CONTACTS
SUBJECTS
Meeting Doctor Examination 12th Review Start Treatment #12 After Mas
1103 -
1103 - ..
1104 - Summary/Objective
1105 -
110501 - Follow up ref SDS L7 0000. ref SDS K1 0000.
110502 -
110503 - Faced with conflicting evidence, the doctor made a difficult, decision
110504 - for treatment to continue unchanged. ref SDS 0 T85J It was later
110505 - validated by diagnostics which had been generated for decision
110506 - support, but could not be obtained today. ref SDS 0 GJ5M A week
110507 - later, on 070307 Millie's CA 15-3 cancer marker dropped to 36, the
110508 - lowest in over a year, ref SDS 0 087J, suggesting dramatic improvement
110509 - with cetuximab treatment. Over the past month during the 1st cycle of
110510 - treatment with cetuximab on the clinical study, IBC has seemed to
110511 - expand, raising concern today of failed treatment and peril.
110512 - Examination today confirmed expanding disease. ref SDS 0 4140 The
110513 - doctor and her team were, also, impressed by possible declining
110514 - intensity of IBC rash, indicating response to treatment. ref SDS 0
110515 - M68J Doctor Rugo considered changing the treatment protocol to
110516 - increase effectiveness by adding carboplatin, allowed within the study
110517 - protocol. ref SDS 0 AE3I Without CA 15-3 diagnostics, there was
110518 - uncertainty about measurable disease, ref SDS 0 M652, i.e., whether
110519 - expansion of disease was already underway before starting treatment on
110520 - 070201, and whether treament has brought improvement or worsening IBC.
110521 - ref SDS 0 NY7N Another problem was unexpected drop of ANC blood
110522 - counts below the level of safety for treatment. ref SDS 0 T85J These
110523 - conflicts were resolved today by approving treatment for one week, and
110524 - the doctor scheduling another meeting next week to further evaluate
110525 - ANC and CA 15-3. ref SDS 0 Q57O The doctor wants also another CT test
110526 - to evaluate progress starting the next cycle on 070329. ref SDS 0 UR9J
110527 - Millie has tolerated side effects of treatment well. Energy has been
110528 - elevated during this period compared to the past 6 months. However,
110529 - last week, after the 4th treatment with cetuximab, Millie has been
110530 - tired, possibly aligning with declining ANC blood counts. ref SDS 0
110531 - TQ6L Facial dryness is a new side effect. UCSF prescribed Curel
110532 - lotion. ref SDS 0 5V73 UCSF referral has developed patient care
110533 - coordination issues. ref SDS 0 RM4G Since the meeting was behind
110534 - schedule today, there was not enough time to review coordination
110535 - planning. ref SDS 0 O65N UCSF asked the patient to coordinate with
110536 - Kaiser. ref SDS 0 O67N
110538 - ..
110539 - [On 070306 UCSF called to schedule interim meeting with Doctor
110540 - Rugo on 070308 1000 to assess changing treatments based on ANC and
110541 - CA 15-3 blood test results. ref SDS N7 7Y5N
110543 - ..
110544 - [On 070306 Millie requested results of CA 15-3 tests on 070208 and
110545 - 070215 to support follow up meeting at UCSF on 070208. ref SDS N7
110546 - PY6N
110548 - ..
110549 - [On 070307 UCSF reports CA 15-3 36 for test today on 070301, which
110550 - is lowest level in 12 months, ref SDS N8 U85L; Kaiser submitted CA
110551 - 15-3 results for tests in February, showing consistent trend down
110552 - that align with impression from visual examination that intensity
110553 - of IBC rash is subsiding. ref SDS N8 IE5O
110555 - ..
110556 - [On 070308 since CA 15-3 36 indicates cetuxinab treatment is
110557 - effective, and since blood test showed ANC increased to the normal
110558 - range for cetuximab treatment, the doctor cancelled the meeting to
110559 - evaluate changing treatment. ref SDS N9 407N
110561 - ..
110562 - [On 070315 progress report submitted to primary care physician at
110563 - Kaiser on recovering from IBC 3rd relapse with treatment that
110564 - started 070201 under a clinical study for cetuximab at UCSF.
110565 - ref SDS O2 VP5N
110566 -
110567 -
110568 -
110569 -
110571 - ..
1106 -
1107 -
1108 - Progress
1109 -
110901 - Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
110902 -
110903 - Follow up ref SDS M2 SM6M, ref SDS L7 SM6M.
110905 - ..
110906 - Doctor Rugo met with Millie today at UCSF starting the 2nd cycle and
110907 - 5th treatment of IBC with cetuximab, as planned in the launch meeting
110908 - on 070130. ref SDS L7 WM7G This is a referral from Kaiser for a
110909 - clinical study drug trial ordered by the primary care physician on
110910 - 070105. ref SDS K1 PK68 It is the 12th physician meeting to start the
110911 - 9th chemotherapy cycle, since treatments began on 060711, ref SDS D6
110912 - SM6M, for the 3rd relapse of IBC. ref SDS D6 8Y8I This is the 2nd
110913 - meeting with Doctor Rugo, and follows meeting with the primary care
110914 - physician at Kaiser on 070202. ref SDS M2 0001 UCSF had a hectic
110915 - schedule today. The meeting scheduled for 1330 started at 1415; the
110916 - doctor reviewed findings at 1450, discussed strategy, and determined
110917 - treatment.
110919 - ..
110920 - Complete listing of treatments for 3rd relapse is reported in the
110921 - record of treatment following the meeting today. ref SDS N3 SG8I
110923 - ..
110924 - The agenda for the meeting at UCSF on 070130 provides a structure for
110925 - organizing results of the meeting.
110926 -
110927 - 1. Coordination Plan.............................. ref SDS 0 RM4G
110928 - 2. CA 15-3 3 tests pending........................ ref SDS 0 GJ5M
110929 - 3. Breast exam IBC spreading...................... ref SDS 0 025H
110930 - 4. Measurable disease pictures tape measure....... ref SDS 0 M652
110931 - 5. Side effects facial dryness, rash, tired....... ref SDS 0 TQ6L
110932 - 6. CT test Jackie coordinating schedule........... ref SDS 0 EY5O
110933 - 7. Patient work up develop strategy............... ref SDS 0 K36G
110934 - 8. Treatment plan weekly clinical trial........... ref SDS 0 PF3O
110935 - 9. Pulmonary emboli severity right ventricle...... ref SDS 0 CV5L
110937 - ..
110938 - Scheduled next meeting for Thursday 070329. ref SDS 0 N96O
110940 - ..
110941 - The doctor was assisted by two aides...
110942 -
110943 - 1. Brigid, Nurse Practitioner
110944 - 2. Jackie, Clinical Research Coordinator, coordinating
110945 -
110946 -
110947 -
110948 -
110949 -
1110 -
SUBJECTS
Complex Patient History 39 Issues Overwhelms Span of Attention Drive
1503 -
150401 - ..
150402 - Complex Patient History Knowledge Management Dilemma Issues Grow 40
150403 -
150404 - Follow up ref SDS L7 LU3J, ref SDS K1 LU3J.
150405 -
150406 - Sampling of issues patient history diagnosis and treatment...
150407 -
150408 - 1. CA 15-3 monitors advance of cancer response to treatment
150409 - 2. Lymphedema complicated by mastectomy surgery
150410 - 3. Broken finger from minor fall complicates lymphedema
150411 - 4. Esophagitis reflux digestion issues
150412 - 5. Immune system chemotherapy increases risk of infection
150413 - Chemotherapy increase risk of infection
150414 - 6. Cat bites increase risk of infection complicates lymphedema
150415 - 7. Pneumonia chemotherapy increases risk of infection
150416 - 8. Metastatic cancer increases risk pulmonary embolism
150417 - 9. Lymphadenopathy left axilla local regional metastasis
150418 - 10. Lymphadenopathy right axilla distant metastasis
150419 - 11. Lymphadenopathy left supraclavicular diagnose metastatic cancer
150420 - 12. Breast cancer secondary IBC 3rd relapse left breast
150421 - 13. Cancer mutates slow response chemotherapy treatment
150422 - 14. Mastectomy surgery impact on treatment IBC relapse
150423 - 15. Blood vessels removed mastectomy slow chemotherapy treatments
150424 - 16. Treatment options, strategy, planning, schedule
150425 - 17. Drug trials increase declining pool chemotherapy agents
150426 - 18. UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
150427 - 19. Pulmonary embolism blood clots in lungs
150428 - 20. INR weekly adjustments Coumadin treatment blood clots
150429 - 21. Enlarged right ventricle heart problem core pulmonale
150430 - 22. Dizziness symptom enlarged right ventricle cor pulmonale
150431 - 23. Fatigue shortness breath side effect chemotherapy loss fitness
150432 - 24. Fatigue shortness breath symptom pulmonary embolism
150433 - 25. Shortness breath fatigue dizzy symptoms pulmonary embolism
150434 - 26. Coagulapathy hypercoagulable state work up genetic risks
150435 - 27. Testing resolution of errors (see Benz 2nd opinion 060821)
150436 - 28. Testing distant metastatic disease
150437 - 29. Testing pulmonary emoblism and heart disease
150438 - 30. Communication hectic schedule not enough time to manage details
150439 - 31. Emotional stress and well being
150440 - 32. Cellulitis inflammation temperature 102.6 on chemotherapy
150441 - 33. Urinary tract bladder infection
150442 - 34. IBC rash spreads to right breast
150443 - 35. Right breast rash may be "ring" infection, not cancer
150444 - 36. Lung cancer seems to be diagnosed in the Medical Chart
150445 - 37. IBC rash spreads to stomach and toward back
150446 - 38. IBC rash spreads to left arm
150447 - 39. Facial dryness
150448 - 40. Right arm evidence light red rash, may be IBC spreading
150449 -
150450 -
150451 -
150452 -
150453 -
1505 -
SUBJECTS
Vitals Submitted by Doctor UCSF Blood Pressure Pulse High Demonstrat
1703 -
170401 - ..
170402 - Vitals Show Stable Medical Condition
170403 -
170404 - Follow up ref SDS L7 KB5L, ref SDS K1 KB5L.
170406 - ..
170407 - Bld Prssr Pulse Temp Weight SaO2
170408 - ..
170409 - * 070301 1330............ [see treatment record, ref SDS N3 AW4L]
170410 - * 070130 1300............ 140 83 87 98
170411 - 070105 1040............
170412 - 061208 1226............ 152 90 76 97.8 147 99%
170413 - 061201 1430............ 123 76 76 97.5
170414 - 061110................. 136 83 73 97.0 150 98%
170415 - 061020 1534............ 140 79 67 99.8 151 97
170416 - 060929 1452............ 141 78 66 98.3
170417 - 060908 1335............ 139 79 73 98.1
170418 - 060814 1610............ 139 80 59 98.2
170419 - * 060808.................
170420 - 060711................. 172 87 54 97.5 147
170421 - 060623................. 141 87 71 98.0 147 99%
170422 - 060428................. 129 73 80 99.4 149 99%
170423 - 060217................. 153 81 61 98.6 150 99%
170425 - ..
170426 - * For some reason, vitals not submitted.
170428 - ..
170429 - High blood pressure reflects pressure on patient about effectivenss of
170430 - new treatment and arrangements between UCSF and Kaiser for timely
170431 - care, discussed below. ref SDS L7 Y642
170432 -
170433 -
170434 -
1705 -
SUBJECTS
Coordination Plan Communication UCSF Kaiser Collaboration Hectic Sch
4803 -
480401 - ..
480402 - Coordination Plan Divided Responsibilities Kaiser UCSF Referral
480403 - Collaboration Primary Care at Kaiser with UCSF Clinical Study Cetuximab
480404 -
480405 - Follow up ref SDS L7 RM4G.
480406 -
480407 - Treatment by UCSF is on referral from Kaiser creating divided
480408 - responsibilities, discussed by the primary care physician at Kaiser
480409 - and Doctor Rugo in correspondence on 061230. ref SDS J8 3X6K Case
480410 - study on 070130 reviews referral work during January that shows
480411 - requirements for coordination planning to strengthen care. ref SDS L7
480412 - 4T5N
480414 - ..
480415 - On 070201 Jackie, UCSF Clinical Research Coordinator, submitted a
480416 - telephone number for patients to call for emergencies, and questions
480417 - on the clinical study. ref SDS M1 407N The record on 070202 meeting
480418 - at Kaiser the next day with the primary care physician reviewed need
480419 - for written coordination plan between Kaiser and UCSF with respect to
480420 - medication prescriptions and emergencies. ref SDS M2 2O5H
480422 - ..
480423 - On 070216 Jackie submitted a letter confirming instructions for
480424 - patients to call UCSF for emergencies. ref SDS M8 AM4N On 070217
480425 - Millie requested clarification of emergency care procedures, and
480426 - presented advantages of emergency treatment at Kaiser in this case.
480427 - ref SDS M9 AM4N
480429 - ..
