CONTACTS 

SUBJECTS
Meeting Examination Doctor Review Strategy Work Plan 5th Cycle 1st T

1403 -
1403 -    ..
1404 - Summary/Objective
1405 -
140501 - Follow up ref SDS 90 0000. ref SDS 87 0000.
140502 -
140503 - Millie was approved to start the 5th cycle of treatment with
140504 - cetuximab.  Examination today shows subsiding and stable IBC rash, and
140505 - no new sites, since treatment started on 070201 under a clinical study
140506 - of cetuximab alone. ref SDS 0 LB5L  A few days after meeting with the
140507 - medical team today, UCSF reported CA 15-3 37 increased 30%.
140508 - ref SDS 0 087J  Favorable examination, together with CT tests that
140509 - show no metastatic cancer present strong response to treatment,
140510 - ref SDS 0 EY5O, that supports starting cycle #5 today in the drug
140511 - trial. ref SDS 0 7X6N  NEUTS (ANC) blood counts rising to safe levels
140512 - support approval for treatments. ref SDS 90 1R4H  Pulmonary embolism
140513 - and enlarged right ventricle have not been tested nor compared for
140514 - progression of lung and heart disease with methods that discovered
140515 - preconditions. ref SDS 0 CV5L  Progress communicating and
140516 - collaborating strengthen coordination of Kaiser referral to UCSF.
140517 - ref SDS 0 ZO6F  Difficulty reporting patient history of lung and heart
140518 - disorders, ref SDS 0 GH5L, limits usefulness of CT scans by analysing
140519 - only 20% of test data. ref SDS 0 SY4K  Wicked problems implementing
140520 - policies to save time and money for health care costs arise from
140521 - failure to perform comparisons to evaluate progression of pulmonary
140522 - embolism and enlarged right ventricle, ref SDS 0 0136, in the context
140523 - of patient history that requires increased scrutiney. ref SDS 0 VF5M
140524 - Stress rises from conflicts in communication and coordination for case
140525 - management to reduce cost and provide increased scrutiney. ref SDS 0
140526 - FR6J
140528 -         ..
140529 -        [On 070625 CA 15-3 30 improved 30% for blood test on 070621
140530 -        aligns with clinical findings of IBC subsiding, indicating
140531 -        response to treatment with cetuximab alone. ref SDS A5 PD4N
140532 -
140533 -
140534 -
140536 -  ..
1406 -
1407 -
1408 - Progress
1409 -
140901 - Agenda Develop Work Plan Stage IV Breast Cancer 15 Mos after Mastectomy
140902 -
140903 - Follow up ref SDS 90 SM6M, ref SDS 87 SM6M.
140905 -  ..
140906 - Millie met today with the medical team at UCSF starting the 5th cycle
140907 - and 17th treatment of IBC with cetuximab, as planned in the launch
140908 - meeting on 070130. ref SDS 56 WM7G  Treatment at UCSF is on referral
140909 - from Kaiser for a clinical study drug trial ordered by the primary
140910 - care physician on 070105. ref SDS 51 PK68  This meeting starts the
140911 - 12th chemotherapy cycle since treatments began on 060711, ref SDS 27
140912 - SM6M, for the 3rd relapse of IBC. ref SDS 27 8Y8I
140914 -  ..
140915 - Complete list of treatments for IBC 3rd relapse is reported in the
140916 - record of treatment today in the Infusion Clinic. ref SDS A0 PR8Q
140918 -  ..
140919 - Case studies for Millie's patient history are listed on 061018.
140920 - ref SDS 38 0001
140922 -  ..
140923 - Agenda for meeting at UCSF on 070419 provides a structure for planning
140924 - the meeting today...
140925 -
140926 -    1.  Coordination plan.............................. ref SDS 0 S58J
140927 -    2.  CA 15-3 37 signals rising cancer............... ref SDS 0 GJ5M
140928 -    3.  Lymphedema restricts exercise.................. ref SDS 0 4Y93
140929 -    4.  Breast exam IBC stable subsides................ ref SDS 0 025H
140930 -    5.  Measurable disease declines and rises.......... ref SDS 0 M652
140931 -    6.  Side effects minimal........................... ref SDS 0 TQ6L
140932 -    7.  CT no metestatic disease, no test PE........... ref SDS 0 EY5O
140933 -    8.  Patient work up continue strategy.............. ref SDS 0 K36G
140934 -    9.  Treatment plan weekly clinical trial........... ref SDS 0 7X6N
140935 -   10.  Pulmonary emboli how serious r ventricle....... ref SDS 0 CV5L
140936 -   11.  Dizziness mild recurrence...................... ref SDS 0 PT4K
140938 -  ..
140939 - Scheduled next meeting for Thursday 070524 0830, reported in the
140940 - record on 070315. ref SDS 73 159O
140942 -  ..
140943 - The doctor could not support the meeting today;  Millie met with two
140944 - (2) assistants...
140945 -
140946 -        1.  Brigid, Nurse Practitioner
140947 -        2.  Jackie, Clinical Research Coordinator, coordinating
140948 -
140949 -
140950 -
140951 -
1410 -

SUBJECTS
Complex Patient History 45 Issues Overwhelms Span of Attention Drive

2303 -
230401 -  ..
230402 - Complex Patient History Knowledge Management Dilemma Issues Grow 45
230403 -
230404 - Follow up ref SDS 90 LU3J, ref SDS 87 LU3J.
230405 -
230406 - Sampling of issues patient history diagnosis and treatment...
230407 -
230408 -    1.  CA 15-3 monitors advance of cancer response to treatment
230409 -    2.  Lymphedema complicated by mastectomy surgery
230410 -    3.  Broken finger from minor fall complicates lymphedema
230411 -    4.  Esophagitis reflux digestion issues
230412 -    5.  Immune system chemotherapy increases risk of infection
230413 -        Chemotherapy increase risk of infection
230414 -    6.  Cat bites increase risk of infection complicates lymphedema
230415 -    7.  Pneumonia chemotherapy increases risk of infection
230416 -    8.  Metastatic cancer increases risk pulmonary embolism
230417 -    9.  Lymphadenopathy left axilla local regional metastasis
230418 -   10.  Lymphadenopathy right axilla distant metastasis
230419 -   11.  Lymphadenopathy left supraclavicular diagnose metastatic cancer
230420 -   12.  Breast cancer secondary IBC 3rd relapse left breast
230421 -   13.  Cancer mutates slow response chemotherapy treatment
230422 -   14.  Mastectomy surgery impact on treatment IBC relapse
230423 -   15.  Blood vessels removed mastectomy slow chemotherapy treatments
230424 -   16.  Treatment options, strategy, planning, schedule
230425 -   17.  Drug trials increase declining pool chemotherapy agents
230426 -   18.  UCSF Doctor Benz 2nd opinion apply diagnosis and treatment
230427 -   19.  Pulmonary embolism blood clots in lungs
230428 -   20.  INR weekly adjustments Coumadin treatment blood clots
230429 -   21.  Enlarged right ventricle heart problem core pulmonale
230430 -   22.  Dizziness symptom enlarged right ventricle cor pulmonale
230431 -   23.  Fatigue shortness breath side effect chemotherapy loss fitness
230432 -   24.  Fatigue shortness breath symptom pulmonary embolism
230433 -   25.  Shortness breath fatigue dizzy symptoms pulmonary embolism
230434 -   26.  Coagulapathy hypercoagulable state work up genetic risks
230435 -   27.  Testing resolution of errors (see Benz 2nd opinion 060821)
230436 -   28.  Testing distant metastatic disease
230437 -   29.  Testing pulmonary embolism and heart disease
230438 -   30.  Communication hectic schedule not enough time to manage details
230439 -   31.  Emotional stress and well being
230440 -   32.  Cellulitis inflammation temperature 102.6 on chemotherapy
230441 -   33.  Urinary tract bladder infection
230442 -   34.  IBC rash spreads to right breast
230443 -   35.  Right breast rash may be "ring" infection, not cancer
230444 -   36.  Lung cancer seems to be diagnosed in the Medical Chart
230445 -   37.  IBC rash spreads to stomach and toward back
230446 -   38.  IBC rash spreads to left arm
230447 -   39.  Dry skin face chest arm
230448 -   40.  Right arm evidence light red rash, may be IBC spreading
230449 -   41.  Rash right upper right chest near port catheter
230450 -   42.  Restless legs side effect Benadryl pre-treatment
230451 -   43.  Sleeping difficulty side effect cetuximab
230452 -   44.  Rash intense .5" round rash about .75" above port catheter
230453 -   45.  Sleep nap after cetuximab treatments fatigue accumulating
230454 -
230455 -
230456 -
230457 -
230458 -
2305 -

SUBJECTS
Vitals Submitted by Doctor UCSF Blood Pressure Pulse Normal Low Anxi

3003 -
300401 -  ..
300402 - Vitals Show Stable Medical Condition
300403 -
300404 - Follow up ref SDS 90 KB5L, ref SDS 87 KB5L.
300405 -
300406 -     Conversion Celsius to Farhenheit...
300407 -
300408 -              http://www.wbuf.noaa.gov/tempfc.htm
300409 -
300410 -                     Blood
300411 -    Date   Time   Pressure  Pulse  Temperture  Weight So2
300412 -    .
300413 -    070524 1235..... 134  75     61   36.6c  97.88f         99
300414 -    070524 1145..... 119  69     58   37.1c  98.78f         98
300415 -    070524   standing..........  67 ................
300416 -    070524 0945..... 132  80     56   37.0c  98.60f         98
300417 -    070517 1120..... 126  72     56   36.7c  98.06f        100
300418 -    070517 1020..... 140  75     54   36.6c  97.88f         98
300419 -    070517 0940..... 140  75     54   36.1c  96.98f         99
300420 -    070510 1145..... 145  86     54   35.9c  96.62f        100
300421 -    070510 1045..... 149  82     69   37.0c  98.60f         97
300422 -    070510 0900..... 132  75     62   36.8c  98.24f         99
300423 -    070503 1150..... 113  67     59   36.8c  98.24f         98
300424 -    070503 1055..... 125  72     54   36.1c  96.98f        100
300425 -    070503 0915..... 127  70     60   36.9c  98.42f         99
300426 -    070426 1130..... 119  70     57   36.3c  97.34f         96
300427 -    070426 1030..... 141  73     67   36.4c  97.52f         99
300428 -    070426 0900..... 130  78     52   36.5c  97.70f         97
300429 -    070419 1230..... 133  79    57    36.3c                 98
300430 -    070419 1130..... 141  78    56    37.6c                 99
300431 -    070419 0930..... 153  80    53    36.1c         147    100
300432 -    070330 1540..... 136  92    52    99.4          150     98
300433 -    070329 0900..... 141  76    60    36.6c                 99
300434 -    070301 1505..... 112  69    86    36.6c                 98
300435 -    070130 1300..... 140  83    87    98
300436 -    070105 1040.....
300437 -    061208 1226..... 152  90    76    97.8          147    99%
300438 -    061201 1430..... 123  76    76    97.5
300439 -    061110.......... 136  83    73    97.0          150    98%
300440 -    061020 1534..... 140  79    67    99.8          151    97
300441 -    060929 1452..... 141  78    66    98.3
300442 -    060908 1335..... 139  79    73    98.1
300443 -    060814 1610..... 139  80    59    98.2
300444 -    060808..........
300445 -    060711.......... 172  87    54    97.5          147
300446 -    060623.......... 141  87    71    98.0          147    99%
300447 -    060428.......... 129  73    80    99.4          149    99%
300448 -    060217.......... 153  81    61    98.6          150    99%
300450 -  ..
300451 - High blood pressure reflects pressure on patient about effectiveness
300452 - of new treatment and arrangements between UCSF and Kaiser for timely
300453 - care, discussed on 070130, ref SDS 56 Y642, and again on 070301.
300454 - ref SDS 65 Y642
300456 -  ..
300457 - Today, Millie's vitals are normal, indicating reduced emotional
300458 - strain, discussed with Brigid on 070315, ref SDS 73 6A7J, and reviewed
300459 - again during the meeting last week with the doctor on 070419,
300460 - ref SDS 87 Y642, citing improvement in patient status beginning a
300461 - month ago on 070329, ref SDS 80 Y642, and continuing today, per
300462 - below. ref SDS 0 Y642
300463 -
300464 -
300465 -
300466 -
3005 -

