CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 45 0000. ref SDS 44 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Doctor Rugo is in Texas with Jackie attending a professional event.
040902 -
040903 -
040904 -
040905 -
040906 -
0410 -

SUBJECTS
CT Test 071210 3 Needle Penetrations Required Medical Mistakes Painf

1003 -
100401 -  ..
100402 - CT Test 071210 New Findings Right Axillary Enlarged Heart
100403 -
100404 - Follow up ref SDS 37 4N7K.
100405 -
100406 - Brigid discussed the report with Doctor Rugo which UCSF received from
100407 - Kaiser for the CT scan on 071210, ref SDS 50 IA5N, and requested
100408 - during the meeting at UCSF on 071115. ref SDS 44 EZ48  The test was
100409 - ordered by Jackie from Kaiser on 071203. ref SDS 49 I09N  Plans for
100410 - ordering the test were discussed with the doctor at Kaiser on 071116.
100411 - ref SDS 45 OR72  A reminder was submitted to UCSF on 071130.
100412 - ref SDS 48 NL7T
100414 -  ..
100415 - Today, Millie asked Brigid during the meeting how UCSF helps patients
100416 - avoid suffering prolonged testing due to difficulty finding a vein for
100417 - IV injections of CT test contrast medium, reported on 071210.
100418 - ref SDS 50 456M
100420 -  ..
100421 - Brigid said there is not yet a good solution.  Some patients are
100422 - trying to inject contrast medium through a new port catheter designed
100423 - for high pressure injections, but his is still controversial.
100425 -         ..
100426 -        Test History No Evidence Distant Metastasis
100427 -        Distant Metastasis No Evidence 5 Years Imaging Tests
100428 -
100429 -        Follow up ref SDS 37 FJ4G, ref SDS 31 LW6M.
100430 -
100431 -        Type    Date           Received          Source
100432 -         CT     071210 reported on 071213........... ref SDS 0 UG4L
100433 -         CT     070930 reported on 071018........... ref SDS 37 VK8L
100434 -         CT     070723 reported on 070802........... ref SDS 31 IM6M
100435 -         CT     070520 reported on 070524........... ref SDS 30 DA6Q
100436 -         CT     070326 reported on 070329........... ref SDS 29 DA6Q
100437 -         CT     070131 reported on 070202........... ref SDS 27 1Y8G
100438 -         PET/CT 061227 reported on 070102........... ref SDS 22 1Y8G
100439 -         CT     060930 reported on 061012........... ref SDS 21 284J
100440 -         MRI    060708 reported on 060711........... ref SDS 19 PT4K
100441 -         Xray   060623 reported on 060711........... ref SDS 19 WJ6G
100442 -         CT     060505 reported on 060523........... ref SDS 17 E355
100443 -         PET    060414 reported on 060428........... ref SDS 16 WJ6G
100444 -         PET    060120 reported on 060126........... ref SDS 15 WJ6G
100445 -         PET/CT 051005 reported on 051007........... ref SDS 14 WJ6G
100446 -         CT     050530 reported on 050610........... ref SDS 13 G75L
100447 -         CT     050325 reported on 050422........... ref SDS 12 G75L
100448 -         CT     041217 reported on 041230........... ref SDS 11 G75L
100449 -         CT     041103 reported on 041104........... ref SDS 10 WV7H
100450 -         CT     040921 reported on 041005........... ref SDS 9 NL4N
100451 -         CT     040710 reported on 040811........... ref SDS 8 H85S
100452 -         CT     040410 reported on 040416........... ref SDS 7 LK5L
100453 -         CT     040307 reported on 040318........... ref SDS 6 LK5L
100454 -         CT     031031 reported on 031205........... ref SDS 5 IG9K
100455 -         CT     030626 reported on 030710........... ref SDS 4 AL6N
100456 -         CT     030428 reported on 030508........... ref SDS 3 LK5L
100457 -         PET    021218 reported on 030109........... ref SDS 2 LK5L
100458 -         PET    020529 reported on 020603........... ref SDS 1 0001
100459 -
100460 -
100462 -  ..
