James -- son of Marguerite -- will bring a form of these additional web site notes to Visit, today, Tuesday, 12 November 2024.
During 17 October 2024 scheduled visit with primary Dr. Corey of CHA he was assessing my continued concern regarding (R) thigh edemic-appearing (about a year since significant observed increase in size post (L) femur fx, details below) and "puffy" knee unlike (L)..ED started course of antibiotic for cellulitis. [son notes, BP was "well above" base at this visit)]
"Extrem: Right knee warm, mildly erythematous, exquisitely tender to light palpation, scanty effusion. Left knee contracted, nontender, no heat"
[...]
"(M25.561, M25.461) Pain and swelling of right knee (primary encounter diagnosis)
Comment: Patient with hist of saddle PE, now on secondary prophylaxis dose apixaban.
Has new onset exquisite tenderness, effusion, and heat at right knee
Given extreme limits on patient's transportability, will send via ambulance to CHA Everett Hospital rather than attempt to schedule urgent dopplers"
"(D50.9) Iron deficiency anemia, unspecified iron deficiency anemia type Comment: Patient has made informed decision against endoscopy - colonoscopy to workup iron deficiency anemia
Transferrin sat was near rock bottom in 9% in 08/2024, may still benefit from IV iron or nonurgent transfusion for breathing, comfort"
Hopefully, this summary from late October 2023 to present regarding resultant and continued c/o -- especially during changing of position and of brief --
of "knee" pain (L) and (R) is of some use to (new?) PA...
Prior to late October 2023 and over twenty (20) years after bilateral knee surgery Marguerite was able to passively lift (L) leg while in bed in supine position ~90 degrees and flex and extend w/o "buckle," and following being forced, into "stair chair," after D/C CHA ED (nurse asked how go home and stretcher was reserved) i.e., after her saying she did want to go in stair chair; her cries of pain while legs dangling, not supported.
She did not expect to travel in ambulance via stretcher and then transfer in front of her home from stretcher to above, chair, I think, any one, layperson or otherwise would deem such a chair not appropriate and this is without also knowing she uses her manual 'chair with legs fully extended since pain when legs flex when sitting, not ambulatory, compressed discs. demyelinzation, and quite 'frail.
Now the (L) knee hyperflexes and the (R) though it had been the knee following surgery that tended to hurt at times and not bend smoothly both have been more painful since last October.
Recent images 17 October 2024 -- Everett ED -- displayed a new to us (R) fracture. It was son's hope it was fluid buildup causing (R) knee pain since d/c of furosemide last summer after only being prescribed again after a few months prior after years of taking 40 mg. The (R) hip remains much larger since last year.
we can get DME of lateral rotating mattress to make change of positions less painful. A prior note to primary details this as well as a new Quickie M6; The current 'chair is more than twelve (12) years old.
When Marguerite was D/C above two ambulance personnel -- same company -- did not insist her to use stair chair, and did not look at steps. Last year when I asked why the look of concern. I was told "there are a lot of steps." Even if I did not offer to put ramp as I had done last October the people would have got her in safely via stretcher. She was take up ramp, up over outer vestibule threshold and up over living room threshold as through vestibule into her home..
A lot of steps?
to CHA, Dr. Van ...
I am sorry...usually I keep track of the details. Am I correct Marguerite does not require an appointment (radiology in Cambridge with lift) for the images (L) and (R) femurs and (R) shoulder noted in Visit Notes, and she can get them taken any day after the "expected" date of 30 November but before 5 December, the next visit?
p.s. It was a nice The Ride trip home too, as was on inbound, pleasant passengers for mom to talk with but upon return I immediately noted someone was quick to act upon me not returning the 6-foot aluminum ramp to the side of house as I usually do when we are out -- instead leaning upon sidewalk tree with protective cardboard for trunk. The latter was all the remained.
We managed to get mom with much effort and me unable to continue to do alone using a 3-foot ramp. I am trying to quickly build a wooden landing extension to be placed over two steps -- facilitating tilting 'chair back to get in / out of house.
Thank you, Judy....I ought to have got up quicker (when trying to assist medical assistant) than I did when I saw you enter the room to assist with immobilizer being placed on (R) leg, not (L) as stated in "Visit Notes," and please thank Dr. Van Lanker too for the notes including "quality of life.":
Marguerite does understand she was transferred -- she usually recalls her clear requests to not do it and stating bending legs hurts and cries of pain ignored too -- to "stair chair" in front of her home and contrary to her response when kindly asked by a nurse in ED last year, October 2023. ...
