Doctor Benz 2nd opinions were examined for
BR0528 - comprehensive understanding of Millie's condition, reported on 041117,
BR0529 - ref SDS 37 OS7P, and for the more recent consultation at UCSF on
BR0530 - 060821, which was received from Kaiser on 060929. ref SDS 90 WP4V
BR0532 -  ..
BR0533 - Millie was again questioned on details of medical care over the past 5
BR0534 - years, begining on 020208, and which are listed chronologically in the
BR0535 - record on 050812. ref SDS 54 6L4M  This took about 40 minutes today,
BR0536 - following the practice at UCSF on 060821, ref SDS 85 TQ4X, and earlier
BR0537 - on 041018. ref SDS 34 EN63
BR0539 -  ..
BR0540 - The assistant then briefed the doctor for about 20 minutes.  During
BR0541 - this briefing in another room, Jackie provided more information about
BR0542 - working with the Clinical Research Department under Doctor Rugo's
BR0543 - leadership.
BR0544 -
BR0546 -  ..
BR0547 - Referral Authorization Resolution
BR0548 -
BR0549 - After Doctor So-Rosillo's briefing, Doctor Rugo came into the
BR0550 - examination room and introduced herself.  The doctor initially noted
BR0551 - emotional relief to finally work on medicine, rather than shuffle
BR0552 - paperwork for complex communications coordinating referral that has
BR0553 - dominated efforts the past few months, beginning on 061208,
BR0554 - ref SDS A3 WR6G, reported on 070101, ref SDS A8 YP8O, and complicated
BR0555 - on 070123. ref SDS B9 0001
BR0556 -
BR0557 -     [On 070906 Millie's letter to UCSF reports not having been
BR0558 -     notified about coinsurance charges. ref SDS F3 KC8S
BR0559 -
BR0560 -
BR0562 -  ..
BR0563 - Examination Initial Patient Work Up Starting Cetuximab Treatments
BR0564 -
BR0565 - The doctor made a thorough examination to complement initial work up
BR0566 - on patient history per above. ref SDS 0 LC49  Doctor So-Rosolli,
BR0567 - assisting today, took notes to capture the record of examination,
BR0568 - following the practice at Stanford Medical Center, reported on 041019.
BR0569 - ref SDS 35 5W6H
BR0571 -  ..
BR0572 - During this time, Jackie briefly examined patient history on the
BR0573 - computer, previously reviewed by Margaret Rubino on 060809.
BR0574 - ref SDS 82 I73H  There was discussion of difficulty transforming from
BR0575 - traditional printed documents, to computer records that support
BR0576 - precision access, noted by Margaret on 060821, ref SDS 85 TQ5F, when
BR0577 - the 2nd opinion consultation repeated past practices relying on
BR0578 - printed documents.
BR0580 -  ..
BR0581 - Jackie commented on difficulty preparing for the meeting today from
BR0582 - wading through several folders of papers UCSF has on file for Millie's
BR0583 - case.  This aligns with experience at UCSF on 060821 during
BR0584 - consultation with Doctor Benz. ref SDS 85 TQ7I
BR0586 -  ..
BR0587 - Case studies on 40 issues from Millie's care are listed on 061018.
BR0588 - ref SDS 93 0001
BR0590 -  ..
BR0591 - Patient history (chronology) from inception on 020208 to 051020 prior
BR0592 - to mastectomy surgery is listed in a case study on 050812. ref SDS 54
BR0593 - 6L4M
BR0595 -  ..
BR0596 - Patient history after mastectomy on 051021 to the present is listed on
BR0597 - 060722. ref SDS 79 6L4M
BR0599 -  ..
BR0600 - The doctor explained that patients who get both drugs are on a 4 week
BR0601 - cycle.  Cetuximab is given every week continuously without breaks.
BR0602 - Carboplatin is given for 3 weeks, and then there is a week off until
BR0603 - the next cycle starts again on the 4th week, as set out in the consent
BR0604 - documents reviewed on 070116. ref SDS B3 5U7S
BR0606 -  ..
BR0607 - Strategy is to continue treatment with a particular drug until disease
BR0608 - progresses, then change to another protocol.  If Millie is randomized
BR0609 - to get only cetuximab in the drug trial program, then if, at some
BR0610 - point, disease gets worse and spreads, the doctor will add carboplatin
BR0611 - to increase strength and effectiveness of treatment, discussed further
BR0612 - below. ref SDS 0 NI6K
BR0613 -
BR0614 -        [On 070201 Millie was randomized to get only Cetuximab.
BR0615 -        ref SDS C9 XR3M
BR0617 -         ..
BR0618 -        [On 070301 IBC spreads, ref SDS E0 LB5L; doctor considered
BR0619 -        changing treatment by adding carboplatin, but decision is
BR0620 -        complicated by falling ANC blood counts below the level that
BR0621 -        allows treatment without increasing risk of contracting other
BR0622 -        lethal diseases from prolonged exposure with weakened immune
BR0623 -        system. ref SDS E0 V95M
BR0624 -
BR0626 -  ..
BR0627 - Patients can remain in the program indefinitely until there is
BR0628 - evidence of disease progression, as previously noted from the Consent
BR0629 - document reviewed on 070116. ref SDS B3 5U7S
BR0630 -
BR0631 -
BR0632 -
BR0633 -
BR07 -