100463 - CT Test Results
100464 -
100465 -
100466 -    1.  CT Scan - chest, abdomen and pelvis performed at Kaiser in
100467 -        Walnut Creek on 071210
100469 -         ..
100470 -    2.  History
100471 -
100472 -        71 yaer old with metastatic breast cncer on clinical trial.
100474 -  ..
100475 - Test report continues to err, repeating prior mistakes failing to note
100476 - patient history of pulmonary embolism and enlarged right ventricle
100477 - (core pulmonale), failing to apply standards implemented for Kaiser's
100478 - CT test on 060930, reported on 061012. ref SDS 21 2857
100480 -  ..
100481 - CT test 071210 report continues...
100482 -
100483 -    3.  Comparison:   prior study 070930. [received at UCSF on 071018.
100484 -        ref SDS 37 4N7K]
100486 -         ..
100487 -    4.  Technique:
100488 -
100489 -        CT evaluation of the chest abdomen and pelvis was performed
100490 -        following the uneventful administration of oral and intravenous
100491 -        contrast material.
100492 -
100493 -
1005 -

SUBJECTS
IBC Relapse 4th Progression Disease Lymphadenopathy Increase CT Test
Right Axillary Lymph Node 11 x 11 MM Previously 8 x 7 MM CT Test 071

3804 -
380501 -         ..
380502 -    5.  Findings:
380503 -
380504 -        a.  Patient appears to be status post left mastectomy.
380505 -
380507 -  ..
380508 - Making Sense Possible Conflicting Reports and Terminology
380509 - Lymphadenopathy Not Identified Right Axillary Lymph Node Increased
380510 - Right Axillary Lymph Node Increased Not Identified Lymphadenopathy
380511 -
380512 -
380513 -        b.  There is an 11 x 11 mm right axillary lymph node, which
380514 -            previously measured 8 x 7 mm.  There is no significant
380515 -            left-sided lymphadenopathy.
380517 -  ..
380518 - This report conflicts with the report for the CT test on 070930, which
380519 - makes no findings of a right axillary lymph node, as shown on 071018.
380520 - ref SDS 37 KK6J
380522 -  ..
380523 - During the meeting today, Brigid related discussion with Doctor Rugo
380524 - to make sense of conflicting test reports.  They feel the analyst for
380525 - the test on 071210 checked the scans for the prior test on 070930,
380526 - despite no express written findings, and observed conditions which at
380527 - the time either were overlooked, i.e., missed, or were considered too
380528 - small for mentioning in the report for the CT scan on 070930.
380530 -                 ..
380531 -                [On 080118 Kaiser examination reports in Medical Chart
380532 -                seems like there is a slow increase in disease
380533 -                progression based on gradually increasing CA 15-3 and
380534 -                changes in CT scan. ref SDS 53 DR4L
380536 -                 ..
380537 -                [On 080215 CT test on 080212 reports node reported
380538 -                today 11 x 11 mm is minimally enlarged, yet says the
380539 -                dimensions are 12.7 x 11.3 cm which is 10 times
380540 -                greater, ref SDS 54 EO8F; analysis assumes this report
380541 -                is an error. ref SDS 54 H65F
380543 -                 ..
380544 -                [On 080215 CT test on 080212 found total of three (3)
380545 -                nodes, 300% greater than the test on 071210 reported
380546 -                today, though the later test on 080212 says all three
380547 -                (3) nodes are present in the current test. ref SDS 54
380548 -                H73U  Issues of conflicting and erroneous units of
380549 -                measure evident for the primary node, cannot be
380550 -                determined for the other nodes. ref SDS 54 H73O
380551 -
380552 -
380553 -
3806 -

SUBJECTS
Default Null Subject Account for Blank Record

3903 -
390401 -  ..
390402 - Pretracheal Lymph Node New Findings Conflices Prior Tests
390403 -
390404 -
390405 -        c.  There is a stable 1.6 x 0.7 cm pretracheal lymph node.
390407 -  ..
390408 - As well, the report for the CT test on 070930 shows no findings of a
390409 - "stable 1.6 x 0.7 cm pretracheal lymph node." ref SDS 37 KK6J  The
390410 - report today therefore conflicts with prior findings.