SUBJECTS
Coordination Plan Communication Collaboration Improve UCSF Schedules

6503 -
650401 -  ..
650402 - Coordination Plan Divided Responsibilities Kaiser UCSF Referral
650403 - Collaboration Primary Care at Kaiser with UCSF Clinical Study Cetuximab
650404 -
650405 - Follow up ref SDS 90 2S4H, ref SDS 87 RM4G.
650406 -
650407 - Background on coordination plan to manage divided responsibilities
650408 - between Kaiser and UCSF is reported on 070301. ref SDS 65 RM4G  Case
650409 - study on 070130 shows better communication can strengthen care.
650410 - ref SDS 56 4T5N  Requirements are listed on 070222. ref SDS 63 KL5G
650411 - On 070418, Millie reported that coordination improved, ref SDS 86
650412 - EQ6I, using email on 070406 for timely, accurate communication.
650413 - ref SDS 84 EQ6I.  Progress using explicit links for precision access
650414 - to find critical details was reported on 070419, ref SDS 87 DI8J, and
650415 - UCSF presented feedback on support needed for transitioning to
650416 - Knowledge Management modalities. ref SDS 87 DI9F  On 070426 Brigid
650417 - demonstrated skills using the Interent that brings "good management"
650418 - (see POIMS, ref OF 1 1X6G) within reach at UCSF. ref SDS 90 514G
650419 - Coordination of blood tests on 070426 demonstrated that following
650420 - protocols to test for safe treatments prior to getting treatment,
650421 - provides time to make adjustments. ref SDS 90 T15M
650423 -         ..
650424 -        [On 070610 primary care physician at Kaiser reports right
650425 -        communication channels are now open for coordination and
650426 -        collaboration with UCSF to treat Millie on referral.
650427 -        ref SDS A4 OG7F
650429 -  ..
650430 - Coordination took a big step forward on 070510 with UCSF contacting
650431 - Kaiser to schedule the next CT test, which previously was left for the
650432 - patient to coordinate. ref SDS 93 DT8I  UCSF reported comprehensive
650433 - care is difficult because coordinating the work to correct mistakes is
650434 - stressful. ref SDS 93 V36R  On 070511, Kaiser reported coordination
650435 - breakdown getting blood test reports from UCSF, and so ordered
650436 - additional testing, duplicating UCSF's work. ref SDS 94 T76M
650438 -  ..
650439 - At that time, Millie coordinated with Kaiser to correct mistakes in
650440 - the CT test schedule. ref SDS 94 T77M  Millie also ordered CA 15-3
650441 - testing to cross-check the lab at UCSF, and provide data for meeting
650442 - with the primary care physician at Kaiser scheduled for 070525.
650443 - ref SDS 94 B64J  Millie notified Kaiser on 070514 that UCSF calibrated
650444 - CA 15-3 dropped down to 29 in a test on 070426.  She requested results
650445 - of Kaiser's test to cross-check accuracy at the UCSF Lab. ref SDS 95
650446 - IN5P
650448 -  ..
650449 - UCSF concern that people avoid coordinating to reduce stress from
650450 - adjusting schedule issues, also, occurs managing scope of CT testing,
650451 - shown on 070510. ref SDS 93 VP4H  Communication and coordination with
650452 - Kaiser to perform requirements for the cetuximab study takes extra
650453 - effort to study and present patient history, ref SDS 93 HW5I,
650454 - including risks of compounding preconditions in this case. ref SDS 93
650455 - AL48  Since medical professionals avoid coordination to reduce stress,
650456 - ref SDS 93 TK8H, on 070514 the patient worked with Kaiser to implement
650457 - plans to assess lung and heart disorders with CT testing. ref SDS 95
650458 - IM9O
650460 -  ..
650461 - On 070517 the primary care physician advised that planning to assess
650462 - pulmonary embolism and enlarged right ventricle could be implemented,
650463 - but policy considerations prevent comprehensive care.  Kaiser's policy
650464 - position to save money by reducing tests on the basis that case
650465 - management will not be guided by test findings, ref SDS 98 OS5G,
650466 - reconciles prior conduct failing to peform required testing during
650467 - 2004, reported on 041007, ref SDS 13 RZ4I, and again this year
650468 - distorting good policy with bad implementation that prevents saving
650469 - lives, time, and money. ref SDS 98 KV3F  Doctor Benz noted on 041018
650470 - that patient history in this case requires increased scrutiney.
650471 - ref SDS 98 WX8I
650473 -  ..
650474 - Review on 070517 presents questions whether doctors can coordinate
650475 - internal services to manage care by specifying scope of tests based on
650476 - patient history. ref SDS 98 KV3F
650478 -  ..
650479 - Coordination is closely related to other subjects...
650480 -
650481 -        1.  Coordination........................... ref SDS 0 ZP3L
650482 -        2.  Wicked problems........................ ref SDS 0 VF5M
650483 -        3.  CT test scope history.................. ref SDS 0 GH5L
650484 -        4.  CT test scope comparison............... ref SDS 0 0136
650485 -        5.  Strategy risk management............... ref SDS 0 A67L
650486 -        6.  Treatment approval..................... ref SDS 0 L49O
650487 -        7.  Side effects assessment................ ref SDS 0 NY6N
650488 -        8.  Emotional stress....................... ref SDS 0 Y642
650489 -        9.  Pulmonary embolism..................... ref SDS 0 CV5L
650491 -  ..
650492 - Review on 070517 showing notification to Kaiser of CA 15-3 29 reported
650493 - at UCSF, and does not appear in Kaiser's medical chart for assessing
650494 - patient progress, ref SDS 96 RH9H, presents communication questions on
650495 - maintaining test data accurately to coordinate external referral for
650496 - comprehensive patient care. ref SDS 96 CG4I
650498 -  ..
650499 - The challenge of comprehensive care requires finding time to capture
650500 - an accurate record of patient history, and then finding critical
650501 - details in time to guide the work.  Timely, accurate understanding is
650502 - essential to make both internal and external coordination effective.
650503 - This is reflected in UCSF's letter on 070517 describing difficulties
650504 - coordinating lab work for referral patients. ref SDS 98 CV6K  When
650505 - people do not have time to understand correlations, implications, and
650506 - nuance bad implementation with snap judgements from cursory first
650507 - impressions turns good policy into poor care.
650508 -
650509 -
650510 -
650511 -
650512 -
6506 -

SUBJECTS
CA 15-3 37 Blood Tests 070524 Cancer Marker Begins Rising Possible 4

7303 -
730401 -  ..
730402 - CA 15-3 Cancer Marker 37 Shows Possible Progression of Disease
730403 -
730404 - Follow up ref SDS 90 087J, ref SDS 87 087J.
730405 -
730406 - Millie had a blood draw at Kaiser on 070511, and another this morning
730407 - in the Infusion Clinic at UCSF.  Results of the test at Kaiser were
730408 - received on 070516, and reported to UCSF at that time. ref SDS 96 J55T
730409 - Results of the test today at UCSF were reported a few days later
730410 - 070531, and show suprising increase from 29 to 37, reported in another
730411 - record today. ref SDS A0 A16M
730413 -           ..
730414 -         Test Date                         Date Received
730415 -          070524......... 37 H U........... 070524, ref SDS A0 A16M
730416 -          070511......... 56 H K........... 070516, ref SDS 96 RH9H
730417 -          070426......... 29 ..U........... 070501, ref SDS 92 EQ6I
730418 -          070329......... 33 H U........... 070406, ref SDS 84 EQ6I
730419 -          070301......... 36 H U........... 070307, ref SDS 66 A16M
730420 -          070215......... 52 H K........... 070307, ref SDS 61 ER5O
730421 -          070208......... 55 H K........... 070307, ref SDS 61 ER5O
730422 -          070201.....cetuximab begins...... 070201, ref SDS 59 G68I
730423 -          070131......... 56 H K........... 070202, ref SDS 60 087J
730424 -          070123......... 52 H K........... 070202, ref SDS 60 087J
730425 -          070118......... 68 H K........... 070123, ref SDS 55 GK5B
730426 -          070104......... 56 H K........... 070110, ref SDS 52 087J
730427 -          061218......... 74 H K........... 061227, ref SDS 46 6P9F
730428 -          061214......... 63 H............. 061227, ref SDS 46 6P9F
730429 -          061201....Pause treatments..... . 061201, ref SDS 42 GJ5M
730430 -          061130......... 67 H............. 061201, ref SDS 42 087J
730431 -          061116......... 66 H............. 061201, ref SDS 42 087J
730432 -          061110......... 56 H............. 061201, ref SDS 42 087J
730433 -          061109......... 61 H............. 061110, ref SDS 41 087J
730434 -          061026......... 57 H............. 061110, ref SDS 41 087J
730435 -          061019......... 56 H............. 061020, ref SDS 39 087J
730436 -          060928......... 51 H............. 060929, ref SDS 36 087J
730437 -          060907......... 68 H............. 060929, ref SDS 36 087J
730438 -          060813......... 73 H............. 060817, ref SDS 33 U24M
730439 -          060809......... 87 H............. 060810, ref SDS 32 2N5J
730440 -          060721..Taxotere capecitabine.... 060721, ref SDS 28 0001
730441 -          060708......... 71 H............. 060711, ref SDS 27 087J
730442 -          060616......... 63 H............. 060623, ref SDS 26 UQ5Q
730443 -          060522......... 59 H............. 060605, ref SDS 25 UQ5Q
730444 -          060501......... 49 H............. 060522, ref SDS 24 MC4F
730445 -          060421......... 44 H............. 060428, ref SDS 22 087J
730446 -          060330......... 40 H............. 060428, ref SDS 22 087J
730447 -          060303......... 36............... 060428, ref SDS 22 087J
730448 -          060210......... 33............... 060217, ref SDS 21 087J
730449 -          060109......... 34............... 060126, ref SDS 20 KV59
730451 -  ..
730452 - Note:  CA 15-3 test history prior to 2006 listed on 070426.
730453 - ref SDS 90 CY4F
730454 -
730456 -  ..
7305 -
7306 -
7307 - Analysis
7308 -
730801 - CA 15-3 37 Cancer Marker Rising Conflicts Favorable CT and Examination
730802 -
730803 - Follow up ref SDS 90 GJ5M, ref SDS 87 GJ5M.
730805 -  ..
730806 - Patient history applying CA 15-3 cancer marker data is shown in a case
730807 - study on 030710. ref SDS 5 IA7H
730809 -  ..
730810 - On 070514 Millie notified Kaiser that on 070426 UCSF reported CA 15-3
730811 - 29 in her case. ref SDS 95 IN5P
730813 -  ..
730814 - On 070516 Kaiser reported CA 15-3 increased to 56 in Millie's test on
730815 - 070511, 2 weeks after UCSF reported the lowest level in 6 years of
730816 - systemic treatments.  Disparity between cancer marker falling below
730817 - the safe level at UCSF, and rising well above at Kaiser was
730818 - disturbing, reviewed below reporting emotional issues. ref SDS 0 Y642
730820 -  ..
730821 - CA 15-3 for the blood test today was not available for review during
730822 - the meeting with the medical team at 0830, since blood was drawn later
730823 - at about 0930 in the Infusion Clinic.  At 1020, the Lab submitted test
730824 - results, ref SDS A0 A64L, for assessing safety of Millie getting
730825 - chemotherapy today based on ANC (NEUTS) blood counts, which showed
730826 - rising strength in the immune system. ref SDS A0 P560  UCSF contracts
730827 - with an outside company to perform CA 15-3 calibrations, and this
730828 - usually takes a few days. ref SDS A0 A16M
730830 -         ..
730831 -        [On 070531 UCSF not concerned results of blood test today show
730832 -        CA 15-3 37 rising 30% from the prior report on 070426, because
730833 -        CT scans show no metastatic cancer, and IBC inflammation
730834 -        appears to be subsiding. ref SDS A2 NQ6K
730836 -  ..
730837 - A week later, on 070531 Brigid submitted a letter reporting CA 15-3 37
730838 - for the test today using the Roche Elecsys 2010 ECLIA calibration
730839 - method. ref SDS A0 A16M   This increased 30% compared to CA 15-3 29
730840 - reported by UCSF a few weeks ago on 070426. ref SDS 90 087J  Rising
730841 - cancer marker aligns with concerns raised by Kaiser's test on 070511,
730842 - showing CA 15-3 56 using a different methodology, and reported by
730843 - Kaiser on 070516. ref SDS 96 RH9H
730844 -
730845 -        [On 070625 CA 15-3 30 improved 30% for blood test on 070621
730846 -        aligns with clinical findings of IBC subsiding, indicating
730847 -        response to treatment with cetuximab alone. ref SDS A5 PD4N
730849 -  ..
730850 - On 070516 Millie asked Kaiser to verify results of the report for the
730851 - test on 070511. ref SDS 96 ZJ9N  UCSF was also notified of disparity
730852 - in results for tests 2 weeks apart. ref SDS 96 J55T  There is no
730853 - record that Kaiser and UCSF have investigated.
730855 -  ..
730856 - On 070517 Nurse's Notes at UCSF report elevated CA 15-3.  Nurse
730857 - practitioner ordered retest; but, no test was actually performed to
730858 - check on accuracy of test findings. ref SDS 97 FG5N
730860 -  ..
730861 - Disparity between Laboratory test results for CA 15-3 occurs in part
730862 - from differences in calibration methods, noted by Kaiser in a letter
730863 - on 070517, which characterized UCSF and Kaiser modalities as "apples
730864 - and oranges." ref SDS 98 NT3O  UCSF commented the same day that rising
730865 - cancer marker remarkably different from UCSF diagnostics reported by
730866 - Kaiser does not require consideration to change treatment, nor verify
730867 - test results, and indicated that accuracy of tests can be improved by
730868 - avoiding cross-checking lab results. ref SDS 98 CV6K,
730870 -  ..
730871 - If the test today at UCSF had shown further decline of CA 15-3, or if
730872 - it had remained stable, this might have signalled greater concern to
730873 - investigate accuracy of testing at Kaiser and UCSF.  Since Kaiser
730874 - diagnostics track the rise at UCSF this may be grounds to ignore
730875 - disparity in test results at this time.
730877 -  ..
730878 - CT testing on 070520 was received today at UCSF and shows no basis for
730879 - rising CA 15-3, since the test finds no evidence of metastatic
730880 - disease. ref SDS 0 TV7N  Physical examination today further showed
730881 - continuing improvement with IBC inflammation subsiding at all sites.
730882 - ref SDS 0 M68J  On 070517 Brigid cited conflicting evidence of rising
730883 - CA 15-3. ref SDS 98 6E4G
730884 -
730885 -        [On 070531 UCSF not concerned results of blood test today show
730886 -        CA 15-3 37 rising 30% from the prior report on 070426, because
730887 -        CT scans show no metastatic cancer, and IBC inflammation
730888 -        appears to be subsiding. ref SDS A2 NQ6K
730889 -
730890 -
730891 -
730892 -
7309 -

