This week, on Wednesday, Kody has a writing assessment for school.  The teacher is bringing out a computer to have him do it on.  That might take a while but he will get his point across. I have to schedule his appointments soon and get them taken care of.  I have to remember to email CMS and keep them in the loop for everything just incase his state insurance were to not be working for some reason or another. 

He has been doing good.  Of course mom is his favorite word when I am home.  For the most part it does not bother me except when I walk into the room and answer whatever it is that he is asking and then get into doing something else only for him to call me again.  

Right now his PS3 is out of commission because he needs a new dual shock wireless controller for it and at the moment I do not have the funding to be able to get it for him.  This sucks since he just got 3 months of PS+ and a new game.  Once money is right though we will work towards getting him a new remote.

Kody loves the new dog.  Sadie has blended in well and is spoiled by everyone.

Cardiologist Notes .....

Dear D. Champagne (this is because this letter was sent to us)

Chief Complaint: Friedreich's Ataxia and Hypertrophic Cardiomyopathy

Pertinent Clinical History: Kody is a 17 year old male who is seen for the first time in our practice, having recently relocated from the Tampa, FL area where he was followed by Pediatric Cardiology Associates for his hypertropic cardiomyopathy secondary to Friedreich's Ataxia which was diagnosed at the age of 7 years while the family was living in Michigan at the time.  He is not currently on any cardiac medications, having failed even low-dose atenolol due to low BP (50's/30's) with recurrent syncope.  He was also tried on the investigational medication idebenone as part of a research trial but has to stop it due to an "allergic reaction."  He has occasionally taken lasix PRN when he has leg edema, but he is not on any standing lasix dose due to concerns over his dynamic left ventricular outflow tract obstruction being worsened by hypovolemia.  When he was last seen by his cardiologist in Florida in February 2013, a 24 hour Holter monitor was placed, the results of which are not available for my review.  His mother was told that it revealed "arrhythmic moments" and was as expected given his condition.  His cardiac records have been requested, and his mother will be scheduling him to be seen by neurology, orthopedics, and pulmonary medicine locally.  He denies any palpatations, but he will occasionally have pressure-like right-sided chest pain that is not associated with other symptoms and which does not require any treatment to resolve spontaneously.  He also has significant scoliosis and restrictive lung disease and is wheelchair bound.

Kody has a past medical history and family history are documented in the medical record.

A 10 system review was performed and is documented in the medical record.

Medications:  No current outpatient prescriptions on file.

Pertinent physical findings: 

Pulse 100, Resp 18, BP RUE 100/78 mmHg, BP LLE 112/0 mmHg, Wt (wheelchair bound), Ht (wheelchair bound)

Constitutional: no distress, wheelchair bound with profound muslce weakness and difficulty speaking, cachectic, and small for age.

Head: normocephalic, atraumatic

Eyes: normal sclera, conjunctiva, and lids

ENT: inspection of nares, gums, oral mucosa, and external ears appears normal

Neck: mobile with weak muscle tone

Chest and lungs: clear to auscultation and fair air exchange without wheezes with asymmetric chest shape.

Cardiac: normal active precordium, regular rhythm, normal S1, physiologically split S2, no diastolic murmurs, clicks, rubs, or gallops, brachial and femoral pulses are 2+ and symmetric without delay, normal distal perfusion with brisk capillary refill, no jugular venous distention and no clubbing, cyanosis, or edema; grade I-II/VI medium frequency systolic ejection murmur maximal at the left sternal border and radiating along the sternal border.

Abdomen: no masses, no hepatamegally, no splenomegally and soft and nontender / active bowel sounds.

Muscoskeletal: severly decreased muscle strength diffusely; sever scoliosis

Extremities: decreased muscle tone in extremities

Skin: clearn, no rashes, no lesions.

Neurological: cooperative, able to speak a few words at a time without becoming out of breath.

Laboratory:

ECG: due to his known hypertrophic cardiomyopathy, a 12 lead electrocardiogram was performed in order to assist with the evaluation of his rhythm and ventricular forces.  This was obtained and demonstrated: normal sinus rhythm at 96 bpm with a normal corrected QTc interval of 401 msec.  There was inferolateral T-wave inversions as previously reported with ST segment elevation in leads V1-V3 as previously seen.

Echocardiogram: Given his past hypertrophic cardiomyopathy I did recommend an echocardiogram in order to evaluate for any worsening of his ventricular function or left ventricular outflow tract obstruction.  This study was obtained and demonstrated severe concentric left ventricular hypertrophy with a IVSd of ~18-19 mm and a LVPWd of 14 mm.  There was a near LV cavity obliteration in systole with systolic anterior motion of the mitral valve resulting in very mild mitral regurgitation.  There was no effusion and no evidence of cor pulmonale.  There was good biventricular systolic function but evidence of significant left ventricular diastolic dysfunction based on tissue Doppler imagine. Overall, the left ventricular wall thickness seems compariable to his report from his previous study in Florida.

Impressions:

1) Friedreich's Ataxia

2) Severe hypertrophic cardiomyopathy without significant resting LVOT obstruction.

3) Systolic anterior motion of the mitral valve (SAM) with very mild regurgitation.