390411 -
390412 -                [On 080215 CT test on 080212 finds stable
390413 -                sub-centimeter nodes in right paratracheal. ref SDS 54
390414 -                RV70
390416 -  ..
390417 - Why are units of measure changed between mm and cm?  This invites
390418 - questions of typing errors?  1.6 x 0.7 cm seems like about .25 inches,
390419 - which might be large enough to cause awareness if not discomfort; yet
390420 - the patient has not complained nor noticed a lump in the throat.
390422 -  ..
390423 - The record on 060523 reports findings in the CT test on 060505 of less
390424 - than 1 cm lymph nodes in the right paratrachael region. ref SDS 17 4O8P
390425 - There is a note of prior findings of possible esophagitis in the
390426 - report for the PET test on 060120 received on 060126. ref SDS 15 DH4O
390428 -  ..
390429 - On 060607 Millie admitted to emergency room for temperature of 104.2;
390430 - xray shows pneumonia, ref SDS 18 PT7S, doctor reports Kaiser's computer
390431 - says Millie has been diagnosed with esophagitis, and asks how
390432 - esophagitis is being treated. ref SDS 18 LO3H  Research indicates
390433 - possible correlation between esophagitis and pneumonia. ref SDS 18 I24L
390435 -  ..
390436 - The record on 070523 reports disparity in terminology with PET test
390437 - citing "esophagitis" and CT test describing nodes in right
390438 - "paratracheal region" may cause busy doctors and staff to overlook
390439 - alignment in testing that confirms issue for investigation and
390440 - possible treatment, in this case esophagitis. ref SDS 17 Q65O
390442 -  ..
390443 - Correlations between "paratrachael" and "pretrachael" and esophagitis,
390444 - if any, are not clear in the record.  "Stable pretrachael node"
390445 - reported today, ref SDS 0 SR5P, could be the paratracheal node
390446 - reported on 060523, ref SDS 0 YK6J; or, these may be totally separate
390447 - issues.  Curbside research on the Internet seems suggest paratracheal
390448 - and pretracheal are either the same thing or closely related, but this
390449 - could be completely incorrect.
390451 -                 ..
390452 -                [On 080219 report for CT test on 080212 says node in
390453 -                right axilla measures 12.7 x 11.3 cm, which is a 10
390454 -                fold increase, indicating typing error or misreading.
390455 -                ref SDS 55 1K8T
390456 -
390457 -
390458 -
3905 -

SUBJECTS
Default Null Subject Account for Blank Record

4003 -
400401 -  ..
400402 - Hilar Lymphyadenopathy No Significant Findings
400403 -
400404 -
400405 -        d.  There is no significant hilar lymphadenopathy.
400406 -
400407 -
400408 -
4005 -

SUBJECTS
Default Null Subject Account for Blank Record

4103 -
410401 -  ..
410402 - Heart Enlarged Mildly No Correlation with Prior Findings
410403 -
410404 -
410405 - CT test 071210 report Findings continue...
410406 -
410407 -        e.  The heart appears mildly enlarged.
410409 -  ..
410410 - There is no comparison with prior findings of pulmonary embolism from
410411 - test on 060930, reviewed on 061012, ref SDS 21 294Q; and similarly no
410412 - comparison today with enlarged right ventricle (cor pulmonale).
410413 - ref SDS 21 7E5L
410414 -
410415 -            [On 080118 meeting with primary care physician at Kaiser
410416 -            reviewed CT test findings of mildly enlarged heart; doctor
410417 -            feels no referral to cardio pulmonary specialist required
410418 -            to investigate until treatable symptoms become evident.
410419 -            ref SDS 53 HP9T
410421 -             ..
410422 -            [On 080215 CT test for 080212 repeats errors in the report
410423 -            today, and further does not list patient history of
410424 -            enlarged heart reported today. ref SDS 54 IX4F
410426 -             ..