SUBJECTS
Lymphadenopathy Axillary No Findings Left Arm Patient No Complaint S

8203 -
820401 -  ..
820402 - Axillary Left Arm No Lymphadenopathy Lymphedema Prominent
820403 - Lymphadenopathy Axillary Left Arm No Evidence Local Edema
820404 -
820405 - Follow up ref SDS 90 MW8J, ref SDS 87 MW8J.
820406 -
820407 - Patient has a long history of IBC on the left breast and associated
820408 - lymphadenopathy symptoms in the left axillary, see case study on
820409 - 040517. ref SDS 11 OW3I
820411 -  ..
820412 - Brigid examined the left axilla.  Clinical palpation made no findings
820413 - of lumps or other indications of cancer, including swelled lymph nodes
820414 - that might indicate lymphadenopathy that has previously occurred with
820415 - CA 15-3 rising, reported at Kaiser and for the test today at UCSF, per
820416 - above. ref SDS 0 087J  The patient made no complaint of lumps or
820417 - discomfort from swelling under the left arm.  This aligns with CT test
820418 - on 070520 showing no findings of lymphadenopathy, reported today,
820419 - ref SDS 0 B74K, although, there is no express finding that the analyst
820420 - actually looked at the left and right axillary.
820421 -
820422 -
820423 -
8205 -

SUBJECTS
Lymphedema Swelling Persistent Left Arm Upper Intensity Subsides Ras

A103 -
A10401 -  ..
A10402 - Lymphedema Cellulitis Complications Resolved Left Arm Swelling
A10403 - Swelling Left Arm Lymphedema Cellulitis Complications Resolved
A10404 - Left Arm Lymphedema Cellulitis Complications Resolved
A10405 - Cellulitis Lymphedema Complications Resolved Left Arm Swelling
A10406 -
A10407 - Follow up ref SDS 90 4Y93, ref SDS 87 4Y93.
A10408 -
A10409 - Medical history of lymphedema in the left arm is reported in a case
A10410 - study on 070130, ref SDS 56 VX6F, including recent increased swelling
A10411 - and inflammation from mild cellulitis diagnosed by the primary care
A10412 - physician during examination at Kaiser on 070330. ref SDS 83 T87G
A10414 -  ..
A10415 - The left arm today has continued swelling from lymphedema.  Recent
A10416 - measurement below the elbow was 10.75 inches, showing improvement, but
A10417 - increased above previous norms reported in a study on 060509.
A10418 - ref SDS 23 HO7F
A10420 -  ..
A10421 - There wasn't enough time again today for discussing correlations
A10422 - between exercise to strengthen the immune system that resists cancer,
A10423 - and helps dissipate emotional stress, reviewed at UCSF on 070315,
A10424 - ref SDS 73 6A7J, but may compound lymphedema with increased swelling,
A10425 - and complications of Cellulitis, discussed at UCSF on 070222.
A10426 - ref SDS 63 GG4H  Lymphedema and Cellulitis in relation to side effects
A10427 - of redness that occur on the cetuximab clinical study were considered
A10428 - on 070419. ref SDS 87 F57K
A10430 -  ..
A10431 - Examination today shows no evidence of elevated inflammation on the
A10432 - left arm diagnosed at Kaiser on 070330, ref SDS 83 T87G, and
A10433 - consideration on 070419 in connection with rising IBC, cellulitis,
A10434 - and/or side effects of cetuximab. ref SDS 87 115F  Findings today
A10435 - support Millie's letter on 070418 reporting resolution of erratic rash
A10436 - on 070330, ref SDS 86 PZ3P, discussed further below reviewing side
A10437 - effects. ref SDS 0 LS8L
A10439 -         ..
A10440 -        [On 070607 recurrent cellulitis diagnosed during examination at
A10441 -        UCSF for treatment of IBC with cetuximab, ref SDS A3 8H3I;
A10442 -        condition worsened during treatment in the Infusion Clinic,
A10443 -        temperature over 102, ref SDS A3 8J37; UCSF treated Millie with
A10444 -        ceftriaxone antibiotics, ref SDS A3 8J9R, cellulitis seemed to
A10445 -        subside, and temperature dropped to 101.4, UCSF released Millie
A10446 -        to go home, ref SDS A3 8J5C; Kaiser prescribed outpatient
A10447 -        ceftriaxone antibiotics for 5 days. ref SDS A3 8L46
A10448 -
A10449 -
A10450 -
A10451 -
A105 -

SUBJECTS
IBC Left Arm Examination Stable Subsides Rash Less Intense Conflicts

AG03 -
AG0401 -  ..
AG0402 - IBC Left Arm Stable Subsiding Responds Treatment Cetuximab Drug Trial
AG0403 - Left Arm IBC Stable Subsiding Responds Treatment Cetuximab Drug Trial
AG0404 -
AG0405 - Follow up ref SDS 90 527G, ref SDS 87 527G.
AG0406 -
AG0407 - Examination this moring shows stable to reduced intensity of IBC rash
AG0408 - on the upper left arm.
AG0410 -  ..
AG0411 - The area of IBC inflammation on the upper left arm has been stable to
AG0412 - subsiding, i.e., improving by responding to treatment, since the prior
AG0413 - examination at UCSF on 070426. ref SDS 80 527G  Observation of IBC
AG0414 - subsiding on the upper left arm aligns with the CT test on 070520 and
AG0415 - received from UCSF this morning, which shows impression of no evidence
AG0416 - for metastatic cancer, per below. ref SDS 0 TV7N
AG0418 -  ..
AG0419 - Rising CA 15-3 33 cancer marker reported for the blood test today, per
AG0420 - above, ref SDS 0 087J, seems to conflict with impression of subsiding
AG0421 - IBC rash on the left arm.
AG0423 -  ..
AG0424 - Since today starts a new treatment cycle, per above, ref SDS 0 SM6M,
AG0425 - Jackie took photographs for measurable disease.
AG0427 -  ..
AG0428 - Brigid took measurements, and indicated the area of rash is about the
AG0429 - same as last month on 070426, ref SDS 90 2E9I, and discussed further
AG0430 - below. ref SDS 0 M652
AG0431 -
AG0432 -
AG0433 -
AG0434 -
AG0435 -
AG05 -

SUBJECTS
Right Axillary Lymphadenopathy No Findings Right Arm Patient No Comp

AP03 -
AP0401 -  ..
AP0402 - Right Axillary Possible Involvement Red Rash Spreads Right Breast
AP0403 -
AP0404 - Follow up ref SDS 90 3D6K, ref SDS 87 3D6K.
AP0405 -
AP0406 - Background on patient history testing for lymphadenopathy in the right
AP0407 - axilla is reported in the record on 060929. ref SDS 36 3D6K
AP0409 -  ..
AP0410 - Examination of the right axillary yielded the same negative results
AP0411 - finding no evidence of lymphadenopathy, as occurred examining the left
AP0412 - axilla, per above. ref SDS 0 VU6O  Also aligns with CT test on 070520,
AP0413 - reviewed during the meeting today, per below. ref SDS 0 B74K
AP0414 -
AP0415 -
AP0416 -
AP0417 -
AP05 -

SUBJECTS
Right Arm Examination Rash Slight Blemishes No Evidence IBC No Findi

AX03 -
AX0401 -  ..
AX0402 - IBC Right Arm No IBC Red Rash or Cellulitis
AX0403 -
AX0404 - Follow up ref SDS 90 H15M, ref SDS 87 H15M.
AX0405 -
AX0406 - Background on slight red dots, rash or blemishes on the right arm is
AX0407 - reported on 070301. ref SDS 65 H15M  Examination at that time
AX0408 - concluded the rash is not IBC.  Further examination on 070315 reached
AX0409 - the same conclusion, ref SDS 73 FO6H, supported by another review on
AX0410 - 070322. ref SDS 74 LI4M
AX0412 -  ..
AX0413 - Examination today yielded no change in analysis that IBC has not
AX0414 - spread to the right arm, and Cellulitis has not occurred in the right
AX0415 - arm.  Similarly, there is no evidence of side effects in the right arm
AX0416 - from cetuximab treatment for IBC, reported on 070426. ref SDS 90 H15M
AX0417 -
AX0418 -
AX0419 -
AX0420 -
AX0421 -
AX05 -

SUBJECTS
IBC Right Breast Examination Stable Subsides Rash Inflammation Less

B703 -
B70401 -  ..
B70402 - Right Breast IBC Rash Intensity Subsides
B70403 - Rash Right Breast Inflammation Intensity Subsides
B70404 -
B70405 - Follow up ref SDS 90 W58J, ref SDS 87 W58J.
B70407 -  ..
B70408 - On 061204 IBC inflammation spread from the left chest area infected
B70409 - with IBC across the sternum and slightly onto the right breast.
B70410 - ref SDS 44 AE5I  Since then, IBC has not spread farther.  It became
B70411 - more intense through January, and then has continued to subside with
B70412 - treatment.
B70414 -  ..
B70415 - Examination of right breast today shows reduced intensity of IBC rash,
B70416 - and there is no spreading of the rash, suggesting favorable response
B70417 - to treatment.  This aligns with CT test on 070520 that presents
B70418 - impression of no evidence for metastatic disease, reported below.
B70419 - ref SDS 0 TV7N  Rising CA 15-3 33 cancer marker reported for the blood
B70420 - test today, per above, ref SDS 0 087J, may conflict with impression of
B70421 - subsiding IBC on the right breast.
B70423 -  ..
B70424 - Today starts a new cycle, so Brigid took measurements; Jackie took
B70425 - photographs, per above, ref SDS 0 2E9I, and discussed further below.
B70426 - ref SDS 0 M652
B70427 -
B70428 -
B70429 -
B70430 -
B705 -