SUBJECTS
Strategy Treatment Plan Surgery Remove Pockets of Resistance to Chem

BW03 -
BW0401 -  ..
BW0402 - Surgery Left Breast Region Remove Pockets of Resistance Chemotherapy
BW0403 -
BW0404 - Follow up ref SDS B0 ZZ5F, ref SDS A3 ZZ5F.
BW0405 -
BW0406 - Surgery to treat "pockets of resistance" to chemotherapy was discussed
BW0407 - briefly on 061208, ref SDS A3 ZZ5F, citing prior considerations
BW0408 - reported on 040416. ref SDS 38 657F
BW0410 -  ..
BW0411 - Surgery to remove infected tissue and rebuild the breast for better
BW0412 - response to chemotherapy in the event of relapse was postponed by the
BW0413 - Surgery Department on 051007, and then considered again to treat
BW0414 - relapse on 060711. ref SDS 76 X54L
BW0416 -  ..
BW0417 - Doctor Rugo seemed to support Millie's primary care physician at
BW0418 - Kaiser indicating today that breast reconstruction is not a good
BW0419 - course for Millie's condition of IBC.
BW0420 -
BW0421 -
BW0422 -
BW0423 -
BW0424 -
BW0425 -
BW05 -

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

C003 -
C00401 -  ..
C00402 - Treatment 1st Cycle Cetuximab Carboplatin 070201 8th Cycle 3rd Relapse
C00403 - 8th Cycle Treatment 3rd Relapse 1st Cycle Cetuximab Carboplatin
C00404 - Drug Trial Clinical Study Protocol Side Effects Randomized Cetuximab
C00405 - Cetuximab Carboplatin Randomize Patient Can Still Get Carboplatin
C00406 -
C00407 - Follow up ref SDS B0 PF3O, ref SDS A3 PF3O.
C00408 -
C00409 - UCSF will submit Millie's case to randomize treatment for both
C00410 - cetuximab and carboplatin, or only cetuximab.
C00411 -
C00412 -        [On 070201 Millie randomized for treatment with only cetuximab;
C00413 -        provides additional treatment with carboplatin, if needed.
C00414 -        ref SDS C9 XR3M
C00416 -  ..
C00417 - Since at this time, diagnostics in image test history indicates
C00418 - evidence of only local disease, discussed above, ref SDS 0 EY5O, and
C00419 - since clinical examination today seems to find moderate, though
C00420 - expanding IBC, ref SDS 0 M68J, Millie might be better to get initial
C00421 - treatment with cetuximab, and if that is effective, then additional
C00422 - treatment with the study protocol would not be needed, and could be
C00423 - available later if disease progresses.
C00424 -
C00425 -        [On 070202 primary care physician at Kaiser indicated starting
C00426 -        treatment with cetuximab gives Millie another treatment option
C00427 -        in the event that disease progresses. ref SDS D0 QO6O
C00429 -         ..
C00430 -        [On 070419 IBC subsiding; Millie fortunate responding to
C00431 -        treatment with cetuximab alone, clinical study changes protocol
C00432 -        eliminating this option because not enough patients getting
C00433 -        favorable response with cetuximab alone. ref SDS E7 Q665
C00435 -  ..
C00436 - As noted, UCSF wants Millie to get treatment on Thursday, 070201, so
C00437 - that Doctor Rugo can monitor the work for the first cycle.  This
C00438 - requires getting CT testing done on Wednesday, 070131, a day before
C00439 - treatment begins.  Jackie is coordinating with Arlette to get Kaiser's
C00440 - support, per above. ref SDS 0 M85Q  Blood work previously performed on
C00441 - 070123 seems to be adquate for Millie to get treatment, per above.
C00442 - ref SDS 0 MP4H
C00444 -  ..
C00445 - Doctor Rugo confirmed understandings from the study consent documents
C00446 - reviewed on 070116 that, if initial treatment is only with cetuximab,
C00447 - and Millie does not respond well, UCSF can switch to try both
C00448 - cetuximab and carboplatin together for a stronger treatment regimen.
C00449 - ref SDS B3 NL7I  This flexibility in the study protocol fits the
C00450 - doctor's strategy for Millie's treatment plan discussed above.
C00451 - ref SDS 0 N13L
C00453 -        ..
C00454 -       [On 070201 Millie randomized to cetuximab. ref SDS C9 XR3M
C00456 -        ..
C00457 -       [On 070202 primary care physician notices new rash on upper left
C00458 -       arm, which is a symptom of cellulitis, ref SDS D0 JP6F but may
C00459 -       progression of IBC. ref SDS D0 JP6L
C00461 -        ..
C00462 -       [On 070222 examination at UCSF indicates new rash likely
C00463 -       progression of IBC. ref SDS D8 B64F
C00465 -        ..
C00466 -       [On 070301 IBC progression to left arm, evident rise CA 15-3
C00467 -       cancer marker presents prognosis of failed response to
C00468 -       treatment, requiring increasing prescription from cetuximab
C00469 -       alone to add carboplatin. ref SDS E0 OL5M
C00471 -        ..
C00472 -       [On 070524 CA 15-3 37 cancer marker rises 30% signals
C00473 -       effectiveness of treatment with cetuximab alone may be
C00474 -       ending; since IBC continues to subside, and CT tests
C00475 -       shown no progression of disease, decided to continue
C00476 -       with cetuximab alone now. ref SDS E8 357I
C00477 -
C00478 -
C00479 -
C00480 -
C005 -

