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Suggest treatment for pulmonary embolism

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Posted on Thu, 19 Nov 2015
Question: Breathing Problems:

I believe medicine is like Art and should be tailored to the individual, so i will do my best to provide the complete picture. My apologies if it’s too long.



Symptom:
Shortness of Breath (difficulty experienced when i need to take deep breaths), After every 3 to 4 normal breathing (which is every 15 seconds)
I find the need to take a deep breath, Obtaining that deep breath requires conscious effort, sometimes i can get a deep satisfying breath the first try, other times i have to try multiple times, this goes on the entire day, i find it exhausting, distracting and it gives me anxiety when i realize i can’t get a deep breath.
I am still using the spirometer every day. Not at every hour anymore, but at least a couple of hours a day when i am home.


Start date:      10/1/2015

End date:     Still on-going. It has been a month

Progress:      
The shortness of breath was extreme when admitted to the ER on 10/1. I couldn’t complete a sentence without running out breath:
Taking deep breaths was extremely difficult to achieve:
It was at it’s worse upon standing and moving, but better when sitting
After 2 weeks of using Spirometer & light walking, significant improvement
Now, i feel like i have healed upto 60% and i feel stuck there. No further changed


Background:
30 year old, completely healthy all lab tests, no past medical issues, fairly thin and slim, 85 lbs and 5’5 , East XXXXXXX XXXX,

09/18/2015:     
I had Bilateral Breast Augmentation : Under the Muscle : General Anesthesia : 2 hour in hospital Surgery : No Complications : 250 cc Moderate Plus Mentor Implants: Was 32 AA increased to 32 Full B: No Infections : Incisions have healed perfectly

09/25/2015:      
7 days post op, Fever started (after a really bad and heated argument with a family member), Was instructed to take 2 X 500 mg tynenol, fever lasted for 2 days and was under control.

10/1/2015     
13 days post op, started experiencing shortness of breath

10/3/2015:      
15 days post op, i was admitted to the ER. I couldn't complete a sentence without running out of breath, several attempts needed to take deep breath

Tests Done:     
CBC, Complete Metabolic Profile , EKG and Chest CT with Contrast
Test Result:
Please look at attachment : All tests came back negative except for CT


Medications:     
I was taking Valium since surgery date until a week ago.
I started muscle relaxer but stopped it as it was giving insomnia and not helping
Currently, i am taking NO medications
But i am going to ask for Valium to help with sleeping and anxiety at night


Doctor's Recommendation:
I was discharged home with a spirometer, to practice deep breathing and that’s it. While that has helped, now i don’t see further improvement after a month.


What i have noticed:

* I started exercising 2 days ago : Treadmill for 20 minutes : Fast walking : I am able to take deep breaths with no problem the entire time. Once i stop, maybe 15 minutes later, the symptoms come right back again
* It is worse when i lay back in a seated position, when lay down to sleep and generally during the evenings
Sleeping on the sides feels better. I feel that position allows me to breath better
* When i sit up or stand up or bend over to the front, i can breath better
* Once i fall asleep, it is as if i don’t have any problems at all. I DON”T wake up in the middle of the night needing to take deep breaths
* It feels better after i cough
* i have have a clear discharge after the cough, usually.
* If i am struggling to take deep breaths, i use the spirometer and that helps me right away
* I feel the spirometer that was given to me is odd. Please look at the picture/attachment


Questions:
What do you make of this?
1. Do you think there is inflammation that's adding to this behind the implant?
2. How long does it usually take for such kind of atelectasis to heal or expand?
3. How can progress be tracked? Will X-ray help?
4. Can the CT scan have missed a possible small Pulmonary Embolism in the lungs?
5. No one in the ER even looked at my calves for DVT before the scan , is that normal?
6. Why wasn’t a D-miter test used before going for a CT scan to rule out PE?
7. Why do i breath normally during exercise? (brisk walk) Why does it go back after ?
8. Why do i breath normally at night ?
9. Is the spirometer that was given to me the right one?
10. How long should i be using the spirometer ?
11. Why has my progress been halted at this point?



Thank you in Advance!


doctor
Answered by Dr. Kaushal Bhavsar (5 hours later)
Brief Answer:
No need to worry for Pulmonary embolism.

Detailed Answer:
Thanks for your question on Health Care Magic.
I can understand your concern.
Thanks for the detailed information. I have gone through the reports you have attached.

Answer to your 1st question.

No, your symptoms are not due to any inflammation behind the implants.