480430 - A letter to Kaiser on 070218 cites confusion coordinating Kaiser and
480431 - UCSF on medication prescriptions and emergencies. ref SDS M7 VW6U
480432 - Similarly, review of the blood test today, shows numerous differences
480433 - between Kaiser and UCSF that require coordination to avoid medical
480434 - mistakes. ref SDS N3 HI6O Examples are INR analysis for prescribing
480435 - Coumadin to treat pulmonary embolism, ref SDS N3 SE6N, and ANC
480436 - diagnostics for approving cancer treatment. ref SDS N3 P560
480438 - ..
480439 - On 070222 Jackie discussed coordination planning to manage Millie's
480440 - care with responsibilities divided between Kaiser and UCSF.
480441 - ref SDS N1 VK5N Preliminary scope for coordination planning is
480442 - presented on 070222. ref SDS N1 KL5G
480444 - ..
480445 - Millie's letter yesterday on 070228 requested submission of a draft
480446 - coordination plan for discussion during the meeting today. ref SDS N2
480447 - LQ6R An example of current coordination is Millie facilitating
480448 - coordination on getting CA 15-3 reports for blood tests on 070208 and
480449 - 070215, also, cited in the letter on 070228. ref SDS N2 ED5H
480451 - ..
480452 - Today, the meeting started about an hour late, ref SDS 0 SM6M, so
480453 - there wasn't enough time to review coordination issues, except that
480454 - Jackie reported there wasn't enough time to coordinate with Kaiser to
480455 - get CA 15-3 diagnostics for the meeting today, per below. ref SDS 0
480456 - MP58
480458 - ..
480459 - Brigid said that some coordination has to be performed by USCF staff.
480460 - Examples are scheduling treatments and ordering tests. UCSF will
480461 - schedule the follow up blood test that Doctor Rugo wants for next week
480462 - to check ANC again, because ANC 1.23 in the test today is too low for
480463 - treatment, reported below, ref SDS 0 VF5M, and if this continues, then
480464 - remedial measures will be required, explained under strategy, also
480465 - below. ref SDS 0 T85J Brigid said the patient cannot order a blood
480466 - test, because this requires professional training and standing to
480467 - specify the scope and authorize the work.
480468 -
480469 - [On 070302 Millie confirmed understandings that UCSF ordered a
480470 - follow up blood test on 070308. ref SDS N4 EZ6P
480472 - ..
480473 - [On 070308 the blood test had not been ordered; the nurse
480474 - placed the order based on patient coordination relating
480475 - patient history showing requirement for follow up blood test
480476 - to evaluate ANC. ref SDS N9 JG4G
480478 - ..
480479 - [On 070315 chemotherapy treatment in the Infusion Clinic had
480480 - not been scheduled, ref SDS O3 1M6H; treatment delayed for
480481 - pharmacy to perpare drugs. ref SDS O3 4N5M
480483 - ..
480484 - Brigid advised that coordinating communications with referral care
480485 - providers takes a lot of time. UCSF practice relies on patients to
480486 - coordinate communications, diagnostics, planning, and analysis between
480487 - Kaiser and UCSF for comprehensive care. She related that many
480488 - patients hand carry documents between UCSF and the primary care
480489 - provider. Best practices for medical professionals to coordinate
480490 - complex patient history in this case, shown above, ref SDS 0 LU3J,
480491 - were not discussed today, due to limited time.
480492 -
480493 - [...below, Jackie asks Millie to coordinate with Kaiser to get
480494 - results on CA 15-3 for blood tests on 070208 and 070215.
480495 - ref SDS 0 2E5G
480497 - ..
480498 - [On 070307 case study on level of effort to coordinate
480499 - communications getting CA 15-3 diagnostics for blood tests
480500 - previously performed on 070208 and 070215. ref SDS N8 Q65K
480502 - ..
480503 - [On 070315 UCSF follows up requesting feedback on emotional toll
480504 - coping with everything flowing from having cancer. ref SDS O3 OR5K
480506 - ..
480507 - Brigid said an example of UCSF saving time and effort involving
480508 - patients in the coordination process is requesting Kaiser to schedule
480509 - the next CT test, discussed below, ref SDS 0 EY5O, and then follow up
480510 - to get feedback verifying a test is actually scheduled, and if not,
480511 - sending reminders in order to meet UCSF requirements. Avoiding
480512 - stressful coordination by asking others to verify accuracy of
480513 - performance aligns with research on 931130, and showing Drucker notes
480514 - that complexity increases stress, frustration, and delay that drives
480515 - people to give up on communication. ref SDS 1 3851
480516 -
480517 - [On 070307 case study on level of effort to coordinate
480518 - communications getting CT test ordered to meet requirements of the
480519 - clinical study. ref SDS N8 G56L
480521 - ..
480522 - [On 070309 Arlette advised that email for coordination of
480523 - work on Kaiser's referral to UCSF should go to the primary
480524 - care physician, which does not support efficient common
480525 - distribution, rather than through Arlette, ref SDS O0 VP73,
480526 - which provides both efficient distribution, and a backup
480527 - for reminding the doctor of critical action items,
480528 - illustrated on 070307. ref SDS N8 9Z9N
480530 - ..
480531 - [On 070510 Jackie coordinated with Kaiser to schedule the next CT
480532 - test, which Kaiser set for 070514. ref SDS O7 DT8I
480534 - ..
480535 - [On 070610 primary care physician advises channels of
480536 - communication now established with UCSF for referral case
480537 - management. ref SDS O8 GV9G
480538 -
480540 - ..
480541 - Communications Big Risk Feedback Accuracy Stressful Cognitive Overhead
480542 - Follow Up Feedback Resisted Avoid Stress Communications Biggest Risk
480543 - Vigilence Diligence Accuracy Continual Refining Emotionally Traumatic
480544 - Continual Improvement Continual Refinement of Accuracy Very Stressful
480545 -
480546 - Many factors increase tension in communication causing people to avoid
480547 - coordination. Errors are endemic from meaning drift, explained in
480548 - POIMS, ref OF 2 049O, and become ticking time bombs, cited in POIMS.
480549 - ref OF 2 8844 Accurate communication, like freedom, requires
480550 - continual vigilence. However, cognitive overhead for diligence
480551 - explained in NWO. ref OF 4 3077, is extremely stressful, causing
480552 - anger, frustration, accusation, and reprisals. Therefore,
480553 - coordination to close the loop on pending issues is avoided....
480554 -
480555 - 1. Calling entails stream-of-conscious conversation, which
480556 - must be transcribed to construct an object that controls
480557 - long term action, e.g., tomorrow, next week, next month.
480558 - People are busy, so 99% of calls are never transcribed,
480559 - which reduces management to guess and gossip, hunch and
480560 - hope that people will accurately remember complex
480561 - correlations, implications, and nuance. However, personal
480562 - memory is constantly buffetted by calls, meetings, and
480563 - other tasks that puts situational awareness under great
480564 - stress. Andy Grove at Intel explains that mental maps are
480565 - awfully forgiving of ambiguity, reviewed on 980307.
480566 - ref SDS 4 3668 When ambiguity manifests error, people
480567 - suffer pain, get mad, and lash out, pointing fingers in
480568 - accusation and blame because they cannot point to an
480569 - accurate record.
480570 -
480571 - [On 070329 poor communication, bumbling management
480572 - create worry, stress, and emotional trauma, ref SDS O6
480573 - II7H; compounds difficulty sleeping that reduces
480574 - recovery from cancer. ref SDS O6 MR99
480576 - ..
480577 - 2. Coordination brings accountability for results. People
480578 - fear and hate accountability, reviewed on 980405,
480579 - ref SDS 5 5065, especially for coordinating, since there is
480580 - no authority for performing the work, and there is high
480581 - visibility for bringing up unpleasant tasks which others
480582 - often seek to avoid.
480584 - ..
480585 - 3. Effective communication requires metrics using feedback
480586 - loops to authenticate and verify accuracy by checking
480587 - alignment with original sources, called out in ISO and
480588 - other management standards, reported on 950721. ref SDS 2
480589 - 1740 People are very concerned about accuracy involving
480590 - their personal interests, but get easily frustrated doing
480591 - follow up on feedback to verify accuracy for others.
480593 - ..
480594 - 4. People often hate feedback because verifying accuracy is a
480595 - risk management practice to prevent future mistakes by
480596 - managing a lot of very small details that seem like
480597 - unnecessary overkill, until someone gets killed. Sending
480598 - correspondence including email can seem intrusive to busy
480599 - people, who feel they do not have time to confirm
480600 - understandings either writing or reading correspondence,
480601 - because all of their time is consumed talking to people and
480602 - trying to find information on a computer. As a result,
480603 - very little of what is said between people and what is
480604 - entered into computers is ever verified, and much is
480605 - assumed because finding information on computers, in file
480606 - folders, and from memory is very hard. Without
480607 - verification of alignment meaning drift compounds over
480608 - time, which makes communication the biggest risk in
480609 - enterprise, as explained in POIMS. ref OF 2 049O
480610 -
480611 - [On 070309 Arlette reports her schedule has changed, and
480612 - she can no longer support coordination as done
480613 - previously. ref SDS O0 VP4P
480615 - ..
480616 - 5. Anger and frustration is often vented during communications
480617 - even, when the immediate exhange involves no grounds for
480618 - controversy. Follow up to verify accuracy may occur in a
480619 - context of proximity with anger or simmering anger from
480620 - others, totally apart from the instant communication. An
480621 - immediate exchange is merely the "straw that breaks the
480622 - camel's back," causing someone to explode in anger and lash
480623 - out. People then refuse to cooperate, ignore, or actively
480624 - disrupt to avenge perceived afronts or other grievances
480625 - which do not actually exist.
480627 - ..
480628 - 6. Desire to avoid controversy results in avoiding feedback to
480629 - verify accuracy, which then causes errors, conflict and
480630 - calamity, as set out in NWO. ref OF 4 2670 But since
480631 - mistakes from failed communication occur downstream in the
480632 - future, and usually impact others, there is no experience
480633 - gained to encourage and support feedback. Since people are
480634 - consumed with fixing problems caused by other people at an
480635 - earlier time, there is no awareness they are creating new
480636 - problems for others to fix at a later time.
480638 - ..
480639 - 7. Coordinating often entails reminding people to take action,
480640 - either by direct discussion, or forwarding correspondence.
480641 - Reminding, however, is sometimes resisted and resented by
480642 - perception that others are interferring in the work, even
480643 - though coordinating and follow up are critical to getting
480644 - things done correctly and on time. Since reprisals and
480645 - recriminations create controversey, people resent and
480646 - ignore requests for coordination, until an emergency occurs
480647 - that cannot be avoided.
480649 - ..
480650 - 8. Coordination reminding people to take action at a future
480651 - time often fails because people cannot manage action items
480652 - for planning work hours, days, weeks, and months in the
480653 - future. Providing multiple notices risks reprisals for
480654 - harrassment, or reprisals for failing to follow up because
480655 - the coordinator cannot manage action items. Sometimes
480656 - reprisals occur merely from a "kill the messenger" syndrome
480657 - when people are asked to do difficult tasks, and simply
480658 - strike out at the closest target. When there is a lot
480659 - going on, remembering critical details becomes harder for
480660 - everyone due to limited span of attention, reviewed on
480661 - 990303. ref SDS 6 HE4N
480663 - ..
480664 - This makes coordination a high risk task that is avoided in order to
480665 - avoid emotional trauma of controversy.
480666 -
480667 - [On 070329 poor communication, bumbling management
480668 - create worry, stress, and emotional trauma, ref SDS O6
480669 - II7H; compounds difficulty sleeping that reduces
480670 - recovery from cancer. ref SDS O6 MR99
480672 - ..
480673 - Another example of coordination avoided in this case was discussion
480674 - during the meeting that the report on the blood test today showing INR
480675 - 2.5, should be submitted to Gloria at the Kaiser Coagulation Control
480676 - Clinic in Martinez, CA, who manages Coumadin treatments for Millie's
480677 - pulmonary embolism. INR 2.5 indicates favorable and stable blood
480678 - conditions for several weeks in the middle of the normal range, and
480679 - therefore reduces requirements for near term INR testing and changing
480680 - treatment protocols. There wasn't enough time during the meeting to
480681 - verify this diagnostic on the computer, but everyone remembered seeing
480682 - 2.5 earlier in the day on their computer. Rather than UCSF submit the
480683 - record to Kaiser, there was discussion that the patient would call
480684 - Kaiser and verbally convey results of the blood test today, and that
480685 - Kaiser would rely on that form of communication to decide treatment
480686 - for pulmonary embolism.
480688 - ..
480689 - Subsequent review, indicates UCSF lists INR 2.5, as remembered in the
480690 - meeting; however, the normal range for INR is .9 to 1.2. Therefore,
480691 - 2.5 is more than double the specified norm, indicating immediate
480692 - adjustment is requird to Coumadin treatment for pulmonary embolism in
480693 - order to avoid hemorraging. ref SDS N3 SE6N
480695 - ..
480696 - This suggests that managing blood test results may be an important
480697 - part of a coordination plan for comprehensive care listed on 070222.
480698 - ref SDS N1 KL5G
480699 -
480700 - [...below, coordination on INR blood tests requires complex
480701 - notices due to delays and differences in test reporting standards.