SUBJECTS
Side Effects Cetuximab Similar Symptoms Pulmonary Embolism Fatigue W

C203 -
C20401 -  ..
C20402 - Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
C20403 -
C20404 - Follow up ref SDS B4 QM7I, ref SDS B3 7Y4H.
C20405 -
C20406 - Side effects of fatigue, weakness cause loss of fitness with shortness
C20407 - of breath disclosed in the clinical study consent form, ref DRP 1
C20408 - HW54, reviewed on 070116, ref SDS B3 RT7K, are similar to symptoms of
C20409 - pulmonary embolism, discussed below, ref SDS 0 MO7K, and to symptoms
C20410 - of heart disorder Cor Pulmonale also described as enlarged right
C20411 - ventricle, is also discussed below. ref SDS 0 L56L
C20413 -  ..
C20414 - Millie asked if rash and inflammation side effects of cetuximab,
C20415 - listed in UCSF letter ton 070116, ref SDS B3 MH4Q, can be mistaken for
C20416 - Cellulitis, or otherwise conceal progression of IBC by mistaking the
C20417 - rash for side effects of cetuximab?  This issue was presented in
C20418 - Millie's letter to UCSF on 070117, ref SDS B4 HT3Q, asking for comment
C20419 - on questions in the record on 070116 reviewing cetuximab side effects,
C20420 - ref SDS B3 MH4Q, including skin reacations in relation to IBC...
C20421 -
C20422 -            Will Cetuximab rash side effects compound IBC rash?
C20424 -             ..
C20425 -            How will Cetuximab side effects be distinguished from IBC?
C20427 -  ..
C20428 - The doctor explained today that cetuximab acne-like rash side effects
C20429 - only occur to the face, and that other skin reactions to cetuximab
C20430 - have not previously been mistaken for IBC rash nor otherwise caused
C20431 - conflicting diagnosis.
C20432 -
C20433 -               [On 070330 rising severity of rash and inflammation on
C20434 -               the upper left arm the day after treatment with cetuxiab
C20435 -               at UCSF, ref SDS E6 T87G, was diagnosed as recurrent
C20436 -               Cellulitis, ref SDS E6 7C5F, and later was discovered to
C20437 -               be a side effect of cetuximab. ref SDS E6 N75M
C20439 -  ..
C20440 - Doctor Rugo said that UCSF will prescribe medication as part of the
C20441 - clinical study protocol to treat side effects, as the need arises.  In
C20442 - some case, this is minimal.  She seemed to indicate that patients
C20443 - react differently to treatments of cetuximab side effects.  In some
C20444 - cases several treatments may be needed to fully suppress acne-like
C20445 - side effects.  This generally aligns with Jackie's report on 070117.
C20446 - ref SDS B4 QM7I
C20448 -  ..
C20449 - This aligns with Jackie's comments when she called on 070117.
C20450 - ref SDS B4 QM7I
C20452 -               ..
C20453 -              [On 070201 Brigid advised during follow up examination to
C20454 -              start treatment at UCSF that medication to control
C20455 -              acne-like side effects is provided a week after the 1st
C20456 -              treatment, and if shown by examination to be required.
C20457 -              ref SDS C9 FO66
C20459 -               ..
C20460 -              [On 070208 Millie requested treatment for the rash on her
C20461 -              face that is a side effect of cetuximab chemotherapy;
C20462 -              this was deferred for 2 weeks to the start of the next
C20463 -              cycle on 070301. ref SDS D2 FO66
C20465 -  ..
C20466 - Consent documents reviewed on 070116 say in part...
C20467 -
C20468 -            Approximately 100 patients from around the country are
C20469 -            expected to participate in the study, including
C20470 -            approximately 20 subjects from UCSF. ref SDS B3 1H3O
C20471 -
C20472 - ...which seems fairly limited experience for evaluating effectivenss,
C20473 - and side effects.
C20474 -
C20475 -
C20476 -
C205 -