Answer to your 2nd question.

Atelectesis which you are having is mostly asymptomatic and can not cause any symptoms. So I don't think such tiny atelectesis can cause your symptoms. Usually atelectesis expands in 1-2 weeks with deep breathing exercises.

Answer to your 3rd question.

No need to track progress for your atelectesis because they were accidental findings. But if you really want to see the progress then get done repeat CT thorax and PFT (Pulmonary Function Test).

Answer to your 4th question.

No, not at all. You had CT Pulmonary Angiography. And it is the gold standard, the diagnostic test for Pulmonary embolism. So if it is negative then you are definitely not having Pulmonary embolism.

Answer to your 5th question.

No, this is not normal. Doctor should have look for tenderness in calves for DVT because DVT is most common cause for Pulmonary embolism.

Answer to your 6th question.

D dimer is only a screening test. It is not confirmatory or the diagnostic. Even if d dimer is low, Pulmonary embolism can present.
Even if d dimer is high, Pulmonary embolism can be absent. But yes, they should get done d dimer before CT Pulmonary Angiography.

Answer to your 7th and 8th question.

You are breathing normally while exercising and at night because your breathlessness is not due to any organic causes like bronchitis, Pulmonary embolism, atelectesis etc.
Your breathlessness is mostly due to stress, anxiety, tension etc.

Answer to your 9th and 10th question.

Yes, spirometer which you are using is good. It is for deep breathing exercises. And you can use it lifelong, no harm in it.

Answer to your 11th question.

By your history and description, possibility of stress and anxiety related breathlessness is more.
So please avoid stress and tension, be relax and calm. Consult psychiatrist and get done counseling sessions. Try to identify stressor in your life and start working on its solution. Counselling plays very important role in control of symptoms along with drugs.
Don't worry, you will be alright.

Hope I have solved your query.
I will be happy to help you further.
Wish you good health. Thanks.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (1 hour later)
Thank you for your response. I love the format of your answer it shows me how well you have read my concerns. I have a few concerns.

My recovery period after my surgery went really well. The breasts were beyond my expectations which was amazing and nothing in my life had changed. In fact, i was happier than before the surgery, it was something i wanted for 10 years/ Further more i am a calm and rational person and practice meditation. :)

Therefore, when i first started experiencing shortness of breath, i was not anxious in any way. It was sudden and severe. I found i couldn't sit up right or complete a sentence without gasping for air. It was after i started using the spirometer and daily short walks that i saw improvements.

1. So based on that, wouldn't you say the Atelectasis were symptomatic?

2. If not what else besides anxiety would describe the dyspnea?

3. Please see new attachment labeled "spirometer". The light blue one you saw early, my primary doctor has never seen one like that before. That have me a concern, the one you see attached is the type he is used to, what is the difference?

4. The primary doctor ordered a chest x-ray and wont get the results till this week. Would he be able to see the progress using that?

5. The only other theory that is making sense to me since i find relief when i bend over to the front and sleeping on my sides (Both displaces my implants away from my chest), is that the weight of the implant is depressing or putting pressure on the lungs? Is that possible?

6. Or since its placed under the muscle the muscle hasn't stretched enough just yet?

7. Can the x-ray help see if the implant is putting pressure?


Thanks again!
I also forgot to ask,

8. If its asymptomatic, why was it recomended on the CT paperwork for 8mm size a 3,9, 24 month CT follow up?

9. Isn't that extreme to be subjected to another CT 2 months from now?


Thanks
doctor
Answered by Dr. Kaushal Bhavsar (1 hour later)
Brief Answer:
Both spirometers are same. No difference.

Detailed Answer:
Thanks for your follow up question on Health Care Magic.
Thanks for your kind words.

Answer to your 1st question.

This much small atelectesis is accidental finding and will not cause any symptoms. Most common symptoms of atelectesis are cough, chest pain,fever. And breathlessness develops only if large segment of lung is atelectetic. So I don't think your breathlessness is due to atelectesis.

Answer to your 2nd question.

Besides anxiety, allergic bronchospasm, bronchitis can cause similar symptoms. Allergy at night time due to bed shit, pillow cover or anything can cause this.

Answer to your 3rd question.

Both spirometers are same, function wise. They are made by different companies, so design is different. Otherwise, their purpose of deep breathing will be solved by both of them.

Answer to your 4th question.