Also, I will share with Dr. Corey. The day after 31 October 2024 Visit, there was observed deoxygenation of SpO2 orf 87=88% for most of day though slow, deep breaths did get it increased yet raising HOB did not increase it. About a day and half later base returned, 94-95%, even when flat on bed. For the most part since PE of 15 February 2024 oxygenation has been greatly improved.
I will remove immobilizer today, Friday, and use Stryker Washcloths to observe "knee" betters. It appears less "puffy" but hard to fully see.
Progress Notes Kevin Kyle at 1/10/2024 1:30 PM MGH NEUROLOGY SUPERVISOR NOTE RE: Marguerite Zappia MR#: 2957504
"... status as of 2021. Although she attributes inability to ambulate secondary to her knee replacements, exam reveals substantial hyperreflexia, spasticity most notable on the left side, with substantial atrophy and hypotonia of the right upper extremity. Imaging is notable for multiple ill-defined T2 hyperintensities of the cervical spine, agree with radiologic impression that this likely represents demyelination. Based on available records from Lahey clinic in 2008, similar findings were identified at that time and work-up was not pursued per patient preference. Based on appearance, high concern for chronic demyelinating disease without clear history consistent with flares, concern for pathology within the spectrum of a primary versus secondary progressive multiple sclerosis, unclear to what degree this disease may be active but without evidence of enhancement on recent imaging or report of enhancement on prior imaging.
Given the patient's age, overall health status, progressive nature of her reported deficits, we discussed that there are limited available options for any disease modifying intervention--however..."
My mother, eighty-seven (87), has a Frail Elder Waiver, is non-ambulatory, has a recent diagnosis of demyelination, history of compressed discs, and relatively recent left femur fracture, a year of not yet healing and continued pain -- confirmed via images -- following inappropriate transfer from a requested stretcher -- she was in it from CHA Everett ED to in front of her home -- then transferred to a "stair chair," whereby surely this violated Atlantic Ambulance, a division of Cataldo's own policy, as she was not suitable for it, and she expressed in words and yells of pain she did not want to use it and when it was used her continued cries of pain were ignored.
notes about images (R) hardware misaligned....
I enclose extract from Dr. Peng, Neurology" and Dr. Haatem Reda...and I will "[E]C" (Electronic Copy ! ) to then and CHA Everett, Khare Wilson, PA, and Dr. Van Lanker, evaluated (R) distal demur fracture late October 2023, still "non-union and discomfort, details below.
"Referral for [PT] and [OT] (right shoulder, concern for adhesive capsulitis/frozen shoulder) [specific to you, Alicia] Referral to Physical Medicine and Rehabilitation for further evaluation of right shoulder"
Though the discomfort of the knee (R) and (L) too though it had painful at times and not smooth flex / extend for years it is more bothersome of late, hardware note below, was noted, i.e., I (son) did not stress at neurological visit follow-up, hope it can be addressed via this referral.
I know form asks what one wants to....and I add it came to me when Marguerite canceled....I expected more from the form,
First we got a call from main 617 726 2000, odd no longer displaying "Mass General..." as some other number have also done lately, only number.. but to the form expectations, not only update to new name but e.g., for one not to have to include medications and allergies, for form to be web site-based, etc. and not for one to have to "download" it and "fill it out," but I guess you will accept if I direct to web site medications list, etc., when I send expected form via USPS.
Now details about (R) femur, etc. and I am sorry....
"[a few motjhs ago to] Khare, PA, regarding femur fracture concerns -- now six months since ambulance personnel transfer from stretcher to 'stair chair' [...]
[Marguerite] used to be able to passively get (L) leg to ~ 80 degrees [six] moths ago, and bend knee!
... nurses at Mass General Brigham concern with knee...when Marguerite had "kidney stone..." and 'chest pain' the day prior to 9 April scheduled visit with you -- we had to call on 8 April to cancel -- in response to me stating imagery suggests (L) femur fracture is healing when I was asked about immobilizer they thought otherwise and my observation when we did attempt ROM::
The (L) knee no longer bends, flexes "smoothly," and appears to "buckle" or be "disjointed" and from reading...the knee range -- I could not find descriptive terms for a joint not adhering to expected plane? or such aside form maybe hyperflexion, knee now turning sideways.