SUBJECTS
Rash Chest Right Side Above Breast Below Collar Bone Above Port Cath

BI03 -
BI0401 -  ..
BI0402 - Right Chest Rash Not Visible Above Breast and Port Catheter
BI0403 - Rash Above Port Catheter on Right Upper Chest Not Visible Today
BI0404 -
BI0405 - Follow up ref SDS 90 583G, ref SDS 87 583G.
BI0406 -
BI0407 - Background is reported in the record last week on 070419. ref SDS 87
BI0408 - 583G  There has been no further report of inflammation at this
BI0409 - location.
BI0410 -
BI0411 -
BI0412 -
BI05 -

SUBJECTS
Right Chest Blemish Port Catheter .75" Above Infection .5" Diameter

BW03 -
BW0401 -  ..
BW0402 - Port Catheter Infection Blemish Right Chest Blood Culture Investigate
BW0403 -
BW0404 - Follow up ref SDS 90 IL3L, ref SDS 87 S640.
BW0405 -
BW0406 - Today the entry to the port catheter shows very mild inflammation, if
BW0407 - any, more of a skin blemish.  Last week on 070517 Nurse's Notes report
BW0408 - this location is red and tender again, ref SDS 97 UD4K, but today the
BW0409 - site seems normal, indicating resolution of issue observed by Doctor
BW0410 - Rugo on 070419. ref SDS 87 S640
BW0412 -  ..
BW0413 - The previous blemish above the port catheter observed on 070419,
BW0414 - ref SDS 87 Q564, now presents no visible impression.
BW0415 -
BW0416 -
BW05 -

SUBJECTS
Left Supraclavicular Examination Palpation Neck Lymphadenopathy No F

C503 -
C50401 -  ..
C50402 - Left Supraclavicular Examination PET Test Report Finding SUV 4.5
C50403 - Prognosis Stage IV Metastatic Disease Relapse IBC Seems Likely
C50404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
C50405 -
C50406 - Follow up ref SDS 90 8R6M, ref SDS 87 8R6M.
C50407 -
C50408 - During examination on 070130, Doctor Rugo asked about history of
C50409 - radiation to the neck, and sequence of finding recurrence from Doctor
C50410 - Laio's biopsy reported on 040309. ref SDS 8 0001  Background of image
C50411 - testing, and consideration for radiation treatment of left
C50412 - supraclavicular is reported on 060623. ref SDS 26 8R6M
C50414 -  ..
C50415 - Like the left and right axillary locations, examination today for
C50416 - cancer in left supraclavicular region found no evidence of lumps or
C50417 - other indications of lymphadenopathy, as reported above, ref SDS 0
C50418 - VU6O, and citing conflict with rising CA 15-3, reported at Kaiser and
C50419 - for the test today at UCSF, also, per above. ref SDS 0 087J  CT test
C50420 - on 070520 shows no findings of lymphadenopathy, reported during
C50421 - examination today, per below. ref SDS 0 B74K  There is no express
C50422 - finding in the CT test report that the analyst actually looked at the
C50423 - left and right supraclavicular.
C50425 -  ..
C50426 - Patient history of cancer recurrence discovered from lymphadenopathy
C50427 - in the left supraclavicular, reported on 040227. ref SDS 7 886G
C50428 - Rising cancer marker reported today at UCSF confirming Kaiser's report
C50429 - on 070516 requires careful examination of this area.
C50430 -
C50431 -
C50432 -
C50433 -
C505 -

SUBJECTS
IBC Left Breast Examination Stable No New Sites Rash Intensity Susid

CN03 -
CN0401 -  ..
CN0402 - 2 Scenarios IBC Subsides Conflicts CA 15-3 37 Cancer Marker Rises 30%
CN0403 - IBC Rash Left Breast Stomach and Back Seems to Be Subsiding
CN0404 - Examination IBC Rash Subsiding Responding to Treatment Cetuximab
CN0405 - Cetuximab Effective Treatment IBC Subsiding Left Breast Stomach Back
CN0406 -
CN0407 - Follow up ref SDS 90 025H, ref SDS 87 025H.
CN0408 -
CN0409 - Background of IBC 3rd relapse on left breast beginning on 060623, and
CN0410 - treatment with Taxotere and capecitabine ending on 061201, with
CN0411 - subsequent progression of disease spreading to other areas is reported
CN0412 - on 070301. ref SDS 65 025H
CN0414 -  ..
CN0415 - Case study on 070130 shows erratic changes in severity/intensity of
CN0416 - IBC rash on left chest area, with referral to UCSF. ref SDS 56 5N6L
CN0418 -  ..
CN0419 - All case studies for Millie's patient history are listed on 061018.
CN0420 - ref SDS 38 0001
CN0422 -  ..
CN0423 - Cetuximab treatment started at UCSF on 070201. ref SDS 59 G68I
CN0425 -  ..
CN0426 - Strategy for treating progression of disease was reviewed on 070301.
CN0427 - ref SDS 65 1T4O  Rising CA 15-3 reported by Kaiser and shown in the
CN0428 - blood test today, per above, ref SDS 0 087J, elevates strategy in
CN0429 - treatment considerations.
CN0431 -  ..
CN0432 - Examination today shows intensity of IBC rash continues to subside or
CN0433 - remains stable, and there is no evident expansion of IBC rash areas,
CN0434 - and further there are no new IBC rash sites, as listed on 070301.
CN0435 - ref SDS 65 4140  The current condition today is...
CN0436 -
CN0437 -            left breast chest................. 060623, ref SDS 26 025H
CN0438 -            right breast...................... 061204, ref SDS 44 AE5I
CN0439 -            stomach........................... 070130, ref SDS 56 M68J
CN0440 -            back.............................. 070130, ref SDS 56 M68J
CN0441 -            left arm.......................... 070202, ref SDS 60 6Q5N
CN0443 -  ..
CN0444 - Doctor Rugo carefully examined the stomach and back for signs of rash
CN0445 - previously diagnosed on 070130 ref SDS 56 M68J, and noted these rash
CN0446 - areas have nearly disappeared after 4 cycles of treatment with
CN0447 - cetuximab.
CN0448 -
CN0449 -        [On 070531 UCSF not concerned results of blood test today show
CN0450 -        CA 15-3 37 rising 30% from the prior report on 070426, because
CN0451 -        CT scans show no metastatic cancer, and IBC inflammation
CN0452 -        appears to be subsiding. ref SDS A2 NQ6K
CN0454 -  ..
CN0455 - CT test on 070520, and reported by UCSF today, shows no evidence of
CN0456 - metastatic disease progressing, ref SDS 0 TV7N; typically, IBC does
CN0457 - not register well with CT testing, unless analysts look for thickened
CN0458 - skin, illustrated by the record on 030710, ref SDS 5 VM7I, and which
CN0459 - aligned with prior PET test on 021218, reporting uptakes in upper left
CN0460 - chest wall, received from Kaiser on 030109. ref SDS 3 L66M  Like the
CN0461 - left and right axillary, reported above, ref SDS 0 VU6O, and, also,
CN0462 - the right breast area, ref SDS 0 613F, examination of the left breast
CN0463 - today finding no evidence of IBC progression appears conflicting with
CN0464 - rising CA 15-3.  Patient history shows there is typically a lag
CN0465 - between changes in the cancer marker and observing increased IBC,
CN0466 - ref SDS 0 087J, which suggests requirements for increased scrutiny
CN0467 - with testing and examination for signals to strengthen treatment,
CN0468 - planned under strategy. ref SDS 0 K36G
CN0469 -
CN0470 -
CN0471 -
CN0472 -
CN05 -

SUBJECTS
Prognosis Stable Subsiding IBC Rash Conflicts Rising CA 15-3 37 Canc

CV03 -
CV0401 -  ..
CV0402 - Prognosis Good IBC Stable Cetuximab Clinical Study
CV0403 - Stable Low Intensity IBC Rash Very Good Response to Treatment
CV0404 - Cetuximab Prognosis Good Chance IBC Rash 3rd Relapse Will Clear Up Again
CV0405 -
CV0406 - Follow up ref SDS 90 M645, ref SDS 87 M645.
CV0408 -  ..
CV0409 - Subsiding IBC and no new disease sites, ref SDS 0 M68J, together with
CV0410 - favorable CT test reported today, ref SDS 0 TV7N, indicate treatment
CV0411 - with cetuximab alone seems effective at this time, as discussed with
CV0412 - Doctor Rugo on 070130. ref SDS 56 M645  This aligns with Brigid's
CV0413 - report on 070510 that success treating Millie's cancer is remarkable
CV0414 - and unexpected because other patients have had progression of disease
CV0415 - that required adding carboplatin after only a few weeks of treatment
CV0416 - with cetuximab alone. ref SDS 93 6A9H
CV0418 -  ..
CV0419 - Rising cancer marker at Kaiser and from testing today at UCSF,
CV0420 - reviewed above, ref SDS 0 GJ5M, indicates possible progression of
CV0421 - disease, which may lead to adding carboplatin called out in the
CV0422 - clinical study protocol, received from UCSF on 070116. ref SDS 53 NL7I
CV0423 - Brigid's letter on 070517 advised that UCSF does not propose changing
CV0424 - treatment based on rising CA 15-3 reported by Kaiser. ref SDS 98 6E4G
CV0425 - This aligns with examination today showing IBC continues to subside,
CV0426 - ref SDS 0 M68J, and with CT test showing not evidence of metastatic
CV0427 - cancer, per below. ref SDS 0 TV7N
CV0428 -
CV0429 -     [On 070525 primary care physician at Kaiser concurs with UCSF
CV0430 -     prognosis and recommends continuing with cetuximab alone.
CV0431 -     ref SDS A1 M645
CV0432 -
CV0433 -
CV0434 -
CV05 -