410427 -            [On 080507 Millie reports spike in heart beat (pulse) while
410428 -            laying down in bed; case study shows occassional spike in
410429 -            pulse reported by heart monitor during exercise, evaluated
410430 -            previously as defective equipment. ref SDS 57 CK4K
410432 -             ..
410433 -            [On 080723 CT test on 080718 reports heart appears normal
410434 -            size. ref SDS 58 UR4S
410436 -             ..
410437 -            [On 081012 pulse elevated to maximum of 224, and remained
410438 -            high for most of 2 laps, then returned to normal on the 3rd
410439 -            lap. ref SDS 59 FL7M
410441 -             ..
410442 -            [On 081105 Millie notified that primary care physician
410443 -            orders Muga test for heart damage prior to starting
410444 -            sunitinib clinical study that has some heart related side
410445 -            effects. ref SDS 60 WO72
410447 -  ..
410448 - The analyst does not comment on possible correlations and implications
410449 - finding mildly enlarged heart with also finding atelectasis.
410450 - ref SDS 0 SR66
410452 -  ..
410453 - Does failure to report enlarged right ventrical for the test on
410454 - 071210, establish that the condition reported in the test on 060930
410455 - has been resolved?
410456 -
410457 -
410459 -  ..
410460 - Lung Nodules Remain Stable No Evidence of Disease NED for Cancer
410461 -
410462 -
410463 - CT test 071210 report continues...
410464 -
410465 -        f.  There is some stable interstial/fibrotic change within the
410466 -            left lung apex.  There is a stable ill defined 4 mm nodular
410467 -            density within the left lung base.  There is also a stable
410468 -            3 mm ill defined nodular density within the left lung base
410469 -            on image #51.
410471 -  ..
410472 - Representation of "...stable...change..." within the left lung apex is
410473 - unclear.
410475 -  ..
410476 - Stable nodules in the lungs were cited by the primary care physician
410477 - at Kaiser in a letter on 070117 to explain the medical chart reporting
410478 - lung cancer. ref SDS 25 TS8G
410479 -
410480 -
410482 -         ..
410483 -        Lung Issues Atelectasis Pneumonia Possible
410484 -        Atelectasis Lung Issues Pneumonia Possible
410485 -        Pneumonia Possible Atelectasis Lung Issues
410486 -        Pulmonary Embolism Associated with CT Findings Atelectasis
410487 -
410488 -
410489 - CT test 071210 report continues...
410490 -
410491 -        g.  There is some interstitial prominence and ground-glass
410492 -            opacity within the right lower lobe medially, which is
410493 -            slightly increased.  This appearance may be partially due
410494 -            to atelectasis.  Pneumonia cannot be excluded.
410495 -
410496 -               [On 080507 Millie reports spike in heart beat (pulse)
410497 -               while laying down in bed; case study shows occassional
410498 -               spike in pulse reported by heart monitor during
410499 -               exercise, evaluated previously as defective equipment.
410500 -               ref SDS 57 CK4K
410502 -  ..
410503 - Finding "some interstitial prominence within the right lobe medially
410504 - is slightly increased," appears conflicting with the prior test on
410505 - 070930, since review on 071018 shows no findings of interstitial
410506 - disease in the lungs, noting simply the "lungs are unchanged."
410507 - ref SDS 37 KK6J  The prior CT test on 070723 was reviewed at UCSF on
410508 - 070802 and reported only:  "No new pulmonary nodules identified.  Left
410509 - apical groundglass opacities with associated septal thickening is
410510 - stable in appearance and is likely due to post inflammatory scarring."
410511 - ref SDS 31 OX4O  The next earlier test on 070520 was reviewed on
410512 - 070524 and affirmatively reported "no interstitial disease."
410513 - ref SDS 30 SP3F  If there was none before, how can some be increased
410514 - now?
410516 -  ..
410517 - Millie has patient history of pneumonia, diagnosed on 060607.
410518 - ref SDS 18 PT7S  There is no prior record reporting atelectasis.
410520 -  ..
410521 - Patient history of pulmonary embolism reported on 060722 shows
410522 - difficulties with diagnosis. ref SDS 20 6G6O
410524 -  ..