SUBJECTS
Strategy Other Treatments After Cetuximab Carboplatin Clinical Study

CI03 -
CI0401 -  ..
CI0402 - Strategy Other Treatments After Cetuximab Carboplatin Clinical Study
CI0403 - Other Treatments after Cetuximab Carboplatin Clinical Study
CI0404 - Treatments Millie Qualifies for Other UCSF Clinical Trial Studies
CI0405 - UCSF Other Treatments Clinical Study Drug Trials May Help Millie
CI0406 -
CI0407 - Follow up ref SDS B0 P256.
CI0408 -
CI0409 - Doctor Rugo explained strategy to extend patient quality of life by
CI0410 - switching to other drugs and medications, when cancer progresses.
CI0412 -  ..
CI0413 - This aligns with planning on 070105 at Kaiser. ref SDS B0 P256
CI0415 -  ..
CI0416 - At that time on 070105, Kaiser could not find new treatments for
CI0417 - Millie's triple negative status.  Millie requested Kaiser perform due
CI0418 - diligence review of UCSF clinical study proposals.  ref SDS B0 1R5J
CI0419 - Kaiser then prescribed the cetuximab Carboplatin clinical study as the
CI0420 - best course of treatment for Millie, because triple negative status is
CI0421 - a qualifying asset. ref SDS B0 PK7L
CI0423 -  ..
CI0424 - Progression of disease monitored by examination and testing...
CI0425 -
CI0426 -        1.  Examination taking measurements and photographs of IBC
CI0427 -            inflammation areas.
CI0428 -
CI0429 -        2.  Cancer marker CA 15-3 blood testing every 4 weeks to start
CI0430 -            a new cycle.
CI0432 -             ..
CI0433 -        3.  CT scan tests every 8 weeks.
CI0435 -  ..
CI0436 - Doctor Rugo further advised during discussion today on strategy and
CI0437 - planning that, in the event cancer progresses during treatment with
CI0438 - cetuximab and Carboplatin, Millie qualifies for treatment with other
CI0439 - chemotherapy drugs in clinical study at UCSF, noted by Doctor Benz in
CI0440 - a letter dated 060821, and reviewed at Kaiser on 060929. ref SDS 90
CI0441 - UI9K  This was discussed again at Kaiser on 061208, ref SDS A3 P256,
CI0442 - leading to referral to UCSF on 061230. ref SDS A7 PN5X
CI0444 -  ..
CI0445 - One example is Avastin with abraxane, also cited in the doctor's
CI0446 - letter to Kaiser on 061230. ref SDS A7 PO3Q
CI0447 -
CI0448 -        [On 080712 Millie asks about other treatments after labs at
CI0449 -        Kaiser report CA 15-3 142, ref SDS F9 K15P, even though test
CI0450 -        sample may have been hemolyzed, ref SDS F8 05YW, and this
CI0451 -        affects results, reported on 080708. ref SDS F8 L74K
CI0453 -  ..
CI0454 - The doctor seemed to indicate today that Millie's pulmonary embolism
CI0455 - in 2004, may not have been caused by Avastin (bevacizumab), but rather
CI0456 - was more related to family genetics.  There was further discussion
CI0457 - that the Avastin abraxane treatment could be designed to arrest growth
CI0458 - of disease in Millie's case without increased risks of blood clots and
CI0459 - heart damage.  This analysis relates to comments at Kaiser on 041104.
CI0460 - ref SDS 36 RZ4I
CI0462 -  ..
CI0463 - Correlations between starting treatment with Avastin on 040420, and
CI0464 - Millie's symptoms of pulmonary embolism starting on 040517, and
CI0465 - continuing until treatment was ended with Avastin, reported on 041230,
CI0466 - shown in case study on 060722, ref SDS 78 6G6O, and was further
CI0467 - supported by CT test on 041218 that reported no visualization of
CI0468 - pulmonary embolism, as reviewed on 041230. ref SDS 39 PW3K
CI0470 -  ..
CI0471 - Doctor Rugo discussed strategy to use CT tests for monitoring Millie's
CI0472 - risk for pulmonary embolism lung disease, which is compounded by Cor
CI0473 - Pulmonale (enlarged right ventricle) heart disease.  Both are also
CI0474 - possible side effects of cetuximab treatments, presenting a "wicked
CI0475 - problem," disucssed further below. ref SDS 0 MO7K
CI0476 -
CI0477 -
CI0478 -
CI0479 -
CI0480 -
CI05 -