SUBJECTS
Wicked Problems Complex Compound Issues Policy Conflicts Medical Tes

DT03 -
DT0401 -  ..
DT0402 - Wicked Problems Good Management Looks Like Unnecessary Overkill
DT0403 - Communication Coordination Failure Perform Complex Wicked Problems
DT0404 - Comparison Evaluate Progression Lung Heart Disorders Side Effects
DT0405 - Unnecessary Overkill Evaluate Progression Disease Comparison CT Tests
DT0406 -
DT0407 - Follow up ref SDS 90 VF5M, ref SDS 87 VF5M.
DT0409 -  ..
DT0410 - Wicked problems were reviewed on 070426, ref SDS 90 VF5M, citing
DT0411 - research on 060722 showing complexities of health care cause people to
DT0412 - get confused, mistake, and ignore symptoms of life threatening disease
DT0413 - as expected and benign side effects that patients must tolerate for
DT0414 - cancer treatments. ref SDS 29 346F  Difficult problems require
DT0415 - increased scrutiney to recognize correlations, implications and nuance
DT0416 - in time to be effective, especially in Millie's case of personal and
DT0417 - family history that signals high susceptibility, shown by case study
DT0418 - on 060722, ref SDS 29 6G6O, and where treatment has documented risks
DT0419 - of patient preconditions, in this case for lung and heart disorders,
DT0420 - discussed below, ref SDS 0 CV5L, citing the record on 070116.
DT0421 - ref SDS 53 I75I
DT0423 -  ..
DT0424 - Scope of CT testing for increased scrutiney of side effects from
DT0425 - cetuximab to evaluate progression of disease for preconditions of
DT0426 - blood clots in the lungs, pulmonary embolism, and enlarged right
DT0427 - ventricle, Cor Pulmonale was discussed with the medical team at UCSF
DT0428 - on 070510 to order CT testing at 1 mm scans rather than 5 mm, which
DT0429 - reduces scrutiney to only 20% of the data. ref SDS 93 VP4H  At that
DT0430 - time, UCSF proposed reduced scrutiney at 5 mm intervals, ref SDS 93
DT0431 - XS9L, which conflicts with Millie's patient history identifying lung
DT0432 - and heart disorders with only elevated review using thin slice spiral
DT0433 - CT testing at 1 mm intervals. ref SDS 93 HW5I  UCSF explained
DT0434 - increased risks examining only 20% of test data has been effective for
DT0435 - other patients, ref SDS 93 KD5I, and avoids inconvenience of stressful
DT0436 - coordination with Kaiser from team care practice on referral.
DT0437 - ref SDS 93 TK8H  Desire to avoid stressful communication coordinating
DT0438 - the work is shown by difficulty arranging referral listed in the case
DT0439 - study on 070130, ref SDS 57 2X6L, difficulty obtaining results of
DT0440 - cancer marker tests shown in a follow up case study on 070307,
DT0441 - ref SDS 70 Q65K, and further difficulty scheduling tests, presented in
DT0442 - another case study on 070307. ref SDS 70 G56L
DT0444 -  ..
DT0445 - On 070517 Kaiser notified Millie not to worry about reviewing only 20%
DT0446 - of test data, since this saves Kaiser time and money to treat other
DT0447 - patients. ref SDS 98 OS5G  Review on 070517 shows that saving time and
DT0448 - money does not justify reducing test standards for patients that
DT0449 - require increased test scrutiney, per below. ref SDS 0 X24F
DT0451 -  ..
DT0452 - Patient history reviewed at that time on 070517 does not support
DT0453 - assurances not to worry in the absence of affirmative test data.
DT0454 - ref SDS 98 KV9G  Case study on 061012 shows the Imaging Department at
DT0455 - Kaiser in Walunt Creek CA has consistently ignored doctor's orders to
DT0456 - perform thin slice spiral CT testing, has failed to present patient
DT0457 - history of lung and heart disorders, and failed to compare prior test
DT0458 - findings for evaluating progression of pulmonary embolism and enlarged
DT0459 - right ventricle, ref SDS 37 A55J, which currently presents increased
DT0460 - risk from treatment with cetuximab, discussed by the doctors during
DT0461 - referral arrangements on 061230, ref SDS 48 PN6R, cited in Consent
DT0462 - doucments for the clinical study received on 070116,
DT0464 -  ..
DT0465 - This record suggests that team care, referral, collaboration,
DT0466 - communication and coordinating case management present "wicked
DT0467 - problems" for health care that compound inherent difficulties of
DT0468 - complex medical practice.  On 070517 UCSF confirmed that referral care
DT0469 - presents difficulties for case management, citing conflicting results
DT0470 - from Laboratories.  At that time, UCSF proposed solving this problem
DT0471 - by avoiding cross-checking test data to verify accuracy. ref SDS 98
DT0472 - 466H
DT0474 -  ..
DT0475 - Wicked problems evaluating progression of lung and heart disorders
DT0476 - occur tracking case management in the following subjects....
DT0477 -
DT0478 -        1.  Coordination........................... ref SDS 0 ZP3L
DT0479 -        2.  Wicked problems........................ ref SDS 0 VF5M
DT0480 -        3.  CT test scope history.................. ref SDS 0 GH5L
DT0481 -        4.  CT test scope comparison............... ref SDS 0 0136
DT0482 -        5.  Emotional stress....................... ref SDS 0 Y642
DT0483 -        6.  Strategy risk management............... ref SDS 0 A67L
DT0484 -        7.  Treatment approval..................... ref SDS 0 L49O
DT0485 -        8.  Side effects assessment................ ref SDS 0 NY6N
DT0486 -        9.  Pulmonary embolism..................... ref SDS 0 CV5L
DT0487 -
DT0488 -
DT0489 -
DT05 -

SUBJECTS
Measurable Disease IBC CA 15-3 37 Test 070524 Cancer Marker Rises Co

E803 -
E80401 -  ..
E80402 - Measurable Disease IBC No New Sites No Expansion Intensity Declines
E80403 - Photographs Record Measurable Disease IBC Tumor in Dermal Tissue
E80404 - Measurable Disease IBC Observed with Tape Measure Photograph Pictures
E80405 - CA 15-3 Diagnostic Measurable Disease IBC Not Measured by Image Testing
E80406 -
E80407 - Follow up ref SDS 90 M652, ref SDS 87 M652.
E80408 -
E80409 - Background on measurable disease for IBC using cancer biomarker CA
E80410 - 15-3 and photographic records showing spread of cancer is reported in
E80411 - a case study on 070101. ref SDS 49 4Q6K
E80413 -  ..
E80414 - CA 15-3 37 at UCSF and 56 at Kaiser present sudden reversal of prior
E80415 - favorable trends, ref SDS 0 087J, with implications of possible
E80416 - progression of disease. see "prognosis." ref SDS 0 M645
E80418 -  ..
E80419 - CT testing on 070520 finds no evidence of metastatic disease, shown in
E80420 - the report received today, per below. ref SDS 0 TV7N  This aligns with
E80421 - examination that observes no progression of IBC rash. ref SDS 0 M68J
E80423 -  ..
E80424 - Jackie and Brigid used procedures reported on 070329, ref SDS 80 EX8O,
E80425 - to take pictures today for the clinical study protocol that show
E80426 - measurable disease of IBC has not expanded, and that intensity of rash
E80427 - sites has subsided, since evaluation of the previous cycle on 070426,
E80428 - also, reported above. ref SDS 0 M68J
E80429 -
E80430 -
E80431 -
E80432 -
E805 -

SUBJECTS
Lung Cancer No Discussion Metastatic Disease Nodes Doctor's Progress

EK03 -
EK0401 -  ..
EK0402 - Lung Cancer Lymph Nodes Doctor's Progress Notes Medical Chart
EK0403 - Metastatic Cancer Lung Lymph Node Progress Notes Medical Chart
EK0404 -
EK0405 - Follow up ref SDS 90 G25K, ref SDS 87 G25K.
EK0406 -
EK0407 - Background is reported on 070130 in the record meeting with Doctor
EK0408 - Rugo at UCSF. ref SDS 56 G25K  Findings of no "interstitial disease"
EK0409 - in the most recent CT test on 070520, shown below, ref SDS 0 SP3F, do
EK0410 - not support concern about lung cancer shown in Kaiser's Medical Chart
EK0411 - on 061208, ref SDS 45 G25K, and further indicates this side effect of
EK0412 - cetuximab treatment has not occurred in Millie's case so far, reported
EK0413 - previously on 070329. ref SDS 80 123I  Interstitial lung disease was
EK0414 - listed in the clincial study Consent documents received from UCSF on
EK0415 - 070116. ref SDS 53 0256
EK0417 -  ..
EK0418 - There was no discussion of this issue today, so that attention could
EK0419 - focus on assessing Millie's response to treatment for IBC, with
EK0420 - analysis of rising CA 15-3 cancer marker, per above. ref SDS 0 GJ5M
EK0421 -
EK0422 -
EK0423 -
EK0424 -
EK05 -

SUBJECTS
CT Test Distant Metastasis No Findings Lymphadenopathy Cancer CT Sca

EQ03 -
EQ0401 -  ..
EQ0402 - CT Test 070520 No Findings Metastatic Disease
EQ0403 -
EQ0404 - Follow up ref SDS 80 EY5O, ref SDS 65 EY5O.
EQ0405 -
EQ0406 - Report on results for the CT test on 070520, as scheduled on 070516,
EQ0407 - ref SDS 96 EF9M, was received today during the meeting.  Impressions
EQ0408 - of no metastatic disease, ref SDS 0 TV7N, align with patient history
EQ0409 - showing no evidence of regional nor distant metastasis, reported
EQ0410 - previously on 070329 for the test on 070326. ref SDS 80 EY5O
EQ0411 -
EQ0412 -            [On 070802 received next CT test. ref SDS A6 O85M
EQ0414 -         ..
EQ0415 -        Test History No Evidence Distant Metastasis
EQ0416 -        Distant Metastasis No Evidence 5 Years Imaging Tests
EQ0417 -
EQ0418 -        Follow up ref SDS 80 DA8O, ref SDS 60 GB8J.
EQ0419 -
EQ0420 -        Type    Date           Received          Source
EQ0421 -         CT     070520 reported on 070524........... ref SDS 0 DA6Q
EQ0422 -         CT     070326 reported on 070329........... ref SDS 80 DA6Q
EQ0423 -         CT     070131 reported on 070202........... ref SDS 60 1Y8G
EQ0424 -         PET/CT 061227 reported on 070102........... ref SDS 50 1Y8G
EQ0425 -         CT     060930 reported on 061012........... ref SDS 37 284J
EQ0426 -         MRI    060708 reported on 060711........... ref SDS 27 PT4K
EQ0427 -         Xray   060623 reported on 060711........... ref SDS 27 WJ6G
EQ0428 -         CT     060505 reported on 060523........... ref SDS 24 E355
EQ0429 -         PET    060414 reported on 060428........... ref SDS 22 WJ6G
EQ0430 -         PET    060120 reported on 060126........... ref SDS 20 WJ6G
EQ0431 -         PET/CT 051005 reported on 051007........... ref SDS 19 WJ6G
EQ0432 -         CT     050530 reported on 050610........... ref SDS 18 G75L
EQ0433 -         CT     050325 reported on 050422........... ref SDS 17 G75L
EQ0434 -         CT     041217 reported on 041230........... ref SDS 16 G75L
EQ0435 -         CT     041103 reported on 041104........... ref SDS 15 WV7H
EQ0436 -         CT     040921 reported on 041005........... ref SDS 13 NL4N
EQ0437 -         CT     040710 reported on 040811........... ref SDS 12 H85S
EQ0438 -         CT     040410 reported on 040416........... ref SDS 10 LK5L
EQ0439 -         CT     040307 reported on 040318........... ref SDS 9 LK5L
EQ0440 -         CT     031031 reported on 031205........... ref SDS 6 IG9K
EQ0441 -         CT     030626 reported on 030710........... ref SDS 5 AL6N
EQ0442 -         CT     030428 reported on 030508........... ref SDS 4 LK5L
EQ0443 -         PET    021218 reported on 030109........... ref SDS 3 LK5L
EQ0444 -         PET    020529 reported on 020603........... ref SDS 2 0001
EQ0445 -
EQ0447 -         ..
EQ0448 -        Patient        Personal Physician     71/F Radiology Report
EQ0452 -         ..
EQ0453 -        CT Scan Chest, Abdomen and Pelvis with Contrast (Digital)
EQ0456 -         ..
EQ0457 -        Ordered on 05/20/2007 15:13 at WCR OUTPATIENT
EQ0460 -         ..
EQ0461 -        CT CHEST, ABDOMEN, PELVIS
EQ0462 -
EQ0463 -
EQ0464 -
EQ0465 -
EQ05 -

SUBJECTS
CT Test 070520 History Identifies Breast Cancer Mistakes Testing Fai

F503 -
F50401 -     ..
F50402 -    History Missing Context Pulmonary Embolism Enlarged Right Ventricle
F50403 -
F50404 -    Follow up ref SDS 80 GH5L. ref SDS 60 0Z6O.
F50406 -         ..
F50407 -        HISTORY
F50408 -
F50409 -            Metastatic breast cancer
F50411 -  ..
F50412 - This report repeats past practice omitting context of patient history
F50413 - on pulmonary embolism and Cor Pulmonale heart disorder enlarged right
F50414 - ventricle.  Millie's patient history of lung and heart disorders was
F50415 - diagnosed by Kaiser in a report on a CT test performed on 060930, and
F50416 - received from Kaiser on 061012. ref SDS 37 294Q  Kaiser CT tests on
F50417 - 070131, and reviewed on 070202, ref SDS 60 0Z6O, and again on 070326,
F50418 - reviewed on 070329 all present the same mistake of listing only cancer
F50419 - and omitting lung and heart disorders. ref SDS 80 GH5L
F50421 -  ..
F50422 - Background on managing context to interpret testing is also presented
F50423 - on 070202. ref SDS 60 4I3N
F50425 -  ..
F50426 - CT test report continues...
F50427 -
F50428 -        Methods
F50429 -
F50430 -            Scans were done through the chest, abdomen and pelvis in
F50431 -            the axial projection.
F50433 -             ..
F50434 -            IV contrast: Yes
F50435 -            Oral contrast: Yes
F50436 -            Reformations: No
F50438 -  ..
F50439 - This is the same explanation for the test at Kaiser on 070326, and
F50440 - reported on 070329. ref SDS 80 GR4G
F50441 -
F50442 -
F50443 -
F505 -