480702 - ref SDS 0 4K42
480704 - ..
480705 - [On 070305 Millie requested that Gloria coordinate directly
480706 - with UCSF on interpreting the UCSF blood test report for
480707 - prescribing Coumadin to treat pulmonary embolism, and
480708 - reminded that UCSF has ordered another blood test on
480709 - 070308, so that INR can be tested again if needed.
480710 - ref SDS N5 3A6S
480712 - ..
480713 - [On 070305 Brigid clarified interpreting "normal" range for INR
480714 - blood test results to manage Coumadin treatments for pulmonary
480715 - embolism, and did not include Kaiser in the distribution, perhaps
480716 - relying on UCSF policy for patients to coordinate communcations.
480717 - ref SDS N5 2C7K
480719 - ..
480720 - [On 070306 Millie requests feedback from Gloria to verify accuracy
480721 - of understandings that Kaiser is satisfied with UCSF blood test on
480722 - INR for prescribing Coumadin to treat pulmonary embolism, and
480723 - advises current regimen will continue until further notice.
480724 - ref SDS N6 FJ9K
480726 - ..
480727 - [On 070510 Jackie coordinated with Kaiser to schedule the
480728 - next CT test, which Kaiser set for 070514. ref SDS O7 DT8I
480729 -
480730 -
480731 -
4808 -
SUBJECTS
CA 15-3 36 Falls Dramatically Consistently through February Cancer M
5903 -
590401 - ..
590402 - CA 15-3 Cancer Marker 36 Showing Significant Improvement
590403 -
590404 - Follow up ref SDS L7 087J, ref SDS K1 087J.
590405 -
590406 - Millie had a blood test at Kaiser on 070208 and another on 070215. A
590407 - week after the meeting today, on 070307 Kaiser advised in a letter
590408 - that these tests were 55 and 52. Also, on 070307 CA 15-3 dropped to
590409 - 36 for the blood test today,
590411 - ..
590412 - Test Date Date Received
590413 - 070301......... 36 H............. 070307, ref SDS N3 A16M
590414 - 070215......... 52 H............. 070307, ref SDS M6 ER5O
590415 - 070208......... 55 H............. 070307, ref SDS M6 ER5O
590416 - 070201.....cetuximab begins...... 070201, ref SDS M1 G68I
590417 - 070131......... 56 H............. 070202, ref SDS M2 087J
590418 - 070123......... 52 H............. 070202, ref SDS M2 087J
590419 - 070118......... 68 H............. 070123, ref SDS L1 GK5B
590420 - 070104......... 56 H............. 070110, ref SDS K3 087J
590421 - 061218......... 74 H............. 061227, ref SDS J6 6P9F
590422 - 061214......... 63 H............. 061227, ref SDS J6 6P9F
590423 - 061201....Pause treatments..... . 061201, ref SDS I9 GJ5M
590424 - 061130......... 67 H............. 061201, ref SDS I9 087J
590425 - 061116......... 66 H............. 061201, ref SDS I9 087J
590426 - 061110......... 56 H............. 061201, ref SDS I9 087J
590427 - 061109......... 61 H............. 061110, ref SDS I3 087J
590428 - 061026......... 57 H............. 061110, ref SDS I3 087J
590429 - 061019......... 56 H............. 061020, ref SDS H2 087J
590430 - 060928......... 51 H............. 060929, ref SDS G4 087J
590431 - 060907......... 68 H............. 060929, ref SDS G4 087J
590432 - 060813......... 73 H............. 060817, ref SDS F8 U24M
590433 - 060809......... 87 H............. 060810, ref SDS F6 2N5J
590434 - 060721..Taxotere capecitabine.... 060721, ref SDS E1 0001
590435 - 060708......... 71 H............. 060711, ref SDS D6 087J
590436 - 060616......... 63 H............. 060623, ref SDS D4 UQ5Q
590437 - 060522......... 59 H............. 060605, ref SDS C9 UQ5Q
590438 - 060501......... 49 H............. 060522, ref SDS C6 MC4F
590439 - 060421......... 44 H............. 060428, ref SDS B8 087J
590440 - 060330......... 40 H............. 060428, ref SDS B8 087J
590441 - 060303......... 36............... 060428, ref SDS B8 087J
590442 - 060210......... 33............... 060217, ref SDS A7 087J
590443 - 060109......... 34............... 060126, ref SDS A6 KV59
590444 - 051223......... 34............... 060106, ref SDS A5 087J
590445 - 051202......... 28............... 060106, ref SDS A5 087J
590446 - 051116......... 31............... 051121, ref SDS A3 087J
590447 - 051109......... 30............... 051121, ref SDS A3 087J
590448 - 051102......... 34............... 051121, ref SDS A3 087J
590449 - 051021..Mastectomy surgery....... 051021, ref SDS A0 0001
590450 - 050916...end treatment........... 050916, ref SDS 91 407N
590451 - 050909......... 45 H............. 051007, ref SDS 97 087J
590452 - 050826......... 45 H............. 050913, ref SDS 90 087J
590453 - 050819......... 45 H............. 050913, ref SDS 90 087J
590454 - 050812......... 39 .............. 050819, ref SDS 83 3K6L
590455 - 050729......... 45 H............. 050819, ref SDS 83 EA5G
590456 - 050708......... 46 H............. 050729, ref SDS 82 087J
590457 - 050701......... 37 .............. 050729, ref SDS 82 087J
590458 - 050617......... 45 H............. 050729, ref SDS 82 087J
590459 - 050527......... 56 H............. 050610, ref SDS 79 087J
590460 - 050512......... 67 H............. 050520, ref SDS 77 087J
590461 - 050506......... 80 H............. 050520, ref SDS 77 087J
590462 - ..
590463 - 050415.........105 H............. 050422, ref SDS 74 087J
590464 - 050415..Taxoter capecitabie begin 050415, ref SDS 73 407N
590465 - 050325.........100 H............. 050329, ref SDS 72 087J
590466 - 050318.........101 H............. 050325, ref SDS 71 2N5J
590467 - 050304......... 88 H............. 050311, ref SDS 69 087J
590468 - 050225......... 95 H............. 050308, ref SDS 68 0001
590469 - 050211......... 78 H............. 050214, ref SDS 67 02BB
590470 - 050128......... 67 H............. 050204, ref SDS 65 087J
590471 - 050104...AC start treatment...... 050104, ref SDS 64 407N
590472 - 041228......... 56 H............. 041230, ref SDS 63 087J
590473 - 041204......... 43 H............. 041210, ref SDS 62 087J
590474 - 041021...Taxol bevciz ends....... 041021, ref SDS 57 0001
590475 - 041007......... 39............... 041104, ref SDS 58 087J
590476 - 040923......... 49 H............. 041005, ref SDS 52 087J
590477 - 040908......... 44 H............. 040909, ref SDS 51 087J
590478 - 040825......... 47 H............. 040909, ref SDS 51 087J
590479 - 040811......... 42 H............. 040812, ref SDS 50 087J
590480 - 040728......... 43 H............. 040729, ref SDS 48 2N5J
590481 - 040712......... 47 H............. 040713, ref SDS 47 087J
590482 - 040614......... 55 H............. 040615, ref SDS 46 PX6X
590483 - 040517......... 78 H............. 040601, ref SDS 44 2N5J
590484 - 040420..Taxol becizam starts..... 040420, ref SDS 40 9Z5J
590485 - 040311......... 70 H............. 040318, ref SDS 35 SM6M
590486 - 040205......... 60 H............. 040211, ref SDS 33 SM6M
590487 - 031201......... 62 H............. 031205, ref SDS 32 SM6M
590488 - 030912......... 66 H............. 030915, ref SDS 31 SM6M
590489 - 030708......... 68 H............. 030710, ref SDS 30 SM6M
590490 - 030503......... 54 H............. 030508, ref SDS 28 SM6M
590491 - 030403......... 45 H............. 030508, ref SDS 28 SM6M
590492 - 030215......... 46 H............. 030220, ref SDS 27 5E6L
590493 - 030106......... 37 H............. 030109, ref SDS 26 SM6M
590494 - 021204..Adjuvant chemo ends...... 021204, ref SDS 25 SQ5I
590495 - 021202......... 41 H?............ 021204, ref SDS 25 SP5G
590496 - 021111......... 36 H?............ 021113, ref SDS 24 Y65I
590497 - 021023......... 33 H?............ 021023, ref SDS 23 SQ5I
590498 - 020930......... 33 H?..39........ 021002, ref SDS 22 SQ5I
590499 - 020917......... 36 H?............ 020924, ref SDS 21 SQ5I
590500 - 020717......... 59 H?............ 020726, ref SDS 20 YN5K
590501 - 020629......... 75 H ............ 020705, ref SDS 18 UX6I
590502 - 020608........ 67 H ............ 020614, ref SDS 16 0001
590503 - 020603........ 108 H ............ 020607, ref SDS 15 X67F
590504 - 020511........ 117 H ............ 020603, ref SDS 14 PJ4J
590505 - 020419......... 81 H ............ 020430, ref SDS 12 7N5H
590506 - 020321......... 85 H ............ 020405, ref SDS 11 6T8K
590507 -
590508 -
590509 -
590510 -
590512 - ..
5906 -
5907 -
5908 - Analysis
5909 -
590901 - CA 15-3 36 Cancer Marker Strong Response to Treatment Cetuximab
590902 -
590903 - Follow up ref SDS L7 GJ5M, ref SDS K1 GJ5M.
590904 -
590905 - CA 15-3 for the blood test today was not available in time for the
590906 - meeting, as shown in another record reporting treatment at 1500 in the
590907 - Infusion Clinic. ref SDS N3 2N5J Subsequently in a call on 070307 to
590908 - the Infusion Clinic, UCSF reported CA 15-3 was 36 for the test on
590909 - 070301, as shown above. ref SDS 0 087J Dramatic improvement of the
590910 - cancer marker dropping to the lowest level in over a year, indicates
590911 - that, despite expanding cancer for several months while off treatment,
590912 - shown below, ref SDS 0 LB5L, Doctor Rugo's assessment of clinical
590913 - improvement with subsiding intensity of IBC rash was correct.
590914 - ref SDS 0 M68J
590916 - ..
590917 - [On 070307 Catherine reported CA 15-3 blood test on 070301
590918 - dropped dramatically to 36, the lowest level in over a year.
590919 - ref SDS N8 U85L
590921 - ..
590922 - [On 070328 research on 070328 indicates advances in cancer
590923 - biomarker technology for improving patient care, including
590924 - recognizing response to treatment. ref SDS O5 FN6I
590926 - ..
590927 - However, this was not known at the time of the meeting today, and so
590928 - Doctor faced elevated CA 15-3 56 and spreading disease, seeming to
590929 - indicate no response to treatment, per dilemma below. ref SDS 0 1T4O
590930 -
590931 - [On 070308 meeting at UCSF cancelled because blood test on
590932 - 070301 reported CA 15-3 36 shows dramatic improvement, and ANC
590933 - blood counts increased to a safe level for treatment.
590934 - ref SDS N9 FO6H
590936 - ..
590937 - [On 071023 UCSF explains cancer marker applied to look more
590938 - carefully and does not signal consideration of treatment change
590939 - based on a cut off diagnostic of 80 (using Kaiser Lab
590940 - calibration methods). ref SDS O9 V63L
590942 - ..
590943 - A letter to UCSF yesterday on 070228 discussed coordinating with
590944 - Kaiser to obtain results on CA 15-3 for blood tests on 070208 and on
590945 - 070215, and in order to help assess response to treatment. ref SDS N2
590946 - ED5H Jackie indicated during the meeting today that a hectic schedule
590947 - did not have enough time for coordinating with Kaiser to get CA 15-3
590948 - diagnostics on measurable disease to complement phyisical examination
590949 - showing expanding disease, presented below. ref SDS 0 LB5L Work up on
590950 - a coordination plan, discussed above, ref SDS 0 HH7H, may improve
590951 - communication on CA 15-3 needed to assess strategy on changing
590952 - treatments, as discussed below. ref SDS 0 NY7N
590953 -
590954 - [On 070302 Millie reported UCSF taking decisions on continuing
590955 - current treatment without CA 15-3 test results. ref SDS N4 EY5W
590957 - ..
590958 - [On 070306 Millie requested results of CA 15-3 tests on 070208
590959 - and 070215 to support follow up meeting at UCSF on 070208.
590960 - ref SDS N7 PY6N
590962 - ..
590963 - Today, during the meeting, Jackie advised that CA 15-3 was not ordered
590964 - because reasoning in the letter on 070228, ref SDS N2 LQ5X, conflicts
590965 - with UCSF policy to order CA 15-3 monthly. She explained that, since
590966 - 2 tests were performed by Kaiser during February, then, even though
590967 - there wasn't enough time to get results of the tests, noted above,
590968 - ref SDS 0 MP58, doing another CA 15-3 test today to start the new
590969 - treatment cycle appears conflicting with policy. Brigid seemed to
590970 - indicate that the context of patient history showing expanding disease
590971 - observed at UCSF on 070222, ref SDS N1 B64F, requires another CA 15-3
590972 - test that sets a baseline with UCSF laboratory standards, and so she
590973 - ordered CA 15-3 for the blood test this morning.