410525 - Does finding atelectasis together with failure to report pulmonary
410526 - embolism for the test on 071210, establish that the condition reported
410527 - in the test on 060930 has been resolved?  Does the report today show
410528 - that Kaiser performed the work on this test which was ordered by the
410529 - doctor and not performed for the prior tests?
410530 -
410531 - "Atelectasis" is explained on the Internet at...
410532 -
410533 -            Mediline Plus
410534 -            Medical Encyclopedia
410536 -               ..
410537 -              http://www.nlm.nih.gov/medlineplus/ency/article/000065.htm
410539 -             ..
410540 -            Atelectasis is the collapse of part or all of a lung.  It
410541 -            is caused by a blockage of the air passages (bronchus or
410542 -            bronchioles) or by pressure on the lung
410544 -  ..
410545 - Atelectasis seems associated with pulmonary embolism, either a cause,
410546 - or caused by, and can be mistaken for PE...
410547 -
410548 -            Emedicine
410549 -            Pulmonary Embolism
410550 -            Last updated:  070607
410552 -               ..
410553 -              http://www.emedicine.com/emerg/topic490.htm
410555 -             ..
410556 -            Imaging Studies:
410557 -
410558 -               Over time, an initially normal CXR often begins to show
410559 -               atelectasis, which may progress to cause a small
410560 -               pleural effusion and an elevated hemidiaphragm.
410561 -
410563 -             ..
410564 -            Emedicine
410565 -            Atelectasis
410566 -            Last updated:  060614
410567 -
410568 -              http://www.emedicine.com/med/topic180.htm
410570 -             ..
410571 -            Platelike atelectasis
410573 -             ..
410574 -            Also called discoid or subsegmental atelectasis, this type
410575 -            is seen most commonly on chest radiographs.  Platelike
410576 -            atelectasis probably occurs because of obstruction of a
410577 -            small bronchus and is observed in states of
410578 -            hypoventilation, pulmonary embolism, or lower respiratory
410579 -            tract infection.  Small areas of atelectasis occur because
410580 -            of inadequate regional ventilation and abnormalities in
410581 -            surfactant formation from hypoxia, ischemia, hyperoxia, and
410582 -            exposure to various toxins.  A mild-to-severe gas exchange
410583 -            abnormality may occur because of ventilation-perfusion
410584 -            mismatch and intrapulmonary shunt.
410585 -
410587 -             ..
410588 -            Karger
410589 -            Respiration
410590 -            International Journal of Thoracic Medicine
410592 -             ..
410593 -            Vol 70, No., 5, 2003
410594 -
410595 -              http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowFulltext&ArtikelNr=74195&Ausgabe=229717&ProduktNr=224278#abstract
410597 -             ..
410598 -            Transthoracic Ultrasound of Lung and Pleura in the
410599 -            Diagnosis of Pulmonary Embolism: A Novel Non-Invasive
410600 -            Bedside Approach
410601 -            Angelika Reissig, Claus Kroegel
410603 -             ..
410604 -            ...in PE... the cessation of pulmonary arterial flow in the
410605 -            areas distal to the perfusion stoppage may result in
410606 -            atelectasis due to a rapid breakdown of the surfactant
410607 -            lining the inner surface of the airspace.
410609 -  ..
410610 - CT test 071210 report continues...
410611 -
410612 -        h.  There is a stable 1.7 cm cyst within the liver dome.  The
410613 -            remainder of the liver, adrenal glands, pancreas, and
410614 -            gallbladder are unremarkable.  There are calcific foci
410615 -            within the spleen, compatible with calcified granulomata.
410617 -             ..
410618 -        i.  There is a too small to characterize low attentuation
410619 -            lesion within each kidney, which is unchanged.  Thre is no
410620 -            lymphadenopathyor ascities within the abdomen or pelvis.
410621 -            No evidence of bowel obstruction.  Sigmoid diverticular are
410622 -            again noted.  The unary bladder is underdistended.
410624 -             ..
410625 -        j.  Degenerative changes are noted within the lower lumbar
410626 -            spine.
410628 -         ..