SUBJECTS
CT Test 070520 Comparison Failed Perform Context Management Missing

FN03 -
FN0401 -     ..
FN0402 -    Comparison:  070326 070131 061230 060930 Omitted Chronic Mistakes
FN0403 -
FN0404 -    Follow up ref SDS 80 0136, ref SDS 60 0136.
FN0405 -
FN0406 -        Comparison [omitted]
FN0408 -  ..
FN0409 - Failure to track patient history of lung and heart disorders, per
FN0410 - above, ref SDS 0 GH5L, aligns with failure to perform analysis for the
FN0411 - CT test on 070520 to assess progression of lung and heart disease by
FN0412 - performing comparison with the CT test on 060930 that diagnosed
FN0413 - pulmonary embolism, and enlarged right ventricle, reported on 061012,
FN0414 - ref SDS 37 294Q, presents a recurrent problem shown in case study at
FN0415 - that time on 061012. ref SDS 37 A55J
FN0417 -  ..
FN0418 - Requirements to distinguish lung and heart preconditions with symptoms
FN0419 - of fatigue, weakness, and shortness of breath, cited in patient
FN0420 - history, per above, ref SDS 0 GH5L, were reviewed on 061230 by Kaiser
FN0421 - and UCSF considering treatment with cetuximab. ref SDS 48 PN6R
FN0422 - Clinical study Consent documents received on 070116 list lung and
FN0423 - heart disorders as side effects to monitor safety of patients.
FN0424 - ref SDS 53 I75I  Since fatigue, tiredness and weakness are, also, side
FN0425 - effects of cetuximab treatments, also, listed in the Consent documents
FN0426 - reviewed on 070116, ref SDS 53 O64M, this context of common symptoms
FN0427 - presents a "wicked problem" distinguishing side effects that must be
FN0428 - ignored to benefit from cancer treatments, from avoiding progression
FN0429 - of lung and heart disease in time to be effective avoiding death.
FN0430 - Complex, difficult problems that risk death require increased
FN0431 - scrutiney, discussed above. ref SDS 0 VF5M  On 070130 Doctor Rugo
FN0432 - planned regular CT testing for increased scrutiney. ref SDS 56 456H
FN0434 -  ..
FN0435 - Evaluating progression of lung and heart disease requires comparison
FN0436 - to make sense of findings based on context of patient history, and was
FN0437 - considered in the record on 070329, reviewing the report for the CT
FN0438 - test on 070326 that failed to perform comparisons. ref SDS 80 NO9O
FN0439 - Comparison of the test on 070520 with prior findings on 060930 was
FN0440 - planned on 070419, ref SDS 87 4M5K, to correct errors in testing on
FN0441 - 070131, which Kaiser planned to rememdy on 070202, ref SDS 60 T85F,
FN0442 - and again in the test on 070326, which Kaiser planned to correct on
FN0443 - 070330. ref SDS 83 0136
FN0445 -  ..
FN0446 - On 070517 Kaiser disclosed a new policy saving time and money to care
FN0447 - for more patients by examining only 20% of test data scanned at 1 mm
FN0448 - intervals, and to avoid comparisons for assessing progression of
FN0449 - disease. ref SDS 98 OS5G  Review shows that failure to apply policy in
FN0450 - the context of patient history fails to meet requirements for
FN0451 - effective care. ref SDS 98 WX8I
FN0453 -  ..
FN0454 - Failure to evaluate progression of lung and heart disorders affects
FN0455 - case management in the following subjects....
FN0456 -
FN0457 -        1.  Coordination.............................. ref SDS 0 ZP3L
FN0458 -        2.  Wicked problems........................... ref SDS 0 VF5M
FN0459 -        3.  CT test scope history..................... ref SDS 0 GH5L
FN0460 -        4.  CT test scope comparison.................. ref SDS 0 0136
FN0461 -        5.  Emotional stress.......................... ref SDS 0 Y642
FN0462 -        6.  Strategy risk management.................. ref SDS 0 A67L
FN0463 -        7.  Treatment approval........................ ref SDS 0 L49O
FN0464 -        8.  Side effects assessment................... ref SDS 0 NY6N
FN0465 -        9.  Pulmonary embolism........................ ref SDS 0 CV5L
FN0466 -       10.  Cor pulmonale enlarged right.ventricle.... ref SDS 0 VJ4J
FN0467 -
FN0468 -
FN0469 -
FN0470 -
FN0471 -
FN0472 -
FN0473 -
FN0474 -
FN0475 -
FN05 -

SUBJECTS
CT Test 070520 Findings No Cancer Lymphadenopathy No Evidence Metast

FX03 -
FX0401 -     ..
FX0402 -    CT Scan Failed to Test for Pulmonary Embolism Cor Pulmonale
FX0403 -    Cancer No Findings Lymphadenopathy No Evidence Metastatic Disease
FX0404 -
FX0405 -    Follow up ref SDS 80 B74K ref SDS 60 013T.
FX0406 -
FX0407 -        Findings...
FX0408 -             ..
FX0409 -            Chest CT
FX0410 -
FX0411 -               Mediastinum: No abnormally enlarged lymph nodes.
FX0412 -
FX0413 -               Heart: Normal
FX0414 -
FX0415 -               Hila: No abnormally enlarged lymph nodes
FX0417 -                ..
FX0418 -               Lungs: The previously described 4 very small 2-3mm
FX0419 -               nodules are all stable.  No new lung nodules identified.
FX0420 -               no interstitial disease.  Scarring in the left apex is
FX0421 -               stable; likely post radiation fibrosis.
FX0422 -
FX0423 -                  [On 071018 CT test on 070930 reports some
FX0424 -                  interstitial prominence and ground-glass opacity
FX0425 -                  within the right lower lobe medially, is slightly
FX0426 -                  increased, seems conflicting with the CT test on
FX0427 -                  070723 reviewed on 070802 that makes no finding of
FX0428 -                  interstitial disease, ref SDS A6 OX4O, and which was
FX0429 -                  expressly found not to exist in the test on 070520,
FX0430 -                  reviewed today. ref SDS 0 SP3F
FX0432 -                ..
FX0433 -               Pleura: Normal
FX0435 -                ..
FX0436 -               Effusions: None
FX0438 -                ..
FX0439 -               Bony thorax and soft tissues: S/P left mastectomy.
FX0440 -               Portacath remains in right anterior chest wall entering
FX0441 -               rt subclavian vein.
FX0443 -                ..
FX0444 -               No change in the fat stranding in the left axilla.
FX0446 -             ..
FX0447 -            ABDOMEN CT:
FX0448 -
FX0449 -               Liver: Normal size. Cyst in the dome unchanged.
FX0450 -
FX0451 -               Gallbladder and bile ducts: Normal
FX0452 -
FX0453 -               Spleen: Stable. Calcified granuloma and calcified
FX0454 -               splenic artery aneurysm are stable.
FX0456 -                ..
FX0457 -               Pancreas: Normal
FX0458 -               Right Kidney: Normal
FX0459 -               Left Kidney: Normal
FX0460 -               Adrenal glands: Normal
FX0461 -               Aorta: Normal
FX0462 -               Adenopathy: No abnormally enlarged lymph nodes.
FX0463 -               Ascites: None
FX0465 -                ..
FX0466 -               Bowel and Mesentery: Normal. Diverticuli in the sigmoid
FX0467 -               colon.
FX0469 -             ..
FX0470 -            Pelvis CT:
FX0471 -
FX0472 -               s/p hysterectomy. Left ovarian tissue appears to be
FX0473 -               present.  The right ovary is not seen.
FX0475 -                ..
FX0476 -               Regional skeleton:  No metastatic lesions seen.  There
FX0477 -               are degenerative changes.
FX0479 -         ..
FX0480 -        IMPRESSION
FX0481 -
FX0482 -            No change. No evidence for metastatic disease.
FX0483 -
FX0489 -            ..
FX0490 -           [On 070531 UCSF not concerned results of blood test today
FX0491 -           show CA 15-3 37 rising 30% from the prior report on 070426,
FX0492 -           because CT scans show no metastatic cancer, and IBC
FX0493 -           inflammation appears to be subsiding. ref SDS A2 NQ6K
FX0495 -  ..
FX0496 - Research indicates that Susan graduated from the Lucas Center at
FX0497 - Stanford University in 2002, shown at...
FX0498 -
FX0499 -              http://rsl.stanford.edu/lucas/report/lucas_report-2002.pdf
FX0501 -  ..
FX0502 - Gary H. Glover is the Director, Radiological Sciences Laboratory at
FX0503 - Stanford.
FX0504 -
FX0505 -              http://rsl.stanford.edu/glover/
FX0506 -
FX0507 -        gary.glover@stanford.edu
FX0509 -         ..
FX0510 -        650-723-7577
FX0511 -
FX0512 -
FX0513 -
FX0514 -
FX06 -

SUBJECTS
Emotional Trauma Stress Moderate Pulse Normal Cancer Subsides Reliev

GA03 -
GA0401 -  ..
GA0402 - Emotional Trauma Rising Falling Cancer Symptoms Risks Image Testing
GA0403 - Exercise Vigor Strength Engagement Ease Distress Living with Cancer
GA0404 - Behavior Medical Specialist (BMS) Emotional Counseling Not Effective
GA0405 -
GA0406 - Follow up ref SDS 90 Y642, ref SDS 87 Y642.
GA0407 -
GA0408 - Medical issues create an emotional roller coaster explained on 070105,
GA0409 - ref SDS 51 Y642, and reviewed on 070301. ref SDS 65 Y642  Stress and
GA0410 - trauma are compounded with rising complexity of case history, listed
GA0411 - above. ref SDS 87 LU3J
GA0413 -  ..
GA0414 - Improved prognosis, ref SDS 0 M645, and better coordination,
GA0415 - ref SDS 0 ZO6F, relieve stress reflected in Millie's vitals that
GA0416 - remain calm today, e.g., pulse below 60, ref SDS 0 KB5L, and reported
GA0417 - in patient history for treatment after examination. ref SDS A0 AW4L
GA0418 -
GA0419 -        [On 070607 sudden attack of Lymphedema and Cellulitis that
GA0420 -        require emergency care cause emotional stress to accelerate
GA0421 -        like a roller coaster. ref SDS A3 6A7J
GA0423 -  ..
GA0424 - Sudden rise of the cancer marker reported at Kaiser on 070516, and
GA0425 - confirmed by UCSF today, per above, increase worry and doubt that
GA0426 - create emotional disturbance, noted above. ref SDS 0 VH68  Kaiser
GA0427 - reporting on 070516 that substantial rise of cancer marker is
GA0428 - "stable," ref SDS 96 QN6M, casts further doubt about communication
GA0429 - channels essential for collaborating on referral care. ref SDS 96 CG4I
GA0431 -  ..
GA0432 - Communication breakdowns between UCSF and Kaiser failing to
GA0433 - coordinate, verify, and reconcile lab results, ref SDS 0 4L6N, create
GA0434 - doubt about reliance on test reports that increase stress.
GA0435 -
GA0436 -        [On 070610 Kaiser reported the right channels for communication
GA0437 -        are now open with UCSF for coordinating referral work.
GA0438 -        ref SDS A4 OG7F
GA0440 -  ..
GA0441 - Coordination difficulties between Oncology and the Imaging Department
GA0442 - at Kaiser, and referral issues with UCSF, noted above, on evaluating
GA0443 - progression of of lung and heart disease, ref SDS 0 ZP4N, during
GA0444 - treatment on the cetuximab clinical study add stress when doctors are
GA0445 - prevented from performing case management based on patient history,
GA0446 - with implications for diagnosis, and treatment. ref SDS 0 L49O  As a
GA0447 - result, emotional stress occurs tracking case management in the
GA0448 - following subjects....
GA0449 -
GA0450 -        1.  Coordination........................... ref SDS 0 ZP3L
GA0451 -        2.  Wicked problems........................ ref SDS 0 VF5M
GA0452 -        3.  CT test scope history.................. ref SDS 0 GH5L
GA0453 -        4.  CT test scope comparison............... ref SDS 0 0136
GA0454 -        5.  Emotional stress....................... ref SDS 0 Y642
GA0455 -        6.  Strategy risk management............... ref SDS 0 A67L
GA0456 -        7.  Treatment approval..................... ref SDS 0 L49O
GA0457 -        8.  Side effects assessment................ ref SDS 0 NY6N
GA0458 -        9.  Pulmonary embolism..................... ref SDS 0 CV5L
GA0459 -
GA0460 -
GA0461 -
GA05 -