590975 - ..
590976 - Patient history in the record today shows CA 15-3 closely tracks
590977 - progresssion of disease, and so supports diagnosis and treatment.
590978 - ref SDS 0 087J For example, on 061201 the primary care physician at
590979 - Kaiser relied on CA 15-3 diagnostics to change treatments, which led
590980 - to current care arrangements for Millie at UCSF. ref SDS I9 GJ5M
590981 - Earlier, Doctor Benz relied on CA 15-3 patient history for 2nd opinion
590982 - review at UCSF on 060821, ref SDS F9 GJ5M, which was later relied on
590983 - by Kaiser to make a referral to UCSF.
590984 -
590985 -
590986 -
590987 -
590988 -
590989 -
5910 -
SUBJECTS
Digestion Problems GERD Subside No Examination Nor Consideration PET
6303 -
630401 - ..
630402 - Digestion Problems Increasing Relatively Infrequent Mild
630403 - Esophagitis Not Compared in Current PET Test with Prior Report
630404 -
630405 - Follow up ref SDS L7 JP6K, ref SDS K1 JP6K.
630406 -
630407 - Background is reported in the meeting on 061201. ref SDS I9 JP6K
630408 - During the meeting on 061208, the doctor requested comparison between
630409 - PET scan test scheduled for 061227, and prior PET test on 060120,
630410 - which was reviewed on 060126, ref SDS A6 DH4O, and CT test on 060505,
630411 - reviewed on 060523, ref SDS C6 4O8P, to clarify diagnosis and plan
630412 - treatment of esophagitis or other malady that may be causing increased
630413 - digestion problems. Kaiser's medical chart for the meeting on 061208
630414 - shows GERD worse. ref SDS J2 1248 The medical chart for the meeting
630415 - on 070105 makes no reference to GERD. ref SDS K1 1248
630417 - ..
630418 - There was no discussion of this issue today.
630419 -
630420 -
630421 -
630422 -
6305 -
SUBJECTS
Left Axillary Lymphadenopathy Patient No Complaint of Swelling Disco
7503 -
750401 - ..
750402 - Left Arm Lymphedema Elevated Swelling No Lymphadenopathy
750403 - Axillary Left Arm No Lymphadenopathy Lymphedema Prominent
750404 - Lymphadenopathy Axillary Left Arm No Evidence Local Edema
750405 - Lymphedema Left Arm Remains Elevated Swelling No Cellulitis
750406 -
750407 - Follow up ref SDS L7 MW8J, ref SDS K1 MW8J.
750408 -
750409 - Patient has a long history of IBC on the left breast and associated
750410 - lymphadenopathy symptoms in the left axillary, see case study on
750411 - 040517. ref SDS 43 OW3I
750413 - ..
750414 - Brigid examined the left axilla. Clinical palpation made no findings
750415 - of lumps or other indications of cancer, including swelled lymph nodes
750416 - that might indicate lymphadenopathy. The patient made no complaint of
750417 - lumps or discomfort from swelling under the left arm. A CT test on
750418 - 070131 shows no findings of lymphadenopathy, as reviewed at Kaiser on
750419 - 070202. ref SDS M2 013T
750421 - ..
750422 - Lymphedema in the left arm is reported in a case study on 070131.
750423 - ref SDS L7 VX6F
750425 - ..
750426 - The arm today has reduced swelling from lymphedema. Measurement below
750427 - the elbow is 10.75" stable since 070130, shown in case study on
750428 - 060509. ref SDS C3 HO7F Improvement to stable condition at near
750429 - normal measurement has occurred with increased activity and stress on
750430 - the arm from working out in the gym, reported on 070204, ref SDS M3
750431 - HF5H, and from playing tennis, reported on 070218. ref SDS N0 N05H On
750432 - 070222 Brigid verified that Millie plays tennis right handed, which
750433 - reduces stress on the left arm that could cause complications of
750434 - lymphedema.
750435 -
750437 - ..
750438 - IBC Expands Left Arm Responding to Treatment
750439 -
750440 - On 070202 a new rash on the upper left arm was observed by the primary
750441 - care physician during examination at Kaiser. ref SDS M2 6H6L On
750442 - 070214 Millie cited this new condition in a letter to Kaiser and UCSF.
750443 - Brigid concluded during examination at UCSF on 070222 that the rash
750444 - looks more like IBC than cellulitis. ref SDS N1 B64F
750446 - ..
750447 - There was a general impression today by Doctor Rugo, Brigid, and the
750448 - patient that the rash seems less intense today after 4 treatments with
750449 - cetuximab than when observed earlier, similar to improvement on the
750450 - left and right breast areas, discussed below. ref SDS 0 025H At the
750451 - time of examination today, dramatic improvement in CA 15-3 test
750452 - diagnostic was not known. Subsequent reports of testing this past
750453 - month, including today showing CA 15-3 has dropped to 36, ref SDS 0
750454 - GJ5M, seems to align with observing that IBC on the upper left arm is
750455 - subsiding.
750456 -
750457 -
750458 -
750459 -
750460 -
750461 -
7505 -
SUBJECTS
Right Auxillary Lymphadenopathy Patient No Complaint Swelling Discom
8303 -
830401 - ..
830402 - Right Axillary Possible Involvement Red Rash Spreads Right Breast
830403 - Right Breast Red Rash Spreads Possible Involvement Right Axillary
830404 - Red Rash Right Breast Spreads Possible Involvement Right Axillary
830405 -
830406 - Follow up ref SDS L7 3D6K, ref SDS K1 3D6K.
830407 -
830408 - Background on patient history testing for lymphadenopathy in the right
830409 - axilla is reported in the record on 060929. ref SDS G4 3D6K
830411 - ..
830412 - Examination of the right axillary yielded same results from examining
830413 - the left axilla, per above. ref SDS 0 VU6O
830415 - ..
830416 - On 061204 IBC inflammation spread from the left chest area infected
830417 - with IBC across the sternum and slightly onto the right breast.
830418 - ref SDS J1 AE5I
830420 - ..
830421 - Examination of the right breast shows reduced intensity of IBC rash,
830422 - and there is no spreading of the rash, suggesting favorable response
830423 - to treatment. At the time of examination today, CA 15-3 was not
830424 - known. Subsequently, report of testing this past month, including
830425 - today showing CA 15-3 has dropped to 36, ref SDS 0 GJ5M, seems to
830426 - align with observing that IBC on the right breast is subsiding.
830427 -
830429 - ..
830430 - IBC Right Arm New Minimal Red Rash Not Diagnosed IBC Today
830431 -
830432 - New evidence today presented 5 - 10 barely visible light red dots
830433 - dispersed on the upper, inner right arm running generally along the
830434 - bicep. This is similar to initial appearance on the left breast area
830435 - reported on 060623, ref SDS D4 NE6G, which later increased and was
830436 - diagnosed as IBC on 060711. ref SDS D6 025H Dispersed red dots on the
830437 - upper, inner right arm seem somewhat similar to the rash on the
830438 - stomach, which Doctor Rugo noticed on 070130 and identified as
830439 - progression of IBC. ref SDS L7 M68J Similarly, slight rash on the
830440 - lower left arm reported in the morning of 061027, ref SDS H5 3N83, and
830441 - then increased into severe inflammation of the entire left arm by
830442 - 1728, ref SDS H5 WO6N, and was diagnosed as cellulitis OA 2020.
830443 - ref SDS H5 V65J Later on 070202 the primary care physician at Kaiser
830444 - noticed slight rash on the upper left arm. ref SDS M2 JP6F UCSF was
830445 - notified and on 070222 Brigid diagnosed IBC has spread to the left
830446 - arm. ref SDS N1 B643
830448 - ..
830449 - Initial assessment today is that slight rash or blemishes is not IBC,
830450 - as was diagnosed on the left arm on 070222, ref SDS N1 FO6H, and
830451 - examined again today, per above. ref SDS 0 527G Brigid seemed to
830452 - indicate there are several possibilities to explain the rash besides
830453 - expanding IBC.
830455 - ..
830456 - There is the possibility this is IBC and is responding to treatment,
830457 - as with IBC in other areas, per below. ref SDS 0 4140
830458 -
830459 - [On 070315 examination still results in not diagnosing rash on the
830460 - right arm as IBC. ref SDS O3 FO6H
830461 -
830462 - [On 070322 Millie asked Catherine in the Infusion Clinic to
830463 - look at the right arm, and at that time there was no
830464 - discernable pattern of rash. ref SDS O4 LI4M
830465 -
830466 -
830467 -
830468 -
8305 -
SUBJECTS
Left Supraclavicular Neck Lymphadenopathy Patient No Complaint Swell
9103 -
910401 - ..
910402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
910403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
910404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
910405 -
910406 - Follow up ref SDS L7 8R6M, ref SDS K1 8R6M.
910407 -
910408 - During examination on 070130, Doctor Rugo asked about history of
910409 - radiation to the neck, and sequence of finding recurrence from Doctor
910410 - Laio's biopsy reported on 040309. ref SDS 34 0001 Background of image
910411 - testing, and consideration for radiation treatment of left
910412 - supraclavicular is reported on 060623. ref SDS D4 8R6M
910414 - ..
910415 - Like the left and right axillary locations, examination today for
910416 - cancer in left supraclavicular region found no evidence of lumps or
910417 - other indications of lymphadenopathy, as reported above. ref SDS 0
910418 - VU6O
910419 -
910420 -
910421 -
910422 -
910423 -
9105 -
SUBJECTS
Examination IBC Rash Left Breast Spreads to Right Breast Stomach Bac
9903 -
990401 - ..
990402 - 2 Scenarios Conflict IBC Expanding Intensity Subsides
990403 - IBC Rash Left Breast Stomach and Back Seems to Be Subsiding
990404 - Examination IBC Rash Subsiding Respoinding to Treatment Cetuximab
990405 - Cetuximab Effective Treatment IBC Subsiding Left Breast Stomach Back
990406 -
990407 - Follow up ref SDS L7 025H, ref SDS K1 025H.
990408 -
990409 - Since 060623, IBC has expanded from near the sternum, ref SDS D4 025H,
990410 - and during treatment with Taxotere and capecitabine started on 060721,
990411 - ref SDS E1 0001, and ending on 061201. ref SDS I9 GJ5M Case study on
990412 - 070130 shows erratic changes in severity/intensity of IBC rash which
990413 - led to referral to UCSF. ref SDS L7 5N6L
990415 - ..
990416 - Cetuximab treatment, started at UCSF on 070201, ref SDS M1 G68I, was
990417 - delayed 4 weeks, reported in case study on 070130, ref SDS L8 2W58,
990418 - which increased opportunity for stage IV cancer to spread.
990420 - ..
990421 - Examination today confirmed understandings on 070222 that IBC has
990422 - significantly expanded, most prominently to the left arm, ref SDS N1
990423 - B64F, creating concern about cancer cascading out of control with CA
990424 - 15-3 56 cancer marker seemingly unchanged and possibly increased,
990425 - while getting treatments so far, discussed again below, ref SDS 0
990426 - QN3F; yet, intensity of IBC rash seems to be subsiding...
990427 -
990428 - right breast...................... 061204, ref SDS J1 AE5I
990429 - stomach........................... 070130, ref SDS L7 M68J
990430 - back.............................. 070130, ref SDS L7 M68J
990431 - left arm.......................... 070202, ref SDS M2 6Q5N
990432 - Right arm??....................... 070301, ref SDS 0 H15M
990433 -
990434 - [On 070315 examination still results in not diagnosing rash
990435 - on the right arm as IBC. ref SDS O3 FO6H
990437 - ..
990438 - [On 070329 rash on right chest above port catheter and
990439 - above the right breast reported during treatment on 070315
990440 - was not observed during examination on 070329. ref SDS O6
990441 - 583G
990443 - ..
990444 - [On 070329 examination shows continued clinical
990445 - improvement; no new IBC sites, and subsiding intensity of
990446 - rash; aligns with continuing decline of CA 15-3 33 cancer
990447 - marker. ref SDS O6 M68J
990449 - ..
990450 - Expanding IBC rash indicates progression of disease. On 070130 the
990451 - plan for treating progression of cancer in this case is to increase
990452 - the level of treatment from cetuximab alone by adding carboplatin,
990453 - discussed further under strategy, shown below. ref SDS 0 1T4O
990455 - ..
990456 - Examination today shows intensity of IBC rash seems to be subsiding.
990457 - Doctor Rugo recalled today seeing rash on the left arm during
990458 - examination on 070130; and new rash on the right arm has not yet been
990459 - diagnosed IBC, per above. ref SDS 0 H15M As a result, there has been
990460 - no expansion of IBC with cetuximab treatment on the clinical study.
990461 - At the time of examination today, CA 15-3 was not known, see above.