If atelectesis is worsening and becomes large then only x ray will be able to identify. Otherwise, this much small atelectesis can not be picked up by x ray. For perfect comparison, you need to compare CT thorax with CT thorax. CT thorax and chest x comparison is not appropriate.

Answer to your 5 th question.

No, implants can not cause pressure on lungs. Ribs and intercostal muscles are in between implants and lungs. So implants can not compress lungs.

Answer to your 6th and 7th question.

No I don't think that muscles are not stretched enough. And no chest x ray can not tell that.

Answer to your 8th and 9 th question.

Most common cause for atelectesis is collection of secretions in the lumen. But sometimes tiny nodule can also atelectesis. And so we need to look at the progression of atelectesis at intervals. So repeat CT thorax after 3 months is needed. If it shows same lesion then follow up at 9 months is needed. But if after 3 months CT shows worse atelectesis than bronchoscopy is needed.
If CT scan is needed then it should be done. No harm in it.

Hope I have solved your query.
I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (34 minutes later)
Excellent thank you.

If you don't mind, the implant might not be directly depressing the lungs. But when I in inhale, since I have a tiny frame I can see the chest rise and and expand and with it my implants as well. Maybe the weight of the implant and since my skin has not stretched enough yet, the rib cage is restricted and weighted down? Is that a possibily?
doctor
Answered by Dr. Kaushal Bhavsar (12 minutes later)
Brief Answer:
Have you're ever undergone PFT?

Detailed Answer:
Thanks for your follow up question on HCM.
I can understand your concern. Don't hesitate, I am here to help yourself and solve all your doubts. So feel free to ask anything.
Coming back to your query.
Possibility of this is extremely unlikely, but in medicine, anything can happen. There is no 'no' in medicine.
If we believe that this is the possible cause then you should have restrictive airway defect.
In this lungs are restricted and not expanding completely. This can also cause atelectesis.
So please let me know if you had PFT (Pulmonary Function Test) or not?
I will be happy to help you further.
Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (36 minutes later)
Thank you for follow up!

No I haven't had a PFT. I am looking to see to a pulmonologist soon. A general doctor I saw just keeps telling me I am fine and I am struggling everyday. So I thought I should look for a specialist.

I really want to rule out the restrictive airway defect because of the implants. So when I see the pulmonologist, what tests should he perform or what I should ask him to perform ?

Btw I don't have any cough. I just feel better when I cough.
doctor
Answered by Dr. Kaushal Bhavsar (1 hour later)
Brief Answer:
Do you cough more at night?

Detailed Answer:
Thanks for your follow up question on HCM.
I can understand your concern.
Yes, you should definitely consult pulmonologist.
And get done clinical examination of respiratory system, PFT (Pulmonary Function Test).
Give him detailed history and discuss your problem.
PFT is must for the diagnosis of restrictive lung disease.
Please let me know
1. Do you have feeling of coughing at night?
2. Do you smoke?
3. Are you married? Do you take hormonal contraceptive pills?
I know these are personal questions, so if you are comfortable then only answer, otherwise it's ok.
I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (7 hours later)
I haven't come across a Doctor Who actually asks more questions so please know how much does appreciate it and I don't mind answering any questions

No I don't have any feeling of coughing at night. Even throughout the day I don't have the feeling for cough I just initiate a cough voluntary to try to clear the airway

No I'm not married, I have never smoked, and the last time I took birth control pill was seven years ago before two months.


1. About a week ago I took a new muscle relaxer for my breast called Zanaflex, and after I took it that night about 15 minutes later I felt a rush of tingling such sensation all over my right arm all the way down to my right feet. I remember feeling what was that. Since then I stopped taking it immediately the next day but since then I've been experiencing a rush of tingling sensation all over both of my legs starting from my ties all the way to my toes simultaneously on both legs and also sometimes both my arms down to my fingers it's been every day.

The only time I notice it is during at rest when I sit down Or lay down. Is there any reason related to my breathing problem or the pill I took?

2. Last night, it was worse with the team and tingling sensation I also felt pins and needles kind of discomfort/pain she can call it that. And it's a rushing feeling of sensation on both legs simultaneously all the way down to my feet. So at some point last night I felt weird feeling on my legs and called some feet so I kept checking it most of the night just in case it's not inflamed and I'm not missing a DVT? Shouldn't even be worried about a DVT this point and or health, six weeks after surgery? I only worry about it at night since there's a little movement involved. I'm beginning to hate my implants
doctor
Answered by Dr. Kaushal Bhavsar (28 minutes later)
Brief Answer:
No that pill does not cause tingling or weird feeling.