SUBJECTS
Schedule Treatment Cetuximab 070201 Start Clinical Study Drug Trial

CL03 -
CL0401 -  ..
CL0402 - Schedule Treatment Start Cetuximab Carboplatin 070201
CL0403 - Cetuximab UCSF Clinical Study Treatment Begins 070201
CL0404 - UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
CL0405 -
CL0406 - Follow up ref SDS B0 N96O, ref SDS A3 N96O.
CL0407 -
CL0408 - The doctor proposed starting treatment as soon as possible in order to
CL0409 - recover from severe progression of IBC since Millie's last treatment
CL0410 - at Kaiser 2 months ago on 061201.  Progression of disease increased
CL0411 - the past 4 weeks because treatment was delayed waiting for referral
CL0412 - coordination with Kaiser, reported by case study in another record
CL0413 - today. ref SDS C5 RM4G
CL0415 -  ..
CL0416 - Millie cannot get treatment today, because delay performing referral
CL0417 - coordination with Kaiser makes test diagnostics required for standard
CL0418 - of care and the clinical trial, and previously performed to start
CL0419 - treatment on 070119, ref SDS B7 AS96, are now outdated.  As a result,
CL0420 - Millie needs new tests before getting treatment.
CL0422 -  ..
CL0423 - The doctor schedule the first treatment for 070201.
CL0425 -  ..
CL0426 - UCSF will coordinate with Kaiser to perform CT testing so that Millie
CL0427 - can start treatment on 070201, which will enable Doctor Rugo to
CL0428 - supervise the work, per above. ref SDS 0 PF3O
CL0430 -  ..
CL0431 - Meetings and treatments will continue on Thursdays, so the next
CL0432 - meeting at Kaiser will be on 070208.
CL0433 -
CL0434 -        [On 070201 initial order for treatment with cetuximab is for 8
CL0435 -        weeks. ref SDS C9 5564
CL0436 -
CL0437 -
CL0438 -
CL0439 -
CL0440 -
CL05 -

