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Hx of rheumatic heart disease, mitral valve prolapse, pacemaker placement, severe cough, SOB, weakness, pneumonia, on Z-pak, Levaquin, CT scan, scar tissue, on amoxicillin. Suggest.

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My father is 70 years old with a hx of rheumatic heart disease as a child, mitral valve prolapse, and pacemaker placement 5 years ago. He has been coughing x5-6 week and it is progressively getting worse. He is now often weak and develops SOB with minimal exertion. He says it feels like he can not get a XXXXXXX breath and the cough worsens with talking. He was diagnosed with pneumonia originally and treated with Zpak and Levaquin. Then was told he by a pulmonologist that he did not have pneumonia and treated with Prednisone x10 days. Had a CT scan of lungs, non-conclusive, but scar tissue evident. Went to ER by Rescue Squad 5 days ago for severe SOB and told that xray shows he does not have Pneumonia or CHF. WBC only 0000, no fever, all other labs WNL. O2 Sats 89% to 94% on room air in ER. Yold to f/u with pulmomologist. Back to pulmonologist today with yet worsening symptoms and is now again given Pneumonia Dx and put on Amoxicillin and not to go back for 2wks. Note: he was in New Orleans shortly before sx developed working on homes damaged from flood. We feel he is progressively detriorating while he is being given conflicting dx. Meanwhile, no medication has helped. Where does he go from here? There has been no sputum cultures taken or pulmonary function tests done.
Posted Tue, 24 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Rajkumar Chemudugunta 9 hours later

Thanks for the query.

After going through the details given by you, I could think a possibility about the current clinical state of your father.

It appears that your father might be suffering from decreased pumping capacity of heart(low ejection fraction) due to chronic heart disease he has. The common cause in post pace maker implanted patients is failing pace maker. This can put back pressure on the lungs, which can lead to fluid accumulation in lungs(which leads to SOB).

Fluid accumulation in lungs(pulmonary odema) can sometimes lead to Pneumonia, added to the failing heart.

Ideally If I were your father's personal Physician I would admit him in a multispeciality hospital(where all tests are available under one roof) under my care and refer for Cardiologist, (Electrophysiologist) and Pulmonologist for their evaluation. The reasons for Cardiologist referral is to assess the pace maker functioning and cardiac status.

Meanwhile I would get the following test done: Chest X-Ray, Pulmonary function test, Echocardiography, BNP(Brain Naturetic Peptide) along with a thorough assessment of pace maker functioning. Since a Pace maker's life is around 5 years after which they need a battery change or lead change.

Since his Total WBC counts are raised with no fever and other blood investigations being normal, this can be possibility of sub clinical infection. Hence a sputum culture along with repeat blood investigations will be helpful.

I would rule out the following possibilities:
Cardiac Failure (Echocardiography, BNP, Pace maker assessment).
Pulmonary Oedema (Chest X XXXXXXX Pulmonary function test)
Lung Infections (Sputum Culture, Blood Investigations)

Depending on the results of these investigations he can be treated more accurately on an inpatient basis.

Hope I answered your query.

Wish your Father a Good Health.
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Follow-up: Hx of rheumatic heart disease, mitral valve prolapse, pacemaker placement, severe cough, SOB, weakness, pneumonia, on Z-pak, Levaquin, CT scan, scar tissue, on amoxicillin. Suggest. 23 hours later
Thank you for your recommendations. I agree that he should be in the hospital for further testing. Since I originally asked the question, I have found out that he has had a pulmonary function test and is awaiting the results. He went back to his PCP yesterday to request a 2nd opinion and was told his pulmonologist is the best in our area, so I guess he will continue on with him. They do not want to put him in the hospital right now because they say he is susceptible to further infections. They suspect that he has inhaled something that is irritating his lungs. However, they seem hesitant to do a bronchoscopy. They told him it would be done as a last resort because it is XXXXXXX Apparently he is now stating that he inhaled some sawdust not long before he started having problems. Could that possibly be a reason for his situation and if so, will this resolve with medication alone or will something else need to be done? How XXXXXXX is the bronchoscopy and what could be reason for not doing one now?
Thanks again!
Answered by Dr. Rajkumar Chemudugunta 1 hour later

I understand the situation of your husband better after those comments given by your PCP after preliminary examination.

Inhalation of saw dust can cause such severe symptoms. It irritates the bronchus and cause such reactions. Prednisolone should have helped him along with proper prophylactic low dose antibiotic. Bronchodilators are also be given which can help to get rid of these bothering symptoms.

Bronchoscopy is not required now, and it is the last resort. I agree with the doctor. It is not XXXXXXX if done by experienced pulmonologist. Otherwise it can cause slowing of heart, bleed and gagging.

Let me know the Pulmonary function test reports after they are available.
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