Detailed Answer:
Thanks for your follow up question on HCM.
I can understand your concern.
No need to worry for DVT.
Zanaflex is having tinazidine. It does not cause tingling or weird feeling.
So possibility of that drug as a cause is very less. And single dose can not produce effect for such long time.
So this is not due to that drug.
Please let me know
1. Do you work? Where?
2. Have you ever undergone vitamin b12 level?
Please reply me answers of above asked questions, so that I can guide you better.
I will be happy to help you further.
Wish you good health. Thanks.
Brief Answer:
What was the result of that test?

Detailed Answer:
Thanks for your follow up question on HCM.
Please let me know the result if your vitamin b12. Also tell me why it was done?.
Please reply me answers of above asked questions, so that I can guide you better.
I will be happy to help you further.
Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (24 minutes later)
I read up on Zanaflex list of side effects symptoms and tingling sensation was one of them but I guess you might be right to one does not being able to create lasting effects.

I am currently not working just recovering I'm staying with my aunt and just taking it easy.

The last time I did vitamin B12 level was about a year or two years ago
doctor
Answered by Dr. Kaushal Bhavsar (26 minutes later)
Brief Answer:
Yes, you should definitely get done vitamin b12 level.

Detailed Answer:
Thanks for your follow up question on HCM.
I can understand your concern.
Yes, you should definitely get done vitamin b12 level because vitamin b12 deficiency can cause similar symptoms like tingling.
Also let me know
1. Are you strict vegetarian?
2. Have you ever tested for thyroid function test?
Please reply me answers of above asked questions, so that I can guide you better.
I will be happy to help you further.
Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (4 minutes later)
I'm sorry I'm not able to find that because it was from an old medical provider and I can't access my records anymore there remember it was normal then just don't remember the value.

I guess I should go to a Neurologist and also get my vitamin B12 and folate checked out?
doctor
Answered by Dr. Kaushal Bhavsar (22 minutes later)
Brief Answer:
Did you get my last answer?

Detailed Answer:
Thanks for your follow up question.
I think you have not received my last answer.
I just received. (dot) as your question. So please write your question again, so that I can guide you better.
I will be happy to help you further.
Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Dr. Kaushal Bhavsar

Pulmonologist

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Suggest treatment for pulmonary embolism

Brief Answer: No need to worry for Pulmonary embolism. Detailed Answer: Thanks for your question on Health Care Magic. I can understand your concern. Thanks for the detailed information. I have gone through the reports you have attached. Answer to your 1st question. No, your symptoms are not due to any inflammation behind the implants. Answer to your 2nd question. Atelectesis which you are having is mostly asymptomatic and can not cause any symptoms. So I don't think such tiny atelectesis can cause your symptoms. Usually atelectesis expands in 1-2 weeks with deep breathing exercises. Answer to your 3rd question. No need to track progress for your atelectesis because they were accidental findings. But if you really want to see the progress then get done repeat CT thorax and PFT (Pulmonary Function Test). Answer to your 4th question. No, not at all. You had CT Pulmonary Angiography. And it is the gold standard, the diagnostic test for Pulmonary embolism. So if it is negative then you are definitely not having Pulmonary embolism. Answer to your 5th question. No, this is not normal. Doctor should have look for tenderness in calves for DVT because DVT is most common cause for Pulmonary embolism. Answer to your 6th question. D dimer is only a screening test. It is not confirmatory or the diagnostic. Even if d dimer is low, Pulmonary embolism can present. Even if d dimer is high, Pulmonary embolism can be absent. But yes, they should get done d dimer before CT Pulmonary Angiography. Answer to your 7th and 8th question. You are breathing normally while exercising and at night because your breathlessness is not due to any organic causes like bronchitis, Pulmonary embolism, atelectesis etc. Your breathlessness is mostly due to stress, anxiety, tension etc. Answer to your 9th and 10th question. Yes, spirometer which you are using is good. It is for deep breathing exercises. And you can use it lifelong, no harm in it. Answer to your 11th question. By your history and description, possibility of stress and anxiety related breathlessness is more. So please avoid stress and tension, be relax and calm. Consult psychiatrist and get done counseling sessions. Try to identify stressor in your life and start working on its solution. Counselling plays very important role in control of symptoms along with drugs. Don't worry, you will be alright. Hope I have solved your query. I will be happy to help you further. Wish you good health. Thanks.