990462 - ref SDS 0 MP58
990463 -
990464 - [On 070307 new CA 15-3 36 test results seem to align with visual
990465 - examination showing disease expanding, likely before starting
990466 - treatment on 070201, and now with subsiding intensity. ref SDS N8
990467 - U85L
990469 - ..
990470 - [On 070307 CA 15-3 test results received from Kaiser for February
990471 - present consistent trend down, supporting inference of subsiding
990472 - IBC disease. ref SDS N8 IE5O
990474 - ..
990475 - Conflicting scenarios of expanding disease and declining intensity
990476 - observed by examination today, ref SDS 0 LB5L, was analysed by the
990477 - doctor in light of missing CA 15-3 test data to formulate treatment
990478 - strategy, discussed below. ref SDS 0 1T4O The doctor scheduled
990479 - another examination next week to validate the strategy, also, set out
990480 - below. ref SDS 0 NY7N
990481 -
990482 - [On 070315 Millie submitted to primary care physician at
990483 - Kaiser progress report on recovering from IBC 3rd relapse
990484 - with treatment starting on 070201 clinical study cetuximab
990485 - at UCSF. ref SDS O2 VP5N
990486 -
990488 - ..
990489 - Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
990490 -
990491 - Follow up ref SDS L7 M645.
990492 -
990493 - Subsequently, on 070307 report of testing this past month, including
990494 - today showing CA 15-3 has dropped to 36, ref SDS 0 GJ5M, seems to
990495 - align with observing IBC rash subsiding. Dramatic reduction of CA
990496 - 15-3 cancer marker after switching treatments and starting with
990497 - cetuximab on a clinical study fits prior patient history of improving
990498 - prospects by changing treatments, reported on 050520. ref SDS 77 025H
990499 - This aligns with understandings from meeting with Doctor Rugo on
990500 - 070130. ref SDS L7 M645.
990501 -
990502 - [On 070307 Catherine reported CA 15-3 blood test on 070301
990503 - dropped dramatically to 36, the lowest level in over a year.
990504 - ref SDS N8 U85L
990506 - ..
990507 - [On 070328 research on 070328 indicates advances in cancer
990508 - biomarker technology for improving patient care, including
990509 - recognizing response to treatment. ref SDS O5 FN6I
990510 -
990512 - ..
990513 - Local IBC Infection No Record Distant Metastasis Improves Chances
990514 - Prognosis Favorable No Lymphadenopathy 2006 No Distant Metastasis 5 Years
990515 -
990516 - Follow up ref SDS L7 FF4H.
990517 -
990518 - There is no evidence of distant metastasis in internal organs,
990519 - unchanged from meeting at Kaiser on 070202, when CT test on 070131 was
990520 - reviewed. ref SDS M2 013T
990522 - ..
990523 - IBC expanded during December and January, ref SDS 0 4140, presents a
990524 - grave concern, which seems now to be coming under control again.
990525 -
990526 -
990527 -
990528 -
9906 -
SUBJECTS
ANC 1.23 Blood Counts Below Safe Level for Treatment Cetuximab Weekl
A803 -
A80401 - ..
A80402 - ANC 1.23 Blood Counts Drop Below Safe Level for Treatment with Cetuximab
A80403 -
A80404 - During the meeting today, Brigid showed the report on the blood test
A80405 - earlier this morning. For convenience, the report is listed in the
A80406 - record on getting treatment today. ref SDS N3 075H
A80408 - ..
A80409 - Brigid explained ANC is presented in the UCSF blood test report as
A80410 - "NEUTS," and has dropped to 1.23, well below 1.8 listed as safe for
A80411 - chemotherapy. ref SDS N3 P560 ANC 1.23 corresponds to 1230 in
A80412 - Kaiser's scheme, and so is also below Kaiser's criteria of 1500 for
A80413 - permitting chemotherapy treatments. ref SDS N3 A27K
A80415 - ..
A80416 - Brigid further explained that, even though the UCSF laboratory report
A80417 - for blood tests lists 1.80 as the low value of the target range, UCSF
A80418 - uses 1.5 that Kaiser uses to evaluate safe chemotherapy treatments,
A80419 - since UCSF test reports for NEUTS are multiplied by 1000 to convrt to
A80420 - Kaiser units of measure...
A80421 -
A80422 - UCSF NEUTS 1.5 = 1500 ANC at Kaiser
A80424 - ..
A80425 - [On 070308 ANC increased to 1.51 within the normal range for
A80426 - cetuximab treatments. ref SDS N9 P560
A80427 -
A80429 - ..
A80430 - Wicked Problem Expanding Disease Requires Increasing Treatment
A80431 - Increasing Treatment Reduces Immune System Preventing Treatment
A80432 - Weekly Carboplatin Chemotherapy Increase Difficulty Low Blood Counts
A80433 -
A80434 - Falling ANC blood counts without getting chemotherapy indicate that
A80435 - weekly chemotherapy treatments with Carboplatin may not provide enough
A80436 - time for bone marrow to replenish blood that maintains the immune
A80437 - system. Prolonged weakened immune system increases risk of infection
A80438 - by other lethal diseases, reported on 030606. ref SDS 29 JP7G This
A80439 - was reviewed again a year later on 040614. ref SDS 45 6T7F
A80441 - ..
A80442 - Since IBC disease has expanded significantly, per above, ref SDS 0
A80443 - 4140, the obvious solution is to change treatment by adding
A80444 - Carboplatin, allowed by the clinical study protocol, reported on
A80445 - 070130. ref SDS L7 NI6K
A80447 - ..
A80448 - Doctor Rugo commented today that, since carboplatin chemotherapy
A80449 - reduces blood counts more than cetuximab, ANC blood counts falling
A80450 - below a safe level for treatment today with only cetuximab then
A80451 - maintaining ANC at a safe level for weekly treatments required by the
A80452 - study protocol will be even harder, if carboplatin is added to
A80453 - increase effectiveness of treatment. This presents a "wicked
A80454 - problem." Either expanding cancer will cascade out of control; or,
A80455 - increasing treatment to prevent cancer from expanding will weaken the
A80456 - immune system by lowering blood counts, which exposes the patient to
A80457 - worse diseases than cancer.
A80458 -
A80459 - [On 080313 Carboplatin added to Millie's treatment for rising
A80460 - symptoms of IBC. ref SDS P0 TZ8I
A80462 - ..
A80463 - [On 080403 blood counts falling from adding Carboplatin
A80464 - chemotherapy, so UCSF orders Neupogen treatments to restore
A80465 - strength of immune system so that Millie can continue getting
A80466 - treatments to recover from growing cancer. ref SDS P1 6Y9K
A80467 -
A80468 -
A80469 -
A80470 -
A805 -
SUBJECTS
Neutropenia Research Emedicine Article 00809 Chronic Low Blood Coun
AG03 -
AG0401 - ..
AG0402 - Neutropenia Chronic Low Blood Counts Prevents Chemotherapy
AG0403 -
AG0404 - Neutropenia that weakens the immune system occurs when the bone marrow
AG0405 - system cannot replace blood counts between treatments, per above,
AG0406 - ref SDS 0 D24M, explained in an article published by Emedicine on
AG0407 - 060809...
AG0409 - ..
AG0410 - http://www.emedicine.com/MED/topic1640.htm
AG0412 - ..
AG0413 - Effects of age, exercise, fitness, and chemotherapy on weakening the
AG0414 - immune system, which then prevents getting chemotherpy treatments to
AG0415 - recover from cancer was explained by the primary care physician at
AG0416 - Kaiser on 030606, including benefits of exercise that maintain fitness
AG0417 - which enables robust treatment. ref SDS 29 JP7G
AG0418 -
AG0420 - ..
AG0421 - ANC Calculate Absolute Neutrophils
AG0422 -
AG0423 - The author describes neutropenia...
AG0424 -
AG0425 - Neutropenia is a decrease in circulating neutrophils in the
AG0426 - peripheral blood. The absolute neutrophil count (ANC) number
AG0427 - defines neutropenia. An abnormal ANC value contains fewer than
AG0428 - 1500 cells per mm3. African Americans may have a lower but
AG0429 - normal ANC value of 1000 cells per mm3 with a normal total WBC
AG0430 - count. The ANC is calculated by multiplying the percentage of
AG0431 - bands and neutrophils (segmented neutrophils or granulocytes)
AG0432 - on a CBC differential times the total white WBC count.
AG0433 - ref OF 7 TI7N
AG0435 - ..
AG0436 - Calculating ANC is shown in the record getting treatment at Kaiser on
AG0437 - 060810. ref SDS F6 GL4M This was clarified on 060814. ref SDS F7 C56L
AG0438 -
AG0440 - ..
AG0441 - Severity Neutropenia Greatest with ANC Below 500 Mild Below 1000
AG0442 -
AG0443 -
AG0444 - Research neutropenia continues...
AG0445 -
AG0446 - Severity of neutropenia is mild when the ANC is 1000-1500 cells
AG0447 - per mm3, moderate when the ANC is 500-1000 cells per mm3, and
AG0448 - severe when the ANC is less than 500 cells per mm3. The risk
AG0449 - of bacterial infection is related to both the severity and
AG0450 - duration of neutropenia. ref OF 7 1V9M
AG0452 - ..
AG0453 - Case study today seems to indicate Millie has suffered mild
AG0454 - neutropenia with ANC 1000 - 1500, shown in the record getting
AG0455 - treatment later today. ref SDS N3 AZ8H
AG0457 - ..
AG0458 - Case study on 060810 shows Millie has routinely been treated with
AG0459 - chemotherapy with ANC below 1500 because she has maintained a high
AG0460 - level of fitness. ref SDS F6 HV45
AG0461 -
AG0462 - [On 081205 Millie's ANC 624 very low, required Neupogen
AG0463 - treatments on 081205 and 081206. ref SDS P3 CH40
AG0465 - ..
AG0466 - [On 081210 Kaiser indicated standards and practices of
AG0467 - giving Neupogen treatment when ANC falls below 1000.
AG0468 - ref SDS P4 H46J
AG0470 - ..
AG0471 - Research neutropenia continues...
AG0472 -
AG0473 - Morbidity usually involves infections during severe, prolonged
AG0474 - episodes of neutropenia. Serious medical complications occur
AG0475 - in 21% of patients with cancer and neutropenic fever.
AG0476 - Mortality correlates with the duration and severity of
AG0477 - neutropenia and the time elapsed until the first dose of
AG0478 - antibiotics is administered for neutropenic fever. ref OF 7
AG0479 - 5M3A
AG0481 - ..
AG0482 - Neupogen
AG0483 -
AG0484 - Do not use 12-24 h before or 24 h after administering
AG0485 - cytotoxic chemotherapy because will increase sensitivity of
AG0486 - rapidly dividing myeloid cells to cytotoxic chemotherapy;
AG0487 - obtain CBC before therapy and monitor twice weekly during
AG0488 - therapy to avoid excessive leukocytosis; rarely, cutaneous
AG0489 - vasculitis is reported with long-term use in severe chronic
AG0490 - neutropenia, ref OF 7 IF5K
AG0491 -
AG0492 - [On 080821 Doctor Rugo recommends getting Neupogen
AG0493 - treatment at Kaiser 24 hours after chemotherapy at UCSF.
AG0494 - ref SDS P2 4B4L
AG0495 -
AG0496 -
AG0497 -
AG0498 -
AG0499 -
AG05 -
SUBJECTS
Default Null Subject Account for Blank Record
AH03 -
AH0401 - ..
AH0402 - Patient History Latent Effects Prior Chemotherapy Not Neutropenia
AH0403 - Cetuximab Treatment Approved Recover from Cancer Evaluate Blood Counts
AH0404 -
AH0405 - The doctor noted today that patient history shows ANC has been on a
AH0406 - long, steady decline since starting treatment with Taxotere and
AH0407 - capecitabine on 060721, listed in a case study for the record getting
AH0408 - treatment later today. ref SDS N3 AZ8H Therefore the current fall to
AH0409 - 1.23 could reflect latency effects of prior conventional chemotherapy
AH0410 - treatments, rather than caused by cetuximab. The doctor decided that
AH0411 - scheduled treatment for today with cetuximab should be performed, (see
AH0412 - strategy below, ref SDS 0 T85J), and that another blood test will be
AH0413 - done next week to see if ANC recovers, as expected, or declines
AH0414 - further, and so requires treatment to aid recovery necessary for
AH0415 - weekly treatments, as discussed further under strategy. ref SDS 0 1T4O
AH0417 - ..
AH0418 - Jackie will coordinate with the Infusion Clinic to perform another
AH0419 - blood test next week on 070308. Coordination is required, because on
AH0420 - 070201 blood tests were scheduled only once every 4 weeks under the
AH0421 - clinical study protocol for patients randomized to be treated with
AH0422 - only cetuximab. ref SDS M1 XR40
AH0423 -
AH0424 - [On 070302 confirmed understandings for a blood test on 070308.
AH0425 - ref SDS N4 EZ6P
AH0427 - ..
AH0428 - [On 070308 for some reason the blood test was not ordered,
AH0429 - ref SDS N9 Q659; the Infusion Clinic performed a blood test on
AH0430 - notice by the patient, ref SDS N9 XA9I; ANC increased from 1.23 to
AH0431 - 1.51 that meets requirements for cetuximab treatments.