4) No pericardial effusion.

5) Marked left ventricular diastolic dysfunction with "normal" sytolic function in the setting of marked left ventricular hypertrophy.

Discussion:  At the present time given Kody's stable clinical status, I have not recommended any cardiac medications since he was intolerant of beta-blockers and idebenone.  I did review the importance of keeping him well-hydrated as hypovolemia could potentially result in increased dynamic left ventricular outflow tract obstruction.  I would also suggest that he be followed in our hypertrophic cardiomyopathy clinic and that the family establish care with a local pediatrician as well as a pediatric neurologist, pulmonolgist, and orthopedic surgeon.  His mother is in agreement with this plan.  Overall, it would seen that his prognosis is poor given the severity of his heart disease,  There is a notation in his records from Florida that a DNR order was in place.  This should reasonably be re-addressed once he has been seen by our HCM clinic and by his local subspecialist.

Establishing a Cardiologist In Atlanta

We had an appointment this past Thursday with Sibley's Cardiology in Atlanta.  The appointment was only two hours long which was not bad for an establishing appointment.  The doctor asked us to bring him back in three months to be seen by the doctors who specialize specifically in Hypertrophic Cardiomyopathy.  First impressions of the doctor and the clinic is that we liked them.  Kody was included in conversation and treated with respect.  Of course he liked all the pretty nurse techs.  The doctor came into the room where he had the echo done and explained everything he was seeing on the screen and asked if we had any questions.  At this point his heart has not gotten better but not gotten worse in comparison with the notes from the last appointment in April.  They have not yet reviewed his full chart because it had not been received by the clinic.  It had to be sent via snail mail because of the amount of information.  

Summary of report:

*Mitral valve regurgitation is present and is mild. This means the valve between the upper and lower chamber of the heart on the left side does not close properly so the blood being pumped out trickles back into the bottom chamber.  

*The right portion of the mitral valve when opening has a tendency to suck up to the right side of the wall.

* Thickness of the heart muscle is such that though it is pumping efficiently the walls touch when the chambers fully contract.

I made mention of the aorta narrowing but did not ask about it when he had the sonogram screen in front of me.  

I will call on Tuesday to make the appointment for three months from now.  Because of the HCM he has to be seen on a Monday and at the clinic in Atlanta verses their location in Marietta which is closer to us.

I set up an appointment for 8/26 @ the new cardiology clinic in Atlanta.  The plan was for Kody to go to Sibley Cardiology in Marietta GA BUT when I called to make the appointment I was told he has to be seen at this other place because they SPECIALIZE in HCM.  Yes, this is the first time ever we have dealt with someone who specializes in Kody's heart condition.  Yesterday I had to fax the request for the old clinic to send ALL of his records to the new clinic.  This should be interesting.  Will update at a later date.

Camp Pictures

I have put together a "story book" of some camp photos from Kody's final year at MDA camp.  Click on the photographs below to be able to view all the pictures.  He had a blast and they really did love the heck out of him.... was sad to close that chapter of his life.  

Day 2 At Rotary Camp ..... in Brandon, Florida

In these pictures Kody seems to be in a contest ... I thought it was drinking liquid but apparently he is trying to suck jelly through a straw.  I would not be surprised if he managed to get it done ..... lol ... go Kody. 

The Special Mother by Erma Bombeck

The Special Mother 

by Erma Bombeck 

Did you ever wonder how mothers of disabled children were chosen? 

Somehow I visualize God hovering over the earth selecting his instruments of propagation with great care and deliberation. As He observes, He instructs His angels to make notes in a giant ledger. 

"This one gets a daughter. The Patron saint will be Cecelia" 

"This one gets twins. The Patron saint will be Matthew"

"This one gets a son. The Patron saint.....give her Gerard. He's used to profanity"

Finally He passes a name to an angel and smiles. "Give her a disabled child".

The angel is curious. "Why this one God? She's so happy"

"Exactly," smiles God. "Could I give a disabled child to a mother who does not know laughter? That would be cruel!"

"But has she patience?" asks the angel.

"I don't want her to have too much patience or she will drown in a sea of sorrow and despair. Once the shock and resentment wears off, she'll handle it. I watched her today, she has that feeling of self and independence that is so necessary in a mother. You see, the child I'm going to give her has his own world. She has to make him live in her world and that's not going to be easy."

"But Lord, I don't think she even believes in you"

God smiles, "No matter, I can fix that. This one is perfect - she has just enough selfishness"

The angel gasps - "Selfishness? is that a virtue?"

God nods. "If she can't separate herself from the child occasionally she won't survive. Yes here is a woman whom I will bless with a child less than perfect. She doesn't realize it yet, but she is to be envied. She will never take for granted a 'spoken word'. She will never consider any 'step' ordinary. When her child says "Momma" for the first time she will be present at a miracle and will know it. I will permit her to see clearly the things I see...ignorance, cruelty and prejudice...and allow her to rise above them. She will never be alone. I will be at her side every minute of every day of her life because she is doing my work as surely as if she is here by my side"

"And what about her Patron saint?" asks the angel, his pen poised in mid air.

God smiles "A mirror will suffice"