SUBJECTS
Pulmonary Emboli Blood Clots Lungs Enlarged Right Ventricle Heart Di

CR03 -
CR0401 -  ..
CR0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
CR0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
CR0404 - Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
CR0405 -
CR0406 - Follow up ref SDS B0 CV5L, ref SDS A3 CV5L.
CR0407 -
CR0408 - Background on pulmonary embolism recurrence is reported in the record
CR0409 - for the meeting on 061020. ref SDS 94 CV5L  The record was updated on
CR0410 - 061201 showing symptoms of chronic fatigue, cough, shortness of
CR0411 - breath, clearing of throat, which continue under a Coumadin regimen.
CR0412 - ref SDS A0 CV5L  Treatment with Procrit for anemia was ended when
CR0413 - hemoglobin blood count increased to the normal range, yet symptoms of
CR0414 - pulmonary embolism continued. ref SDS A0 2P9F
CR0416 -  ..
CR0417 - A factor driving further inquiry is failure of pulmonary embolism to
CR0418 - recover after months of treatment beginning on 061002, which contrasts
CR0419 - sharply with prior experience in 2004.  Previously, Millie recovered
CR0420 - former energy and relief from symptoms within a few months after
CR0421 - starting treatment on 041104, as reported on 041230. ref SDS 39 RZ4I
CR0423 -  ..
CR0424 - At that time, a follow up CT test on 041217 reported findings reviewed
CR0425 - on 041230, that stated in part...
CR0426 -
CR0427 -              Previous noted right pulmonary arterial emboli are no
CR0428 -              longer visiualized. ref SDS 39 PW3K
CR0430 -  ..
CR0431 - Since Millie relapsed after this finding, reported on 061012,
CR0432 - ref SDS 92 294Q, and since relapse carries a high risk of death for
CR0433 - pulmonary embolism, reported on 060722, ref SDS 78 BI5J, increased
CR0434 - scrutiny is required to manage elevated risk of further pulmonary
CR0435 - embolism.
CR0437 -  ..
CR0438 - The doctor plans vigorous testing to monitor Millie's reaction from
CR0439 - treatment with cetuximab and carboplatin in the clinical study that
CR0440 - could complicate and compound preconditions of pulmonary embolisma and
CR0441 - Cor Pulmonale (enlarged right ventricle).
CR0443 -  ..
CR0444 - Doctor Rugo advised today that fatigue, shortness of breath, and
CR0445 - weakness that occur from Millie's preconditions of pulmonary embolism
CR0446 - and heart disorders, can be compounded by treatment with cetuximab, as
CR0447 - listed in Consent documents for the clinical study received from UCSF
CR0448 - on 070116. ref SDS B3 I75I, The Consent documents also cite
CR0449 - interstitial lung disease (ILD) that results in inflammation, scarring
CR0450 - and hardening of the lungs.  Interstitial lung disease has been
CR0451 - reported in fewer than 1% of patients treated with cetuximab.
CR0452 - Patients are directed to notify the doctor immediately if shortness of
CR0453 - breath occurs while receiving cetuximab. ref SDS B3 0256
CR0455 -  ..
CR0456 - This presents a "wicked problem" distinguishing between expected side
CR0457 - effects of cancer treatment, which are not lethal and eventually
CR0458 - dissipate after treatment ends, reported on 030606, ref SDS 18 RY5J,
CR0459 - from rising symptoms of pulmonary embolism which can turn lethal
CR0460 - quickly, previously reviewed on 060722. ref SDS 78 346F
CR0462 -  ..
CR0463 - Today, the doctor carefully reviewed patient history to distinguish
CR0464 - symptoms of lung disease, pulmonary embolism, and heart disease,
CR0465 - enlarged right ventricle, discussed below, ref SDS 0 VJ4J, from side
CR0466 - effects of treatment with cetuximab that could complicate and compound
CR0467 - Millie's preconditions.
CR0469 -  ..
CR0470 - Case study on 060722 shows patient history of pulmonary embolism
CR0471 - symptoms. ref SDS 78 ZV41
CR0473 -  ..
CR0474 - Millie began having shortness of breath, fatigue and weakness in late
CR0475 - August associated with normal exertion walking up stairs at home, at
CR0476 - BART, and walking to her office at 2 Embacadero Center in San
CR0477 - Francisco.  On 060914 she fell at the BART station. ref SDS 87 ZQ5I
CR0478 - At that time, attention focused on her swelled left hand and arm,
CR0479 - which eventually cascaded into cellulitus that landed Millie in the
CR0480 - hospital for a week beginning on 061027. ref SDS 96 V77F  During the
CR0481 - meeting on 060929, the doctor ordered a CT test for pulmonary embolism
CR0482 - to investigate rising symptoms. ref SDS 89 B56N  The test was
CR0483 - expedited and performed the next day on 060930.  Two days later, on
CR0484 - 061002 the doctor reported findings of pulmonary embolism recurrence.
CR0485 - ref SDS 91 MI5I  The doctor ordered treatments resumed, which were
CR0486 - previously ended on 051007. ref SDS 60 XN7K  Test report reviewed on
CR0487 - 061012 showed new findings of enlarged right ventricle, discussed
CR0488 - below. ref SDS 0 VJ4J