Also, surely not related to fracture but the (R) knee for over twenty years was the one with more observed difficulty in ROM and more pain had recent pain, along with comments included above from imagery "hardware" alignment.
The state of the femur or knee (L) in particular contributes now greatly to discomfort and difficulty for routine changing of brief and re-positioning.
[From PA Khare Wilson]
"[....] I reviewed the images from October 2023 and March 2024. So the images were better back in October but that was after the acute injury. It does appear more impacted (meaning shaft of femur is squished into the condyles of knee), but I do see a large callus attempting to form.
Her fracture definitely has not healed. It appears its trying, but likely failing. I think likely due to several reasons, most noticeable is her severe osteoporosis. Her cortices (the thick part of bones) are VERY thin.
Given its been over 6 months, this does classify as a non-union. The next recommendation would be surgery, but given her non ambulatory status and co-morbidities, it would be hard to justify surgery, unless her pain is severe enough to warrant that level of intervention. "
[Surgeon Dr. Esposito did not think safe for surgery to 'correct'] I am sorry this is lengthy,
James Zappia
James keeps Dr. Corey's kind, thoughtful and words of experience, i.e. his response to me making clear I was not suggesting a priority of concerns for an upcoming visit, in mind:
" 'What is the most important issue?' Is always, 'What does the patient think is most important to her life and health?' And then build a plan around that."
I add some notes I will keep in mind for visit this Thursday.
I neglected to comment about Marguerite taking at breakfast MegaFood Blood Builder, ~ eight (8) weeks now.
One day when I moved bed after re-positioning with buck wheat (wonderful) pillows Marguerite c/o of dizziness, and one morning of concern as detailed in previous note SpO2 below base and not rising with deep breaths. Also, thighs warm....and one day only (R) hand cold all others extremities felt "normal." The (R) thigh still seems endemic though I keep in mind what doctor said about lowest point and (R) knee still "puffy," all observations from this layperson.
There was a lot of effort by all of us save apparently Sullivan Pharmacy; DME prescription for lateral rotating mattress obtained but communication with them awful. Adding I have experienced the DME process before and have read about some pharmacies no longer accepting orders for DME via Medicare.
Prior to the 1 October visit -- rescheduled -- we hope Dr. Corey is still doing okay -- I hesitated to ask if the process for DME, i.e, acquiring a new Quickie M6 'wheelchair' could begin prior to visit earlier at the start of this month -- the one Marguerite has is ~ twelve (12) or more years old and she has been using daily to have one meal again as of late, and we are considering either an update to MicroAir 65 -- we purchased this on our own as we did the Med-Mizer adjustable to 42-inch width bed, and I add oxygen concentrator and mattresses in past but -- and I am sorry to add personal note...the hopeful sign of Federal Fund Rate -- down 50 basis points earlier this month still has us with a big interest concern on HELOC balance, but I will consider paying ourselves for lateral rotating Invacare MA 900 I think is pressure and this if it again seems a lengthy, grueling, fruitless process -- not you, Medicare and e.g., the pharmacy above..."any one but them (!)"
Of course the rotating mattress includes alternating pressure...as does the MicroAIR 65 we now have on bed.
https://newleafhomemedical.com/invacare-microair-ma900-lateral-rotation-w-true-low-air-loss-mattress-system-36-42-48w-x-80/
Although we have 36-inch wide doors now I still had to move the wheels on the Quickie M6 inward as well at one time make a notch in rear room sliding door to allow the brakes handle to clear the doorway! The chair has leg rests with wonderful support unlike many chairs. Granted it is wider than is required for Marguerite and at times she leans to one side -- I use pillows but I think it has to do with how I get her transferred form ceiling lift to 'chair. ADA change to this term, I think.
https://www.southwestmedical.com/Wheelchairs/Bariatric-Heavy-Duty-Wheelchairs/Quickie-M6-Heavy-Duty-Wheelchair/2443p
Thank you, Suzanne, RN, as you suggest it can wait till tomorrow, Thursday, and I add when Dr. Corey has seen images in the past from me -- those too large to compress, etc. -- not attached but as url I guess he has seen it via some other means, i.e., it one might not be able to view so-called "external" images, etc.
Regarding the image, I checked url again and I can view it...
Lastly, though Dr. Corey can see it I think the Notes from Dr. Heffernan might be telling regarding edemic...concerns above.
Thank you a lot,
James