AH0432 -
AH0433 -
AH05 -
SUBJECTS
Measurable Disease IBC Spreads from Left to Right Breast Stomach Bac
AJ03 -
AJ0401 - ..
AJ0402 - Measurable Disease IBC Spreads from Left to Right Breast
AJ0403 - Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
AJ0404 - Measurable Disease IBC Observed with Tape Measure Photograph Pictures
AJ0405 - CA 15-3 Diagnostic Measurable Disease IBC Not Meaured by Image Testing
AJ0406 -
AJ0407 - Follow up ref SDS L7 M652, ref SDS J9 4Q6K.
AJ0408 -
AJ0409 - Background on measurable disease for IBC using cancer biomarker CA
AJ0410 - 15-3 and photographic records showing spread of cancer is reported in
AJ0411 - a case study on 070101. ref SDS J9 4Q6K
AJ0413 - ..
AJ0414 - There wasn't enough time today to get CA 15-3 test results to evaluate
AJ0415 - progression of disease, per above. ref SDS 0 MP58 Subsequently, a
AJ0416 - week later on 070307, test results from Kaiser on previous tests, and
AJ0417 - UCSF results for the blood test today indicate substantial effect by
AJ0418 - cetuximab treatment, cited in the examination. ref SDS 0 M68J
AJ0420 - ..
AJ0421 - Jackie and Brigid took pictures again today for the clinical study
AJ0422 - protocol to show measurable disease of IBC expanding rash, following
AJ0423 - work on 070222, ref SDS N1 6T6M, and previously on 070201. ref SDS M1
AJ0424 - 6T6M
AJ0425 -
AJ0426 -
AJ0427 -
AJ0428 -
AJ0429 -
AJ05 -
SUBJECTS
Lung Cancer No Discussion Metastatic Disease Lymph Nodes Doctor's Pr
AN03 -
AN0401 - ..
AN0402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
AN0403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
AN0404 -
AN0405 - Follow up ref SDS L7 G25K, ref SDS K1 G25K.
AN0406 -
AN0407 - Background is reported on 070130 in the record meeting with Doctor
AN0408 - Rugo at UCSF. ref SDS L7 G25K
AN0410 - ..
AN0411 - There was no discussion of this issue today, so that attention could
AN0412 - focus on assessing Millie's response to treatment for IBC.
AN0413 -
AN0414 -
AN0415 -
AN0416 -
AN0417 -
AN05 -
SUBJECTS
Biopsy Left Right Breasts Start Clinical Study Treatment IBC Cetuxim
B103 -
B10401 - ..
B10402 - Clinical Study Benefits from Biopsy of IBC Targeted Tissue
B10403 - Biopsy Determine Biology of IBC and Guide Choice of Treatment
B10404 - Treatment Options Expand Pool of Drugs Biopsy Test for Status Change
B10405 -
B10406 - Follow up ref SDS L7 KT7J, ref SDS K1 KT7J.
B10407 -
B10408 - On 070131 Doctor Rugo consulted with a surgeon and discussed Millie's
B10409 - treatment with Coumadin for pulmonary embolism presents elevated risk
B10410 - of bleeding (hemoraging). As a result, the decision on 070130 to
B10411 - perform biopsies for the clinical study, ref SDS L7 M840, was changed
B10412 - on 070131, and so biopsies were not performed in this case.
B10413 - ref SDS M0 6E3J
B10415 - ..
B10416 - There was no discussion today of taking biopsies to verify diagnosis
B10417 - of rash on the left arm. ref SDS 0 527G The rash on the right arm
B10418 - was also not biopsied. ref SDS 0 H15M
B10419 -
B10420 -
B10421 -
B10422 -
B105 -
SUBJECTS
CT Scan Test Ordered Before 070328 Start Cycle 3 Cetuximab Correct M
BF03 -
BF0401 - ..
BF0402 - CT Test Baseline Clinical Trial PE Expedite Collaborate with Kaiser
BF0403 -
BF0404 - Follow up ref SDS L7 EY5O, ref SDS K1 EY5O.
BF0405 -
BF0406 - PET/CT test on 070131 received on 070202. ref SDS M2 1Y8G Test
BF0407 - history listed in the same record on 070202, shows no evidenece of
BF0408 - regional nor distant metastasis. ref SDS M2 GB8J
BF0410 - ..
BF0411 - Jackie related that on 070202 the primary care physician at Kaiser
BF0412 - requested a 4-week notice on the next CT test so that the order for
BF0413 - the test can be written to include special requirements that test for
BF0414 - pulmonary embolism and enlarged right ventricle. ref SDS M2 T85K On
BF0415 - 070204 the patient sent a letter confirming understandings that Kaiser
BF0416 - requests a month notice on the date when the next CT test is needed
BF0417 - for the clinical study. ref SDS M3 4L4T Planning for implementation
BF0418 - was discussed during the meeting at UCSF on 070208. ref SDS M4 PR5L
BF0420 - ..
BF0421 - The doctor advised today that a CT test is needed for the clinical
BF0422 - study to start the 3rd cycle of treatment that begins on 070329.
BF0423 - Brigid prepared a form...
BF0424 -
BF0425 - Department of Radiology Outpatient Request
BF0426 -
BF0427 - ...and requested the next CT test before 070328.
BF0429 - ..
BF0430 - Brigid gave the form to Millie and asked her to transmit the UCSF
BF0431 - request to Kaiser, and coordinate to verify the test is scheduled at
BF0432 - Kaiser in time to accomplish requirements for the drug trial, and to
BF0433 - further test for pulmonary embolism, explained below. ref SDS 0 N19I
BF0435 - ..
BF0436 - Millie asked about UCSF coordinating with Kaiser directly. Brigid
BF0437 - cited UCSF policy to rely on patients for managing communications with
BF0438 - originating referral provider, per above, ref SDS 0 O67N, rather than
BF0439 - UCSF staff, per above. ref SDS 0 CI9L
BF0440 -
BF0441 - [On 070302 Millie submitted a letter to Kaiser presenting
BF0442 - results of the meeting today, and conveying UCSF request for CT
BF0443 - test before 070328, and specifying testing for pulmonary
BF0444 - embolism. ref SDS N4 EZ6T
BF0446 - ..
BF0447 - [On 070306 follow up letter to Kaiser reminding to order CT
BF0448 - test in time for starting next cycle on 070329, and to order
BF0449 - test for pulmonary embolism. ref SDS N7 HS3X
BF0451 - ..
BF0452 - [On 070307 Arlette reminded the doctor to order the CT test.
BF0453 - ref SDS N8 9Z9N
BF0455 - ..
BF0456 - [On 070309 Kaiser scheduled test for 070328 0845.
BF0457 - ref SDS O0 VP5N
BF0459 - ..
BF0460 - [On 070314 Millie requested that Kaiser change the schedule for
BF0461 - the test to 070326 at 2000, providing time for preparing
BF0462 - analyst's report, and distribution in time to prepare for
BF0463 - meeting at UCSF on 070329. ref SDS O1 VP5N
BF0465 - ..
BF0466 - [On 070314 Millie notified UCSF CT test is scheduled for
BF0467 - 070326. ref SDS O1 DT4I
BF0468 -
BF0469 -
BF0470 -
BF0471 -
BF0472 -
BF0473 -
BF0474 -
BF05 -
SUBJECTS
Emotional Trauma Increases Stress Pulse Well Above 80 Complex Medica
BK03 -
BK0401 - ..
BK0402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
BK0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
BK0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
BK0405 -
BK0406 - Follow up ref SDS L7 Y642, ref SDS K1 Y642.
BK0407 -
BK0408 - Medical issues create an emotional roller coaster explained on 070105.
BK0409 - ref SDS K1 Y642 Stress and trauma are compounded with rising
BK0410 - complexity of case history, listed above. ref SDS 0 LU3J
BK0412 - ..
BK0413 - Millie's vitals are very high again today, e.g., pulse well above 80,
BK0414 - where normally her resting heart beat is plus or minus 60, reported in
BK0415 - patient history for treatment today after meeting with Doctor Rugo.
BK0416 - ref SDS N3 AW4L
BK0418 - ..
BK0419 - Expanding IBC reported on 070222, ref SDS N1 B64F, and worry about new
BK0420 - rash on the right arm today, per above, ref SDS 0 H15M, causes
BK0421 - increased alarm. Finding that intensity of the rash seems to be
BK0422 - subsiding, and later learning that CA 15-3 dropped to 36 with
BK0423 - treatment on the cetuximab clinical study, per above, ref SDS 0 4140,
BK0424 - has a powerfully satisfying effect.
BK0426 - ..
BK0427 - Increased energy and fitness with rising exercise from reduced side
BK0428 - effects, discussed below, ref SDS 0 TQ6L, moderates emotional swings
BK0429 - and worry.
BK0431 - ..
BK0432 - Since there wasn't enough time to get CA 15-3 test reports for the
BK0433 - meeting today, there was a lot of tension during the meeting about
BK0434 - whether Millie would get treatment today, because ANC is below the
BK0435 - standard for treatment, discussed below. ref SDS 0 1T4O There was
BK0436 - further concern about expanding treatment to include carboplatin.
BK0437 - This caused greater emotional stress, because adding carboplatin would
BK0438 - put downward pressure on ANC, threatening treatment to recover from
BK0439 - IBC, and/or required adding additional treatment to increase blood
BK0440 - counts. ref SDS 0 OL5M Uncertainty on resolving complex choices can
BK0441 - greatly increase emotional trauma.
BK0442 -
BK0443 - [On 070307 CA 15-3 36 dramatic improvement after concern that
BK0444 - IBC expanded during December and January, another emotional
BK0445 - roller coaster. ref SDS N8 046S
BK0447 - ..
BK0448 - [On 070309 Arlette advised that email for coordination of
BK0449 - work on Kaiser's referral to UCSF should go to the primary
BK0450 - care physician, which does not support efficient common
BK0451 - distribution, rather than through Arlette, ref SDS O0 VP73,
BK0452 - which provides both efficient distribution, and a backup
BK0453 - for reminding the doctor of critical action items,
BK0454 - illustrated on 070307. ref SDS N8 9Z9N
BK0456 - ..
BK0457 - [On 070315 Millie asked about coping emotionally with major
BK0458 - changes in assessment of treatment on the cetuximab clinical
BK0459 - study, ref SDS O3 6A7J; review impact of complex communications
BK0460 - that increase stress, causing vitals to rise. ref SDS O3 OR5K
BK0461 -
BK0462 -
BK0463 -
BK0464 -
BK0465 -
BK0466 -
BK05 -
SUBJECTS
Strategy 3 Issues ANC High IBC Expanding Intensity Subsiding Should
BS03 -
BS0401 - ..
BS0402 - Planning Case Management from Patient Profile Work Up
BS0403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
BS0404 - Strategy Cetuximab Continued with Low ANC Expanding IBC Disease
BS0405 -
BS0406 - Follow up ref SDS L7 K36G, ref SDS K1 K36G.
BS0407 -
BS0408 - Background on requirements and obstacles to planning and proactive
BS0409 - management in time for action to be effective is reported on 060825.
BS0410 - ref SDS G0 K36G
BS0412 - ..
BS0413 - Review of treatment history is listed on 061208, leading to strategy
BS0414 - for referral to UCSF. ref SDS J2 5Q5I Chronology on patient history
BS0415 - along with case studies for critical issues were cited on 070130.
BS0416 - ref SDS L7 GG7I CA 15-3 history listed with changes in treatment is
BS0417 - listed at the top of this record for a summary of the case.
BS0418 - ref SDS 0 087J
BS0420 - ..
BS0421 - There was no discussion today on the role of the Tumor Board process
BS0422 - to support strategy and planning, considered on 061208. ref SDS J2
BS0423 - P69G
BS0425 - ..
BS0426 - Challenges coordinating with Kaiser and limited time due to hectic
BS0427 - schedules that delayed submission of CA 15-3 diagnostics, per above,
BS0428 - ref SDS 0 HH7H, reflect Jackie's report on 070130 that preparing for
BS0429 - meetings requires wading through several folders of papers UCSF has on
BS0430 - file for Millie's case, ref SDS L7 LD39, and citing experience at UCSF
BS0431 - on 060821 during consultation with Doctor Benz. ref SDS F9 TQ7I
BS0432 - Finding time to prepare for meetings was cited in a study of poor
BS0433 - productivity, reviewed on 960205. ref SDS 3 5902
BS0435 - ..
BS0436 - Strategy issues today were...
BS0437 -
BS0438 - 1. Should Millie get treatment today with ANC 1.23 dropping below
BS0439 - UCSF's standard of 1.8, and also below Kaiser's standard of
BS0440 - 1.5, reported in the blood test today, discussed above.
BS0441 - ref SDS 0 VF5M
BS0443 - ..
BS0444 - 2. Should treatment be upgraded at this time to add carboplatin to
BS0445 - the regimen, as planned on 070130, ref SDS L7 NI6K, and in
BS0446 - light of spreading disease, cited during examination today,
BS0447 - ref SDS 0 4140, and uncertainty of cancer marker CA 15-3 56 due
BS0448 - to delays getting test results from Kaiser, per above.