CR0490 -  ..
CR0491 - Side effects of cetuximab that make patients tired and weak, can be
CR0492 - distinguished from symptoms of pulmonary embolism by applying the
CR0493 - practice in 2004 using CT tests to determine if conditions reported on
CR0494 - 060930 have improved, stabalized, or worsened.  If conditions are
CR0495 - worse or stable relative to conditions on 060930, this points to
CR0496 - symptoms of continuing pulmonary embolism.  If comparison shows
CR0497 - pulmonary conditions have improved or are no longer present, as
CR0498 - occurred previusly in 2004, per above, ref SDS 0 GX60, then low
CR0499 - energy, tiredness, and weakness can be reasonably attributed to side
CR0500 - effects of cetuximab treatments.
CR0502 -  ..
CR0503 - Since the most recent image test on 061227 was a combination PET/CT
CR0504 - test, which does not support analysis of pulmonary embolism, Kaiser
CR0505 - was unable to make comparison with the test on 060930 with respect to
CR0506 - pulmonary embolism, as shown in record on 070102 that reviewed the
CR0507 - recent report. ref SDS A9 AK9H
CR0509 -  ..
CR0510 - The doctor asked Millie how she is feeling today?
CR0512 -  ..
CR0513 - Millie's letter to Kaiser on 061227 reported continuing symptoms of
CR0514 - pulmonary embolism: tired, weak, heavy chest, shortness of breath with
CR0515 - routine effort. ref SDS A5 B987
CR0517 -  ..
CR0518 - Millie reported today that energy and strength seem improved over the
CR0519 - past few weeks.  She is starting to feel like getting back in the gym
CR0520 - to resume regular exercise, as discussed with the primary care
CR0521 - physician at Kaiser on 061208. ref SDS A3 HZ39
CR0523 -  ..
CR0524 - The doctor indicated that feeling higher energy and strength aligns
CR0525 - with ending Taxotere and capecitabine chemotherapy treatments 2 months
CR0526 - ago on 061201, ref SDS 99 407N, particularly in light of reports on
CR0527 - 050516 that treatment with Taxotere and capecitabine (Xeloda) was
CR0528 - extremely debilitating. ref SDS 49 AQ6G  This suggests conditions of
CR0529 - fatigue, weakness, heavy chest, and shortness of breath were mostly
CR0530 - attributed to accumulating side effects of chemotherapy, discussed by
CR0531 - the primary care physician on 030606. ref SDS 18 O44J
CR0533 -  ..
CR0534 - Case study on 060722 shows Millie's patient history requires a special
CR0535 - form of test using thin slice spiral CT technology to discover
CR0536 - pulmonary embolism and enlarged right ventricle.
CR0538 -  ..
CR0539 - UCSF will ask Kaiser to perform CT tests to evaluate progression of
CR0540 - lung and heart disorders by comparing with past findings, as specified
CR0541 - by the primary care physician at Kaiser on 061208, ref SDS B0 Q93H,
CR0542 - and to follow prior practice at Kaiser reported on 041230 developing
CR0543 - test results with affirmative findings that former signs of pulmonary
CR0544 - embolism are "no longer visible" in the CT test scan files, per above.
CR0545 - ref SDS 0 RS9O
CR0547 -  ..
CR0548 - Jackie will coordinate with Kaiser on ordering the correct test, per
CR0549 - above. ref SDS 0 M84R
CR0550 -
CR0551 -     [On 070131 technician warns about internal bleeding from needle
CR0552 -     penetration for blood draws; need plan to minimize using needles,
CR0553 -     use Millie's port to reduce risk of bleeding while on Coumadin
CR0554 -     (warfarin) for pulmonary embolism. ref SDS C8 E87I
CR0556 -      ..
CR0557 -     [On 070131 doctor consults with surgeon and decides Millie's
CR0558 -     treatment with Coumadin for pulmonary embolism presents elevated
CR0559 -     risk of bleeding (hemoraging); decides not to do biopsies.
CR0560 -     ref SDS C8 6E3J
CR0562 -      ..
CR0563 -     [On 070202 meeting with primary care physician at Kaiser disclosed
CR0564 -     that CT test for pulmonary embolism was not peformed on 070131;
CR0565 -     the doctor indicated this should be corrected for reasons
CR0566 -     discussed with Doctor Rugo at UCSF today on 070130, ref SDS 0
CR0567 -     915J, and requested a months notice from UCSF to order the next CT
CR0568 -     test required by the cetuximab protocol so that the correct order
CR0569 -     can be placed to test for pulmonary embolism and enlarged right
CR0570 -     ventricle. ref SDS D0 M15I
CR0572 -      ..
CR0573 -     [On 070204 UCSF notified no initial side effects of treatment,
CR0574 -     energy has increased, Millie worked out in the gym 2 days in a
CR0575 -     row, and for the first time in 6 months; planning for CT test to
CR0576 -     evaluate pulmonary embolism. ref SDS D1 JJ7O
CR0578 -      ..
CR0579 -     [On 070218 Millie experienced further increase in energy, playing
CR0580 -     tennis for several days, and for the first time in 5 years.
CR0581 -     ref SDS D7 N05H
CR0582 -
CR0583 -
CR0584 -
CR0585 -
CR0586 -
CR0587 -
CR06 -