410629 -    6.  Impression
410630 -
410631 -        1.  Status post left mastectomy.  Interval enlargement of a
410632 -            right axilary lymph node. ref SDS 0 SR5P
410633 -
410634 -        2.  Mild ground-glass opacity and interstitial prominence
410635 -            within the right lower lobe medially, which is increased
410636 -            from the prior study. ref SDS 0 SR66
410638 -             ..
410639 -        3.  Stable evaluation of the abdomen and pelvis.
410640 -
410642 -  ..
410643 - Brigid reported discussions with Doctor Rugo who is traveling today
410644 - for a professional event in Texas.
410646 -  ..
410647 - Brigid related the doctor's comments noting increased detail in
410648 - findings of the report today for the test on 071210, compared to
410649 - minimal analysis in the report for the CT test on 070930, which was
410650 - reviewed at UCSF on 071018. ref SDS 37 4N7K
410652 -  ..
410653 - The report for the test on 071210 seems confusing because comparison
410654 - is presented for the right axillary with the prior test on 070930,
410655 - which actually reports "...no axillary adenopathy" ref SDS 37 KK6J
410656 - The doctor feels the analyst in this case may have observed findings
410657 - for the test on 071210, and then examined the prior scan on 070930 and
410658 - noted something was missed in the prior report, or not reported
410659 - because 8 x 7 mm is below 1 cm commonly used for reporting.
410661 -  ..
410662 - The doctor feels the report today does not justify consideration for
410663 - changing treatment, for example by adding carboplatin at this time,
410664 - and pending CA 15-3 cancer report for the blood test taken this
410665 - morning.  This will be available next week, per below.
410667 -  ..
410668 - Brigid made a careful examination particularly of the right axillary
410669 - and found no indications of swelling that might suggest adenopathy.
410671 -  ..
410672 - Examination showed possibly expanding or more intense IBC area in the
410673 - stomach and abdomen area.
410675 -  ..
410676 - Since Jackie is traveling with the doctor to the conference in San
410677 - Antonio, Brigid asked Megan to take a photograph of the IBC on the
410678 - stomache.
410680 -  ..
410681 - The rest of the IBC sites appear stable, including the right breast
410682 - and the left arm.
410684 -  ..
410685 - Swelling of the left arm from cellulitis that compounds lymphedema has
410686 - completely subsided, especially below the elbow and the the hand.
410688 -  ..
410689 - Brigid commented on how well Millie looks.
410691 -  ..
410692 - Discussed how to exercise Millie's left arm without causing stress
410693 - that induces cellulitis recurrence.
410695 -  ..
410696 - Brigid said this can only be done through trial and error.
410697 -
410698 -     [On 071214 Millie suffered mild relapse Cellulitis; treated at
410699 -     home with Keflex on hand. ref SDS 52 SR8R
410701 -  ..
410702 - Millie went into the Influsion Clinic at 0750.  Diane was not in this
410703 - morning, but there were two nurses who were able to draw blood for the
410704 - test based on the lab slip, which Jackie submitted a few days ago.
410706 -  ..
410707 - During the meeting, OA 0840, Brigid noticed results of the blood test
410708 - this morning were already posted to the computer.
410710 -  ..
410711 - WBC was low for the first time in 4 or 5 months.  This caused NEUTS to
410712 - fall to 1.49, which is barely below 1.5 standard for safe treatment.
410713 - Brigid approved treatment today consistent with prior practice
410714 - approving treatment with NEUTS as low as 1.23, reported on 070301.
410715 - ref SDS 28 P560
410717 -  ..
410718 - Magnesium was slightly low. ref SDS 51 A14L  Catherine contacted
410719 - Brigid, who prescribed magnesium treatment.  Catherine gave this
410720 - treatment with IV injection during the rest period after treatment
410721 - with cetuximab.
410722 -
410723 -        [On 080404 UCSF reports difficulty communicating quickly and
410724 -        accurately to coordinate referral work with Kaiser ordering
410725 -        Magnesium medication for Millie. ref SDS 56 OP69
410726 -
410727 -
410728 -
410729 -
410730 -
410731 -
410732 -
410733 -
410734 -
410735 -
4108 -