BS0449 - ref SDS 0 464O
BS0450 -
BS0451 - [On 071023 UCSF explains cancer marker applied to look more
BS0452 - carefully and does not signal consideration of treatment
BS0453 - change based on a cut off diagnostic of 80 (using Kaiser
BS0454 - Lab calibration methods). ref SDS O9 V63L
BS0456 - ..
BS0457 - 3. How to avoid "wicked problem" of ignorning relatively benign
BS0458 - side effects of fatigue, weakness, shortness of breath from
BS0459 - treatment for cancer with cetuximab, without also ignoring
BS0460 - similar symptoms of pulmonary embolism and enlarged right
BS0461 - ventrical, a heart disorder called Cor Pulmanele, which
BS0462 - requires immediate treatment to prevent symptoms from
BS0463 - escalating into a lethal event.
BS0465 - ..
BS0466 - Strategy for distinguishing side effects of cetuximab from symptoms of
BS0467 - pulmonary embolism and Cor Pulmonale is discussed below. ref SDS 0
BS0468 - CV5L
BS0470 - ..
BS0471 - The doctor decided treatment should continue today with ANC 1.23 blood
BS0472 - counts below UCSF standard of 1.8 for giving treatment, because there
BS0473 - is concern that disease is expanding. ref SDS 0 LB5L Maintaining a
BS0474 - steady level of chemotherapy drug is a common strategy to treat
BS0475 - expanding cancer. Giving treatment with ANC below target levels
BS0476 - aligns with patient history listed on 060810 showing Millie has been
BS0477 - treated routinely when ANC falls below Kaiser's standard of 1500,
BS0478 - ref SDS F6 HV45, and further chemotherapy has been given in this case
BS0479 - with ANC in the range of 1230 (converted to Kaiser's standard),
BS0480 - reported in the test today, ref SDS N3 P560, e.g., see 050916.
BS0481 - ref SDS 91 R43M Additionally, WBC 4.1, which is a primary component
BS0482 - of ANC, is within the normal range (see blood test reported for
BS0483 - treatment today, ref SDS N3 075H), and Millie's energy has elevated
BS0484 - under treatment with cetuximab, allowing increased exercise that
BS0485 - strengthens the immune system, reviewed below. ref SDS 0 TQ6L
BS0487 - ..
BS0488 - The doctor decided to continue treatment today with cetuximab alone,
BS0489 - rather than add carboplatin at this time. Patient history indicates
BS0490 - expanding IBC occurred prior to starting treatment with cetuximab, per
BS0491 - above study. ref SDS 0 4140 Examinations indicate subsiding intensity
BS0492 - of IBC rash at all infection sites. ref SDS 0 M68J Decision support
BS0493 - was hampered without results of CA 15-3 tests this past month to
BS0494 - cross-check impressions from visual examination of declining disease.
BS0495 - ref SDS 0 MP58 The most recent CA 15-3 fell favorably from 68 to 56,
BS0496 - reported on 070202 for the test on 070131. ref SDS M2 GJ5M While
BS0497 - these results occurred prior to starting treatment with cetuximab on
BS0498 - 070201 and were erratic, noted in the meeting with Doctor Rugo on
BS0499 - 070130, ref SDS L7 S58L, this is the best evidence available. Since
BS0500 - adding carboplatin risks increasing downward pressure on ANC that
BS0501 - would make weekly treatments problematic, a strategy of continuing the
BS0502 - current regimen for at least another week was adopted.
BS0504 - ..
BS0505 - Doctor Rugo ordered another blood test to evaluate ANC next week. She
BS0506 - plans to examine Millie again prior to treatment on 070308, and assess
BS0507 - treatment strategy. By then CA 15-3 test data for the blood test
BS0508 - today should be available, as well as for tests on 070208 and 070215.
BS0509 - This additional test data will supplement visual examination to
BS0510 - evaluate response to treatment, and support deciding on changing the
BS0511 - treatment by adding carboplatin.
BS0512 -
BS0513 - [On 070306 Millie requested results of CA 15-3 tests on 070208
BS0514 - and 070215 to support follow up meeting at UCSF on 070208.
BS0515 - ref SDS N7 PY6N
BS0517 - ..
BS0518 - If CA 15-3 56 is rising, ref SDS 0 OL5M, it aligns with expanding IBC
BS0519 - disease, notably to the left arm, discussed above, ref SDS 0 LB5L, and
BS0520 - so may require adding carboplatin to increase strength and
BS0521 - effectiveness of treatment. similar to issue at Kaiser on 020603.
BS0522 - ref SDS 14 4X5K In that case, if NEUTS (ANC at Kaiser) remains below
BS0523 - criteria for safe treatment, as reported today, per above, ref SDS 0
BS0524 - V95M, then remedial measures will be required. e.g., Neupogen ordered
BS0525 - on 050415. ref SDS 73 KX49 If, on the other hand, CA 15-3 shows a
BS0526 - clear trend downward, this will align with the doctor's impression
BS0527 - that despite IBC having begun to expand prior to starting treatment on
BS0528 - 070201, treatments have been effective reducing the intensity of the
BS0529 - rash, per above. ref SDS 0 M68J
BS0531 - ..
BS0532 - Days later on 070307 a clear trend that CA 15-3 36 falling
BS0533 - significantly during treatment with cetuximab, further supports the
BS0534 - decision today to contiue treatment with cetuximab alone.
BS0535 -
BS0536 - [On 070308 meeting at UCSF cancelled because blood test on
BS0537 - 070301 reported CA 15-3 36 shows dramatic improvement, and ANC
BS0538 - blood counts increased to a safe level for treatment.
BS0539 - ref SDS N9 FO6H
BS0541 - ..
BS0542 - [On 070329 examination shows continued clinical improvement,
BS0543 - with no new IBC sites, and subsiding intensity of rash, and
BS0544 - aligns with continuing decline of CA 15-3 33 cancer marker.
BS0545 - ref SDS O6 M68J
BS0546 -
BS0547 -
BS0548 -
BS0549 -
BS0550 -
BS06 -
SUBJECTS
Treatment IBC 9th Cycle 3rd Relapse 2nd Cycle 1st Treatment Chemothe
BW03 -
BW0401 - ..
BW0402 - Treatment 1st Cycle Cetuximab Carboplatin 070201 9th Cycle 3rd Relapse
BW0403 - 9th Cycle Treatment IBC 3rd Relapse 2nd Cycle Cetuximab Clinical Study
BW0404 - Cetuximab 2nd Cycle 1st Treatment IBC 3rd Relapse Clinical Study Drug Trial
BW0405 -
BW0406 - Follow up ref SDS L7 PF3O, ref SDS K1 PF3O.
BW0407 -
BW0408 - The doctor approved Millie to start cycle #2 treatment with cetuximab
BW0409 - alone today, in accordance with strategy, discussed above. ref SDS 0
BW0410 - T85J She will meet with Millie next week to assess changing treatment
BW0411 - strategy based on blood test results for ANC and CA 15-3, under
BW0412 - analysis above. ref SDS 0 1T4O
BW0413 -
BW0414 - [On 070306 UCSF called to schedule meeting with Doctor Rugo on
BW0415 - 070308 1000. ref SDS N7 7Y5N
BW0417 - ..
BW0418 - [On 070306 Millie requested results of CA 15-3 tests on 070208
BW0419 - and 070215 to support follow up meeting at UCSF on 070208.
BW0420 - ref SDS N7 PY6N
BW0422 - ..
BW0423 - [On 070308 meeting with Doctor Rugo was cancelled because
BW0424 - diagnostics show patient responding to treatment. ref SDS N9
BW0425 - 407N
BW0427 - ..
BW0428 - Following the meeting with the doctor, treatment was given today at
BW0429 - 1500 in the Infusion Clinic, reported in another record, ref SDS N3
BW0430 - 1M6H, and additional blood vials were drawn for the drug trial
BW0431 - research. ref SDS N3 O56V
BW0432 -
BW0433 -
BW0434 -
BW0435 -
BW0436 -
BW05 -
SUBJECTS
Side Effects Cetuximab Acne-like Rash Face Controlled Prescribed Med
BZ03 -
BZ0401 - ..
BZ0402 - Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
BZ0403 - Energy Strength Rising Minimal Side Effects Cetuximab Treatment
BZ0404 - Facial Skin Dryness New Side Effect Cetuximab Curel Loation Prescribed
BZ0405 - Curel Lotion Prescribed Facial Skin Dryness New Side Effect Cetuximab
BZ0406 -
BZ0407 - Until the past few days following the 4th treatment with cetuximab,
BZ0408 - Millie's energy has been elevated compared to the past 8 months. She
BZ0409 - reported starting to work out in the gym on 070204, ref SDS M3 HF5H,
BZ0410 - which has been a goal for a long time, discussed at Kaiser on 070105.
BZ0411 - ref SDS K1 MA9K At that time, the primary care physician commented
BZ0412 - that pulmonary embolism and enlarged right ventrical may have caused
BZ0413 - permenant lung damage that will never permit vigorous exercise to
BZ0414 - strengthen the immune system to help resist cancer, and enable
BZ0415 - aggressive chemotherapy treatments. ref SDS K1 WR4J
BZ0417 - ..
BZ0418 - On 070218, Millie also reported playing tennis for the first time in
BZ0419 - many years, further indicating she is tolerating treatments with
BZ0420 - cetuximab well. ref SDS N0 N05H Higher energy from reduced side
BZ0421 - effects of cancer treatments enables regular exercise that increases
BZ0422 - fitness. Exercise and better fitness moderates emotional trauma
BZ0423 - confronting big changes in disease progression and response to
BZ0424 - treatment, per above. ref SDS 0 Y642
BZ0426 - ..
BZ0427 - Recent history of significantly increased energy seems conflicting
BZ0428 - with ANC falling to such a low count of 1.23, reported for the record
BZ0429 - on treatment today. ref SDS N3 P560
BZ0431 - ..
BZ0432 - Today, Millie feels tired after 4 treatments with cetuximab. Whether
BZ0433 - rising fatigue and weakness reflect falling blood counts, e.g., ANC
BZ0434 - 1.23, well below UCSF 1.8 criteria for giving treatment, and reported
BZ0435 - by Brigid today, per above, ref SDS 0 VF5M, or other short term
BZ0436 - factors that may be correctable is not clear in the record at this
BZ0437 - time.
BZ0438 -
BZ0439 - [On 070308 ANC increased to 1.51 within the normal range for
BZ0440 - cetuximab treatments. ref SDS N9 P560
BZ0442 - ..
BZ0443 - Facial dryness needs treatment in addition to treatment prescribed on
BZ0444 - 070222, ref SDS N1 FO66, as reported to UCSF in Millie's letter
BZ0445 - yesterday on 070228. ref SDS N2 LR4S
BZ0447 - ..
BZ0448 - Brigid presescribed Curel lotion to reduce facial dryness caused by
BZ0449 - cetuximab treatments.
BZ0451 - ..
BZ0452 - On the way home after treatment, Millie stopped at Long's Drugs on
BZ0453 - Treat street in Concord and purchased the lotion.
BZ0454 -
BZ0455 - [On 070308 Millie reported Curel treatment has brought some
BZ0456 - relief to facial dryness. ref SDS N9 JS6M
BZ0457 -
BZ0458 - [On 070329 Millie looks great, and feels fortunate to have
BZ0459 - avoided severe skin rash side effects of cetuximab by applying
BZ0460 - treatment prescribed by Brigid. ref SDS O6 N49K
BZ0462 - ..
BZ0463 - Side effects of fatigue, weakness cause loss of fitness with shortness
BZ0464 - of breath disclosed in the clinical study consent form, ref DRP 1
BZ0465 - HW54, reviewed on 070116, ref SDS K5 RT7K, are similar to symptoms of
BZ0466 - pulmonary embolism, discussed below, ref SDS L7 MO7K, and to symptoms
BZ0467 - of heart disorder Cor Pulmonale also described as enlarged right
BZ0468 - ventricle, is also discussed below. ref SDS L7 L56L
BZ0469 -
BZ0470 -
BZ0471 -
BZ0472 -
BZ0473 -
BZ05 -
SUBJECTS
Cetuximab Clinical Study UCSF Drug Trial Expanding IBC Metastatic Di
C803 -
C80401 - ..
C80402 - Cetuximab UCSF Clinical Study Treatment Begins 070201
C80403 - UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
C80404 - Drug Trials UCSF Has Other Clinical Study Treatments May Help Millie
C80405 -
C80406 - Follow up ref SDS L7 ZJ9N, ref SDS K1 P256.
C80407 -
C80408 - Background on Kaiser referral to UCSF for treatment on clincial study
C80409 - is reported on 070105. ref SDS K1 P256 Purpose of referral is to
C80410 - improve patient care with new treatment. ref SDS K1 PK7L Case study
C80411 - on Kaiser and UCSF collaborating to expedite treatment is listed
C80412 - above. ref SDS L7 4T5N
C80414 - ..