SUBJECTS
Strategy Continue Planning on 070419 Distinguish IBC Progression fro

GR03 -
GR0401 -  ..
GR0402 - Planning Case Management from Patient Profile Work Up
GR0403 - Work Up Patient Profile Develop Options Strategy Treatment IBC Relapse
GR0404 - Strategy Cetuximab Continued with Low ANC Expanding IBC Disease
GR0405 -
GR0406 - Follow up ref SDS 90 K36G, ref SDS 87 K36G.
GR0407 -
GR0408 - Background is reported on 070301. ref SDS 65 K36G
GR0410 -  ..
GR0411 - Sudden increase of CA 15-3 cancer marker reported by UCSF and Kaiser,
GR0412 - noted above, ref SDS 0 087J, increase attention on strategy for the
GR0413 - treatment plan.  On 070517 UCSF advised in a letter that Kaiser's
GR0414 - report of rising CA 15-3 does not require considerations for changing
GR0415 - treatments. ref SDS 98 6E4G
GR0417 -  ..
GR0418 - Current strategy and planning to add carboplatin with progression of
GR0419 - disease is listed in the record on 070419, ref SDS 87 883I, including
GR0420 - coordination issues, ref SDS 87 RM4G, supplemented by further review
GR0421 - today, per above. ref SDS 0 ZO6F
GR0423 -  ..
GR0424 - UCSF Strategy of increased scrutiney to avoid "wicked problems"
GR0425 - distinguishing lung and heart disorders caused by cetuximab treatments
GR0426 - that otherwise relieve IBC disease from side effects of chemotherapy
GR0427 - that must be tolerated and ignored to treat cancer, by using CT
GR0428 - testing for progression of pulmonary embolism and enlarged right
GR0429 - ventricle, per above, ref SDS 0 X24F, was prevented by Kaiser's new
GR0430 - strategy to save time and money for treating other patients with a
GR0431 - policy of reduced scrutiney to review only 20% of test data, and not
GR0432 - performing comparisons to assess progression of lung and heart
GR0433 - disorders. discussed above, ref SDS 0 AL6J, and considering approval
GR0434 - for continuing cetuximab treatments. ref SDS 0 L49O
GR0436 -  ..
GR0437 - Failure to evaluate progression of lung and heart disorders affects
GR0438 - case management in the following subjects....
GR0439 -
GR0440 -        1.  Coordination........................... ref SDS 0 ZP3L
GR0441 -        2.  Wicked problems........................ ref SDS 0 VF5M
GR0442 -        3.  CT test scope history.................. ref SDS 0 GH5L
GR0443 -        4.  CT test scope comparison............... ref SDS 0 0136
GR0444 -        5.  Emotional stress....................... ref SDS 0 Y642
GR0445 -        6.  Strategy risk management............... ref SDS 0 A67L
GR0446 -        7.  Treatment approval..................... ref SDS 0 L49O
GR0447 -        8.  Side effects assessment................ ref SDS 0 NY6N
GR0448 -        9.  Pulmonary embolism..................... ref SDS 0 CV5L
GR0449 -
GR0450 -
GR0451 -
GR05 -

SUBJECTS
Treatment IBC 12th Cycle 3rd Relapse 5th Cycle 1st Treatment Chemoth

GX03 -
GX0401 -  ..
GX0402 - Treatment IBC 3rd Relapse Start 5th Cycle Cetuximab Clinical Study
GX0403 - Cetuximab 5th Cycle Treatment IBC 3rd Relapse Clinical Study UCSF
GX0404 -
GX0405 - Follow up ref SDS 90 7X6N, ref SDS 87 PF3O.
GX0406 -
GX0407 - Patient history of cetuximab treatments in the Infusion Clinic is
GX0408 - listed in the record for today. ref SDS A0 7T3H
GX0410 -  ..
GX0411 - Examination today showing treatment has been effective supports
GX0412 - approval for Millie to start the 5th cycle of treatment with cetuximab
GX0413 - alone, in accordance with strategy reviewed on 070329, ref SDS 80
GX0414 - 1R9H, considered again by Doctor Rugo on 070419. ref SDS 87 883I, and
GX0415 - reviewed today, per above. ref SDS 0 K36G  UCSF advised that rising CA
GX0416 - 15-3, which can signal progression of cancer, does not justify
GX0417 - changing treatment at this time, per review above. ref SDS 0 4L6N
GX0418 -
GX0419 -     [On 070625 CA 15-3 30 improved 30% for blood test on 070621 aligns
GX0420 -     with clinical findings of IBC subsiding, indicating response to
GX0421 -     treatment with cetuximab alone. ref SDS A5 PD4N
GX0423 -  ..
GX0424 - Strategy for managing risks of cetuximab compounding lung and heart
GX0425 - disorders, per above, ref SDS 0 A67L, was also reviewed on 070419.
GX0426 - ref SDS 87 RQ7K  On 070510 discussed coordinating with Kaiser on
GX0427 - evaluating preconditions of pulmonary embolism and enlarged right
GX0428 - ventricle using thin slice spiral technology because patient history
GX0429 - shows this method has been effective in Millie's case.  UCSF noted
GX0430 - that six (6) other patients in the clinical study are tested without
GX0431 - thin slice spiral CT test technology. ref SDS 93 VP4H  Previously, on
GX0432 - 041018 Doctor Benz noted that Kaiser should investigate growing
GX0433 - symptoms of pulmonary embolism, which many CT tests without thin slice
GX0434 - spiral technology failed to diagnose. ref SDS 14 LX42  Kaiser
GX0435 - investigated with thin slice spiral CT testing, and on 041104
GX0436 - diagnosed Millie's condition of pulmonary embolism, which resulted in
GX0437 - major change to her treatment, ref SDS 15 RZ4I, similar to
GX0438 - considerations today.
GX0440 -  ..
GX0441 - On 070514 Millie coordinated with Kaiser to implement plans for follow
GX0442 - up testing to assess risks of cetuximab treatments on compounding
GX0443 - preconditions of lung and heart disorders. ref SDS 95 IN4V  Without
GX0444 - support from UCSF, Kaiser reported on 070517 that all CT scans at
GX0445 - Kaiser (presumably Walnut Creek facility) use thin slice spiral
GX0446 - technology, but that unless the doctor orders a full review, only 20%
GX0447 - of the scans are examined.  The doctor presented Kaiser's policy
GX0448 - position that examining 20% of the data saves Kaiser a lot of time and
GX0449 - money that can be used to help other patients.  The doctor also noted
GX0450 - that even if Kaiser found advancing lung and heart disease with
GX0451 - cetuximab, this would not affect case management, ref SDS 98 D66M,
GX0452 - contrary to practice on 041104, when Kaiser immediately ended
GX0453 - treatment that was associated with blood clots in the lungs.
GX0455 -  ..
GX0456 - Treatment was approved this morning for Millie to begin the 5th cycle
GX0457 - on the cetuximab clinical study.  Approval was based on tests today
GX0458 - showing NEUTS blood counts increased to 1.84, which is a safe level
GX0459 - for treatment using UCSF criteria, ref SDS A0 P560, and in accordance
GX0460 - with Nurse's Notes for treatment on 070426 citing standard practice to
GX0461 - test blood counts for safe treatment in advance of giving treatment.
GX0462 - ref SDS 91 ME4H  Approval was further based on CT testing at Kaiser on
GX0463 - 070520 finding no metastatic disease, indicating cetuxumab treatment
GX0464 - has been effective for Millie, reported above. ref SDS 0 TV7N
GX0465 - Kaiser's report for the CT test on 070520 further presents no findings
GX0466 - on lung and heart disorders. ref SDS 0 B74K  Kaiser's standards for
GX0467 - review on 070517 treat silence as finding stability. ref SDS 98 OS5G
GX0468 - UCSF standards on 070510 seem to present silence from reviewing 20% of
GX0469 - the data adequate for evaluating risks, ref SDS 93 KD5I, which have
GX0470 - never been effective diagnosing lung and heart disorders in Millie's
GX0471 - case, reviewed on 070517, ref SDS 98 WX91, citing prior discussion on
GX0472 - 070510. ref SDS 93 HW5I
GX0474 -  ..
GX0475 - Failure to evaluate progression of lung and heart disorders affects
GX0476 - case management in the following subjects....
GX0477 -
GX0478 -        1.  Coordination........................... ref SDS 0 ZP3L
GX0479 -        2.  Wicked problems........................ ref SDS 0 VF5M
GX0480 -        3.  CT test scope history.................. ref SDS 0 GH5L
GX0481 -        4.  CT test scope comparison............... ref SDS 0 0136
GX0482 -        5.  Emotional stress....................... ref SDS 0 Y642
GX0483 -        6.  Strategy risk management............... ref SDS 0 A67L
GX0484 -        7.  Treatment approval..................... ref SDS 0 L49O
GX0485 -        8.  Side effects assessment................ ref SDS 0 NY6N
GX0486 -        9.  Pulmonary embolism..................... ref SDS 0 CV5L
GX0487 -
GX0488 -
GX0489 -
GX05 -

SUBJECTS
Side Effects Cetuximab Acne-like Rash Face Dry Skin Face Chest Arms

HB03 -
HB0401 -  ..
HB0402 - Side Effects Cetuximab Similar Symptoms Pulmonary Embolism
HB0403 - Energy Strength Rising Minimal Side Effects Cetuximab Treatment
HB0404 - Facial Skin Dryness New Side Effect Cetuximab Curel Lotion Prescribed
HB0405 - Curel Lotion Prescribed Facial Skin Dryness New Side Effect Cetuximab
HB0406 -
HB0407 - Follow up ref SDS 90 TQ6L, ref SDS 87 TQ6L.
HB0408 -
HB0409 - Side effects of cetuximab treatment are listed in the record receiving
HB0410 - treatment today in the Infusion Clinic, ref SDS A0 QU8K, and were
HB0411 - presented in the Clinical Study Consent form received from UCSF on
HB0412 - 070116. ref SDS 53 O64M
HB0414 -  ..
HB0415 - Doctor Rugo observed continuing minimal acne-like rash on the face,
HB0416 - noted previously during examination on 070419, ref SDS 87 847H, and
HB0417 - earlier by the primary care physician at Kaiser on 070330. ref SDS 83
HB0418 - N49K Details are shown in the record on treatment in the Infusion
HB0419 - Clinic later today. ref SDS A0 QU8K
HB0421 -  ..
HB0422 - Erratic changes in intensity of IBC rash on upper left arm, and other
HB0423 - sites, as well as concern about Cellulitis and side effects of
HB0424 - cetuximab treatments have subsided, since starting the previous cycle
HB0425 - on 070426, as discussed above, ref SDS 0 4Y93, and reviewed further in
HB0426 - the record today for treatment in the Infusion Clinic, ref SDS A0 SU6L
HB0428 -  ..
HB0429 - Causes of changes in rash intensity were listed on 070426. ref SDS 91
HB0430 - 8B8Y
HB0432 -  ..
HB0433 - Millie continues to feel good, reported on 070419. ref SDS 87 8477
HB0435 -  ..
HB0436 - Fatigue shown by sleeping for several hours after getting home was
HB0437 - first reported on 070419, ref SDS 87 H59I, and continued today.
HB0438 - ref SDS A0 BB7G
HB0440 -  ..
HB0441 - Strategy to use CT tests, was presented by Doctor Rugo during the
HB0442 - meeting at UCSF on 070130, ref SDS 56 JG5K, for managing side effects
HB0443 - of cetuximab that cause complications of lung and heart disorcers,
HB0444 - blood clots in the lungs, pulmonary embolism, enlarged right
HB0445 - ventricle, Cor Pulmonale, etc., listed in the Consent document for
HB0446 - getting treatment in the Cetuximab Clinical Study, reviewed on 070116.
HB0447 - ref SDS 53 I75I  CT testing helps avoid wicked problems of cetuximab
HB0448 - side effects masking symptoms when life threatening progression of
HB0449 - disease occurs, per above, ref SDS 0 A67L, and discussed further
HB0450 - below. ref SDS 0 XR9N  Complex, "wicked" problems that required
HB0451 - increased scrutiney are reviewed above. ref SDS 0 VF5M
HB0453 -  ..
HB0454 - Failure to evaluate progression of lung and heart disorders from side
HB0455 - effects of treatment with cetuximab affects case management in the
HB0456 - following subjects....
HB0457 -
HB0458 -        1.  Coordination........................... ref SDS 0 ZP3L
HB0459 -        2.  Wicked problems........................ ref SDS 0 VF5M
HB0460 -        3.  CT test scope history.................. ref SDS 0 GH5L
HB0461 -        4.  CT test scope comparison............... ref SDS 0 0136
HB0462 -        5.  Emotional stress....................... ref SDS 0 Y642
HB0463 -        6.  Strategy risk management............... ref SDS 0 A67L
HB0464 -        7.  Treatment approval..................... ref SDS 0 L49O
HB0465 -        8.  Side effects assessment................ ref SDS 0 NY6N
HB0466 -        9.  Pulmonary embolism..................... ref SDS 0 CV5L
HB0467 -
HB0468 -
HB0469 -
HB0470 -
HB0471 -
HB05 -