SUBJECTS
Examination Stethoscope No Findings Enlarged Right Ventricle Heart S

CY03 -
CY0401 -  ..
CY0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
CY0403 -
CY0404 - Follow up ref SDS B0 Q35O, ref SDS A3 Q35O.
CY0405 -
CY0406 - The doctor examined Millie with a stethoscope today.  This included
CY0407 - multiple locations on her back and on the chest.  There were no
CY0408 - findings of cardio pulmonary issues from clinical examination.
CY0410 -  ..
CY0411 - UCSF did not comment today on SaO2 99% diagnostic for oxygenated
CY0412 - blood, which as been cited at Kasier to indicate there is no alarm of
CY0413 - danger, shown by the report on 061208, ref SDS B0 1E5G, that Millie is
CY0414 - not suffering from loss of cardio-pulmonary functioning due to
CY0415 - pulmonary embolism, including enlarged left ventricle.
CY0416 -
CY0417 -
CY0418 -
CY0419 -
CY0420 -
CY05 -

SUBJECTS
Enlarged Right Ventricle Heart Disorder Cor Pulmonale Examples Sympt

D403 -
D40401 -  ..
D40402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
D40403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
D40404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
D40405 -
D40406 - Follow up ref SDS B0 VJ4J, ref SDS A3 VJ4J.
D40407 -
D40408 - Background is reported on 061110, ref SDS 97 VJ4J  Severity of
D40409 - enlarged right ventricle was discussed on 061020. ref SDS 94 VJ4J
D40410 - During the meeting at Kaiser on 061208, Millie requested examination
D40411 - by a heart specialist.  The primary care physician indicated
D40412 - diagnostics are not severe enough yet for referral to cardiologist.
D40413 - ref SDS A3 HZ39, citing vitals Sa O2 99% test diagnostic, ref SDS A3
D40414 - KB5L, and examination with a stethoscope, ref SDS A3 Q35O, indicates
D40415 - strong cardio pulmonary functioning, rather than diminished capacity
D40416 - that signals severe impact of enlarged right ventricle. ref SDS A3
D40417 - VV4H
D40419 -  ..
D40420 - At that time, on 061208 the doctor modified the order for the PET scan
D40421 - test specifying that the analyst compare prior tests on 041103, and on
D40422 - 060930, with the new test scheduled on 061227 to report severity of
D40423 - enlarged right ventricle. ref SDS A3 Y77J
D40425 -  ..
D40426 - On 061218 Millie again requested examination by heart specialist for
D40427 - clearance to resume exercise in the gym and restore fitness.
D40428 - ref SDS A4 HX6V  The primary care physician at Kaiser responded that
D40429 - heart disorder of enlarged right ventricle diagnosed in the CT test on
D40430 - 060929, and reviewed on 061012, ref SDS 92 7E5L, most likely is not
D40431 - clinically relevant because symptoms Cor Pulmonale take years to
D40432 - become life threatening. ref SDS A4 XQ5H  On 061227 Millie requested
D40433 - examination by a heart specialist to backup up first impression that
D40434 - Cor Pulmonale requires no treatment beyond Coumadin at this time.
D40435 - Millie reported continuing symptoms chronic fatigue, shortness of
D40436 - breath, and heavy chest. ref SDS A5 645I
D40438 -  ..
D40439 - On 070102 review of the report for the CT test on 061227 showed that
D40440 - Kaiser did not perform the doctor's order on 061208 to compare with
D40441 - prior tests and provide trend analysis on pulmonary embolism and
D40442 - enlarged right ventricle. ref SDS A9 AK9H
D40444 -  ..
D40445 - During the follow up meeting at Kaiser on 070105, the primary care
D40446 - physician advised that Millie's cardio pulmonary system may be so
D40447 - severely damaged that former active life of regular exercise cannot be
D40448 - restored.
D40449 -
D40450 -    [On 070204 Kaiser and UCSF notified no initial side effects of 1st
D40451 -    treatment with cetuximab; energy has increased, Millie worked out
D40452 -    in the gym 2 days in a row, and for the first time in 6 months;
D40453 -    planning for CT test to evaluate pulmonary embolism. ref SDS D1
D40454 -    JJ7O
D40456 -  ..
D40457 - Today, the doctor asked for examples of symptoms.
D40459 -  ..
D40460 - Patient history on 061110 presents symptoms, ref SDS 97 VD4G, which
D40461 - are similar to pulmonary embolism, discussed above that are further
D40462 - similar to side effects of treatment with cetuximab, per above.
D40463 - ref SDS 0 MO7K
D40465 -  ..
D40466 - As noted, Millie's energy seems to be edging up in the past few weeks,
D40467 - which reflect ending chemotherapy on 061201, and therefore indicates
D40468 - possible recovery from enlarge right ventricle, also, noted above.
D40469 - ref SDS 0 RT6I
D40471 -  ..
D40472 - Besides doing a follow up CT test, discussed above, ref SDS 0 R16N,
D40473 - the doctor seemed to suggest today examination by a cardiologist and
D40474 - perhaps a treadmill test may be helpful to better understand this
D40475 - issue.
D40476 -
D40477 -     [On 070202 meeting with primary care physician, there was no
D40478 -     report of coordination from UCSF on this issue. ref SDS D0 UN9F
D40480 -      ..
D40481 -     [On 070204 Kaiser and UCSF notified no initial side effects of 1st
D40482 -     treatment with cetuximab; energy has increased, Millie worked out
D40483 -     in the gym 2 days in a row, and for the first time in 6 months;
D40484 -     planning for CT test to evaluate pulmonary embolism. ref SDS D1
D40485 -     JJ7O
D40487 -      ..
D40488 -     [On 070218 Millie experienced further increase in energy, playing
D40489 -     tennis for several days, and for the first time in 5 years.
D40490 -     ref SDS D7 N05H
D40491 -
D40492 -
D40493 -
D40494 -
D40495 -
D40496 -
D40497 -
D405 -