C80415 - Consideration of upgrading treatment by adding carboplatin to increase
C80416 - effectiveness of current treatment with cetuximab alone was deferred
C80417 - today under strategy discussed above. ref SDS 0 NY7N
C80418 -
C80419 -
C80420 -
C80421 -
C80422 -
C805 -
SUBJECTS
Schedule Treatment Cetuximab 070301 Clinical Study Drug Trial 2nd Cy
CC03 -
CC0401 - ..
CC0402 - Schedule Treatment Start Cetuximab Carboplatin 070201
CC0403 -
CC0404 - Follow up ref SDS L7 N96O, ref SDS K1 N96O.
CC0405 -
CC0406 - Millie will coordinate with Kaiser to schedule a CT test before
CC0407 - 070328, per planning above, ref SDS 0 5Z6L, and implementing Brigid's
CC0408 - request for the patient to coordinate communications with Kaiser,
CC0409 - ref SDS 0 CI9L, including outstanding CA 15-3 test results to support
CC0410 - meeting next week with Doctor Rugo on assessing changes to treatment,
CC0411 - per above. ref SDS 0 PF3O
CC0412 -
CC0413 - [On 070314 Millie notified UCSF CT test is scheduled for
CC0414 - 070326. ref SDS O1 DT4I
CC0416 - ..
CC0417 - Jackie will schedule Millie for treatments with cetuximab alone during
CC0418 - the next cycle, per strategy above. ref SDS 0 NY7N
CC0420 - ..
CC0421 - Jackie asked Millie to coordinate with Kaiser to get CA 15-3 results
CC0422 - for blood tests on 070208 and 070215 in time for meeting with Doctor
CC0423 - Rugo next week on 070308, as discussed with Brigid above. ref SDS 0
CC0424 - O67N
CC0426 - ..
CC0427 - Jackie will schedule a blood test to evaluate ANC prior to treatment
CC0428 - next week on 070308, ref SDS 0 VF6O, and will schedule a follow up
CC0429 - meeting with Doctor Rugo on 070308 to further evaluate treatment
CC0430 - strategy, per above, ref SDS 0 1T4O, and based on ANC and CA 15-3
CC0431 - cancer marker results from blood tests. ref SDS 0 MP58
CC0432 -
CC0433 - [On 070306 UCSF called to schedule meeting with Doctor Rugo on
CC0434 - 070308 1000. ref SDS N7 7Y5N
CC0436 - ..
CC0437 - [On 070306 Millie requested results of CA 15-3 tests on 070208
CC0438 - and 070215 to support follow up meeting at UCSF on 070208.
CC0439 - ref SDS N7 PY6N
CC0441 - ..
CC0442 - [On 070308 Noral, the Infusion Clinic receptionist, reported
CC0443 - that Millie was not scheduled for a blood test; a blood test
CC0444 - was performed on Millie's request that results are needed for
CC0445 - Doctor Rugo to assess ANC for approving treatment. ref SDS N9
CC0446 - 1M6H
CC0448 - ..
CC0449 - Meetings and treatments continue on Thursdays, so the next meeting at
CC0450 - Kaiser will be on 070308.
CC0451 -
CC0452 -
CC0453 -
CC0454 -
CC0455 -
CC05 -
SUBJECTS
Pulmonary Emboli Blood Clots Lungs Enlarged Right Ventricle Heart Di
CN03 -
CN0401 - ..
CN0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
CN0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
CN0404 - Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
CN0405 -
CN0406 - Follow up ref SDS L7 CV5L, ref SDS K1 CV5L.
CN0407 -
CN0408 - Background on pulmonary embolism recurrence and correlation with IBC
CN0409 - treatment at UCSF is reported in the record meeting with Doctor Rugo
CN0410 - on 070130, ref SDS L7 CV5L, presenting a "wicked problem" to avoid
CN0411 - ignorning needed treatment. ref SDS L7 MO7K
CN0413 - ..
CN0414 - Strategy for overcoming "wicked problems" differentiating side effects
CN0415 - of cetuximab treatment for IBC, from symptoms of pulmonary embolism,
CN0416 - which can quickly escalate into lethal events, ref SDS 0 HL6H, is CT
CN0417 - testing, reported on 070130. ref SDS L7 R16N On 070202, the primary
CN0418 - care physician at Kaiser requested a months notice from UCSF to order
CN0419 - the next CT test required by the cetuximab protocol, so that the test
CN0420 - can, also, test evaluate pulmonary embolism and enlarged right
CN0421 - ventricle. ref SDS M2 M15I UCSF
CN0423 - ..
CN0424 - On 070204 Millie notified Kaiser and UCSF there were no noticable
CN0425 - initial side effects of 1st treatment with cetuximab; energy has
CN0426 - increased, Millie worked out in the gym 2 days in a row, and for the
CN0427 - first time in 6 months; planning for CT test to evaluate pulmonary
CN0428 - embolism. ref SDS M3 JJ7O On 070218 energy increases, shortness of
CN0429 - breath, fatigue, weakness subside 10 weeks after ending treatment for
CN0430 - 3rd relapse of IBC with Taxotere and cacecitabine; exercising in the
CN0431 - gym and playing tennis 2 days her pulse reached 144. ref SDS N0 N05H
CN0433 - ..
CN0434 - On 070204 Millie sent a letter facilitating communications between
CN0435 - Kaiser and UCSF on coordinating this issue. ref SDS M3 4L5Q
CN0437 - ..
CN0438 - Today, Brigid advised that UCSF prefers that the patient coordinate
CN0439 - communications with Kaiser on scheduling and scope for the CT test,
CN0440 - ref SDS 0 UR9J, rather than UCSF medical professionals coordinate the
CN0441 - work, per above. ref SDS 0 CI9L
CN0442 -
CN0443 -
CN0445 - ..
CN0446 - INR 2.5 Blood Test Patient Stable for Coumadin Treatments Pulmonary Emboli
CN0447 -
CN0448 - Brigid advised that the blood test this morning shows INR 2.5 for
CN0449 - Millie, which needs to be submitted to Gloria at Kaiser's Coagulation
CN0450 - Control Clinic in Martinez, CA to prescribe Coumadin treatments for,
CN0451 - pulmonary embolism, as set out Millie's letter to UCSF yesterday on
CN0452 - 070228. ref SDS N2 LQ6W
CN0454 - ..
CN0455 - Earlier, when the meeting began, Brigid explained UCSF policy for
CN0456 - patients to coordinate medical diagnostics with Kaiser, see above.
CN0457 - ref SDS 0 O67N Jackie indicated Millie should submit INR results from
CN0458 - the UCSF blood test to Gloria. ref SDS 0 0U8K
CN0460 - ..
CN0461 - [On 070302 Gloria at the Kaiser Coagulation Control Clinic
CN0462 - in Martinez, CA called and left a message saying that since
CN0463 - Kaiser did not receive results of the blood test at UCSF
CN0464 - the day before on 070301, Millie should get a blood test
CN0465 - for INR the following week on 070308 to evaluate Coumadin
CN0466 - treatments for pulmonary embolism. ref SDS N4 U24Y
CN0468 - ..
CN0469 - [On 070302 Millie called back and left a message for Gloria at
CN0470 - the Kaiser Coagulation Control Clinic in Martinez, CA, and
CN0471 - Millie sent a letter to Arlette in the doctor's office at
CN0472 - Kaiser's oncology clinic in Walnut Creek; copies were sent to
CN0473 - Gloria, and to Jackie, the Clinical Research Coordinator at
CN0474 - UCSF confirming the telephone message to Gloria that reported
CN0475 - the blood test on 070301 shows INR 2.5, ref SDS N4 K14H, and so
CN0476 - testing for INR would occur with the next blood test on 070329
CN0477 - for the next cycle of cetuximab treatment for IBC. ref SDS N4
CN0478 - X84G
CN0480 - ..
CN0481 - After Millie met with Doctor Rugo, Brigid, and Jackie in the Breast
CN0482 - Care Center on the 2nd floor, Pauline in the Infusion Clinic submitted
CN0483 - the blood test report at the end treatment. Subsequent review showed
CN0484 - that the normal range for INR in UCSF blood test reports is different
CN0485 - from the range Kaiser uses to manage Coumadin treatments for pulmonary
CN0486 - embolism. ref SDS N3 SE6N
CN0487 -
CN0488 - [On 070305 entering results of the blood test on 070301 showed
CN0489 - a big difference in the way UCSF and Kaiser set the "normal"
CN0490 - range for INR, ref SDS N3 SE6N, Millie wrote a letter notifying
CN0491 - Jackie at UCSF with copies to Arlette and Gloria at Kaiser,
CN0492 - ref SDS N5 XG5H; and asking UCSF for clarification to
CN0493 - facilitate managing Millie's Coumadin treatments for pulmonary
CN0494 - embolism. ref SDS N5 3A4Y
CN0496 - ..
CN0497 - [On 070305 Millie requested that Gloria coordinate directly
CN0498 - with UCSF on interpreting the UCSF blood test report for
CN0499 - prescribing Coumadin to treat pulmonary embolism, and
CN0500 - reminded that UCSF has ordered another blood test on
CN0501 - 070308, so that INR can be tested again if needed.
CN0502 - ref SDS N5 3A6S
CN0504 - ..
CN0505 - [On 070305 Brigid advised INR 2 - 3 is the correct range for
CN0506 - prescribing Coumadin to treat Millie for pulmonary embolism,
CN0507 - despite being 100% over the normal range in the report for the
CN0508 - UCSF blood test on 070301. ref SDS N5 SN5O
CN0510 - ..
CN0511 - [On 070305 UCSF did not make distribution to coorindate
CN0512 - communciations with Kaiser; Millie sent a letter thanking
CN0513 - Brigid for timely response to INR question, and sent copies
CN0514 - thanking Jackie for timely coordination, and also copies to
CN0515 - Arlette at Kaiser in Walnut Creek, and to Gloria in
CN0516 - Kaiser's Coagulation Control Clinic in Martinez, CA for
CN0517 - managing Coumadin that treats Millie's pulmonary embolism.
CN0518 - ref SDS N5 B18H
CN0520 - ..
CN0521 - [On 070306 Millie requests feedback from Gloria to verify
CN0522 - accuracy of understandings that Kaiser is satisfied with
CN0523 - UCSF blood test on INR for prescribing Coumadin to treat
CN0524 - pulmonary embolism, and advises current regimen will
CN0525 - continue until further notice. ref SDS N6 FJ9K
CN0526 -
CN0527 -
CN0528 -
CN0529 -
CN0530 -
CN0531 -
CN06 -
SUBJECTS
Examination Stethoscope No Findings Enlarged Right Ventricle Heart S
CU03 -
CU0401 - ..
CU0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
CU0403 -
CU0404 - Follow up ref SDS L7 Q35O, ref SDS K1 Q35O.
CU0405 -
CU0406 - Examination with a stethoscope today included multiple locations on
CU0407 - Millie's back and chest. There were no findings of cardio pulmonary
CU0408 - issues from clinical examination.
CU0410 - ..
CU0411 - UCSF did not comment today on SaO2 diagnostic for oxygenated blood,
CU0412 - which has been cited at Kasier to indicate there is no alarm of
CU0413 - danger, shown by the report on 061208, ref SDS K1 1E5G, that Millie is
CU0414 - not suffering from loss of cardio-pulmonary functioning due to
CU0415 - pulmonary embolism, including enlarged left ventricle.
CU0417 - ..
CU0418 - After meeting with Doctor Rugo in the Oncology Clinic, Millie was
CU0419 - treated in the Infusion Clinic. Vitals were taken twice. The first
CU0420 - test reported Sa02 98%. ref SDS N3 AW4L
CU0421 -
CU0422 -
CU0423 -
CU0424 -
CU05 -
SUBJECTS
Enlarged Right Ventricle Heart Disorder Cor Pulmonale Related Pulmon
D003 -
D00401 - ..
D00402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
D00403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
D00404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
D00405 -
D00406 - Follow up ref SDS L7 VJ4J, ref SDS K1 VJ4J.
D00407 -
D00408 - Background on heart disorder Cor Pulmonale from enlarged right
D00409 - ventricle, and plans for follow up testing is reported in the record
D00410 - on 070130. ref SDS L7 VJ4J
D00412 - ..
D00413 - This issue is closely related to pulmonary embolism, reported by the
D00414 - primary care physician on 061228. ref SDS J7 JU7L Evident subsiding
D00415 - of symptoms for pulmoanry embolims reported above, also signals this
D00416 - issue seems under control. ref SDS 0 SX6N
D00418 - ..
D00419 - During the meeting at Kaiser on 070202, there was no discussion of
D00420 - UCSF recommendations on this issue. ref SDS M2 UN9F At this time, the
D00421 - primary care physician at Kaiser has not made referral for examination
D00422 - by a heart specialist, nor to get a treadmill test discussed by Doctor
D00423 - Rugo during the meeting on 070130. ref SDS L7 RV3O
D00424 -
D00425 -
D00426 -
D00427 -
D00428 -
D00429 -
D00430 -
D005 -