SUBJECTS
Cetuximab Clinical Study UCSF Drug Trial Clinical Examination IBC Su

HL03 -
HL0401 -  ..
HL0402 - Cetuximab UCSF Clinical Study Treatment Begins 070201
HL0403 - UCSF Clinical Study Treatment Cetuximab Drug Trial Begins 070201
HL0404 - Drug Trials UCSF Has Other Clinical Study Treatments May Help Millie
HL0405 -
HL0406 - Follow up ref SDS 90 ZJ9N, ref SDS 87 ZJ9N.
HL0407 -
HL0408 - UCSF advised today that treatment with cetuximab alone on the clinical
HL0409 - study continues to be effective, shown by CT test on 070520 finding no
HL0410 - evidence of metastatic disease, and reported today, per above,
HL0411 - ref SDS 0 TV7N, and which aligns with clincial examination today,
HL0412 - also, shown above. ref SDS 0 M68J
HL0414 -  ..
HL0415 - Sudden 30% rise of CA 15-3 37 cancer biomarker, per above, ref SDS 0
HL0416 - 087J, was explained by UCSF as conflicting with CT testing, which does
HL0417 - not typically register findings of IBC, reviewed above, ref SDS 0
HL0418 - EZ4G, and by observations that seem to show continued response to
HL0419 - treatment.
HL0421 -  ..
HL0422 - Strategy to add carboplatin, and transition to an Avastin trial, as
HL0423 - needed, was most recently reviewed on 070419. ref SDS 87 838N  On
HL0424 - 070517 UCSF advised that changing treatment is not needed at this
HL0425 - time, ref SDS 98 6E4G, and was affirmed during the meeting today, per
HL0426 - above. ref SDS 0 X68L
HL0428 -  ..
HL0429 - Strategy to use CT tests for monitoring progression of lung and heart
HL0430 - disorders from side effects of treatment with cetuximab is discussed
HL0431 - above, ref SDS 0 NY6N, citing coordination issues with referral work
HL0432 - on the scope of CT tests, ref SDS 0 ZP3L, for increased scrutiney of
HL0433 - pulmonary embolism and enlarged right ventricle, discussed below.
HL0434 - ref SDS 0 XR9N
HL0435 -
HL0436 -
HL0437 -
HL0438 -
HL0439 -
HL05 -

SUBJECTS
Schedule Treatment Cetuximab 070524 Weekly Through 070802 Clinical S

HX03 -
HX0401 -  ..
HX0402 - Schedule Treatment Start Cetuximab Carboplatin 070201
HX0403 -
HX0404 - Follow up ref SDS 90 N96O, ref SDS 87 N96O.
HX0406 -  ..
HX0407 - On 070510 Nola in the Infusion Clinic scheduled Millie for weekly
HX0408 - treatments through August 2nd. ref SDS 93 QK6L
HX0410 -  ..
HX0411 - Meetings and treatments continue on Thursdays, so the next meeting at
HX0412 - UCSF with the medical team will be on 070607 prior to getting the 3rd
HX0413 - treatment of cycle #5, and then Millie will meet with the medical team
HX0414 - on 070621, to start the 6th cycle, as shown on 070510. ref SDS 73 NM4M
HX0415 -
HX0416 -
HX0417 -
HX0418 -
HX05 -

SUBJECTS
Pulmonary Embolism Blood Clots Lung Disorder Enlarged Right Ventricl

IB03 -
IB0401 -  ..
IB0402 - Tired Breathing Difficulty Routine Activity Signals Pulmonary Emboli
IB0403 - Coumadin Treatment Pulmonary Emboli Family History Genetic Cause
IB0404 - Pulmonary Emboli Hypercoagulable Work Up PET Scan Test Compare History
IB0405 -
IB0406 - Follow up ref SDS 90 CV5L, ref SDS 87 CV5L.
IB0407 -
IB0408 - Background on pulmonary embolism and correlation with IBC treatment
IB0409 - with cetuximab that has documented side effects of blood clots in the
IB0410 - lungs, and heart disorders noted in Consent materials received on
IB0411 - 060116, ref SDS 53 I75I, is reported in the record meeting with the
IB0412 - medical team at UCSF on 070130, ref SDS 56 CV5L, citing requirements
IB0413 - to increase scrutiney for progression of lung and heart preconditions
IB0414 - diagnosed at Kaiser by CT testing on 060930, reported on 061012.  The
IB0415 - need for increased scrutiney to check for progression of lung and
IB0416 - heart disorders was updated on 070329 when the CT test on 070326
IB0417 - failed to report findings and comparisons to assess progression of
IB0418 - pulmonary embolism, and enlarged right ventricle, ref SDS 80 LZ6H,
IB0419 - noted as well the next day at Kaiser on 070330. ref SDS 83 NU55
IB0421 -  ..
IB0422 - As shown above, the recent CT test at Kaiser on 070520 failed again to
IB0423 - compare findings for evaluating progression of lung and heart
IB0424 - disorders needed to evaluate compounding effects of treatment with
IB0425 - cetuximab, noted above. ref SDS 0 0136
IB0427 -  ..
IB0428 - Requirements for increased scrutiney of "wicked," complex problems to
IB0429 - avoid mistaking side effects of cetuximab and failing to treat
IB0430 - complications from blood clots in the lungs, pulmonary embolism, and
IB0431 - enlarged right ventricle are discussed above. ref SDS 0 NZ4F  Failure
IB0432 - to evaluate progression of lung and heart disorders from side effects
IB0433 - of treatment with cetuximab affects case management in the following
IB0434 - subjects....
IB0435 -
IB0436 -        1.  Coordination........................... ref SDS 0 ZP3L
IB0437 -        2.  Wicked problems........................ ref SDS 0 VF5M
IB0438 -        3.  CT test scope history.................. ref SDS 0 GH5L
IB0439 -        4.  CT test scope comparison............... ref SDS 0 0136
IB0440 -        5.  Emotional stress....................... ref SDS 0 Y642
IB0441 -        6.  Strategy risk management............... ref SDS 0 A67L
IB0442 -        7.  Treatment approval..................... ref SDS 0 L49O
IB0443 -        8.  Side effects assessment................ ref SDS 0 NY6N
IB0444 -        9.  Pulmonary embolism..................... ref SDS 0 CV5L
IB0445 -
IB0447 -  ..
IB0448 - INR 2.2 Blood Test Patient Stable for Coumadin Treatments Pulmonary Emboli
IB0449 -
IB0450 - Follow up ref SDS 90 FE9I, ref SDS 87 FE9I.
IB0451 -
IB0452 - On 070330 Millie's letter to Kaiser notified Gloria of INR stable
IB0453 - blood tests for past 2 months; continuing current Coumadin regimen.
IB0454 - ref SDS 82 ZH4H
IB0456 -  ..
IB0457 - The blood test this morning in the Infusion Clinic shows INR 2.2 and
IB0458 - PT 25.5, and remains stable with the current treatment. ref SDS A0
IB0459 - SE6N
IB0460 -
IB0461 -
IB0462 -
IB0463 -
IB0464 -
IB05 -

SUBJECTS
Examination Stethoscope No Findings Enlarged Right Ventricle Heart S

IK03 -
IK0401 -  ..
IK0402 - Examination Breathing Stethoscope No Finding Enlarged Right Ventricle
IK0403 -
IK0404 - Follow up ref SDS 90 Q35O, ref SDS 87 Q35O.
IK0405 -
IK0406 - Examination with a stethoscope today included multiple locations on
IK0407 - Millie's back and chest.  There were no findings of cardio pulmonary
IK0408 - issues from clinical examination.
IK0410 -  ..
IK0411 - After meeting with the medical team in the Breast Care Center, Millie
IK0412 - was treated in the Infusion Clinic.  Vitals were taken three times.
IK0413 - The first test at 0945 reported Sa02 98%. ref SDS A0 AW4L
IK0414 -
IK0415 -
IK0416 -
IK0417 -
IK05 -

SUBJECTS
Enlarged Right Ventricle Heart Disorder Cor Pulmonale Related Pulmon

IV03 -
IV0401 -  ..
IV0402 - Cor Pulmonale Heart Disorder Enlarged Right Ventricle
IV0403 - Heart Examination Not Ordered Investigate Enlarged Right Ventricle
IV0404 - Enlarged Right Ventricle CT Test Aligns Patient Symptoms How Serious
IV0405 -
IV0406 - Follow up ref SDS 90 VJ4J, ref SDS 87 VJ4J.
IV0407 -
IV0408 - Background on heart disorder Cor Pulmonale from enlarged right
IV0409 - ventricle, and plans for CT testing is reported on 070130. ref SDS 56
IV0410 - VJ4J  Considerations on ordering the thin slice spiral CT test to
IV0411 - evaluate enlarged right ventricle, along with pulmonary embolism and
IV0412 - measureable metastatic disease for the cetuximab clinical study, were
IV0413 - reported on 070419, ref SDS 87 CV5L, as further noted above.
IV0414 - ref SDS 0 CV5L
IV0415 -
IV0416 -
IV0417 -
IV0418 -
IV05 -

SUBJECTS
Dizziness Mild Recurrent from 060812 10 Seconds Getting Out of Bed S

JB03 -
JB0401 -  ..
JB0402 - Dizziness Mild Symptoms Recur
JB0403 -
JB0404 - Follow up ref SDS 31 PT4K. ref SDS 27 PT4K.
JB0405 -
JB0406 - Millie reported today that mild dizziness occurring for 10 seconds or
JB0407 - so getting out of bed in the morning has returned the past few weeks.
JB0409 -  ..
JB0410 - Mild dizziness getting up in the morning originally occurred on
JB0411 - 060217, and was carefully reviewed at that time. ref SDS 21 PT4K
JB0412 - Subsequently, on 061012 review of the CT test on 060930 showed
JB0413 - diagnosis of enlarged right ventricle. ref SDS 37 7E5L  Research
JB0414 - indicates that dizziness may be a symptom of this heart disorder.
JB0415 - ref SDS 37 IR46
JB0416 -
JB0417 -        [...in another record, after examination dizziness issue tested
JB0418 -        in the Infusion Clinic by taking vitals standing and showed
JB0419 -        disparity with diagnostics sitting, but not enough to suggest
JB0420 -        significant problem. ref SDS A0 Y14O
JB0422 -         ..
JB0423 -        [On 070525 dizziness was presented to primary care physician at
JB0424 -        Kaiser. ref SDS A1 PT4K
JB0425 -
JB0426 -
JB0427 -
JB0428 -
JB0429 -
JB05 -