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What does this x-ray report of lungs indicate?

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Posted on Sat, 23 May 2015
Question: Would like to know what irreular opacity noted in the left perihilar and paracardiac regions mean in a patient 89 years old, had a bypass ninetten years back and is having parkinsons now.
doctor
Answered by Dr. Kaushal Bhavsar (38 minutes later)
Brief Answer:
Possibility of aspiration pneumonia is more.

Detailed Answer:
Thanks for your question on HCM.
I can understand your relative's situation and problem.
Possibility of pneumonia is more in his case because of x ray report and his symptoms like recurrent fever.
He is also having parkinsonism, so possibility of aspiration pneumonia is more.
And aspiration pneumonia is more on right side due to position of right bronchus. Right sided main bronchus is in line with trachea and it is short and wide. So aspirated particles can easily lodge in right sided lung and cause pneumonia.
Mixed (aerobic and anaerobic) infection is more common in such cases.
He may need additional antibiotic.
Please let me know if he has swallowing difficulty or reflux while eating or coughing while eating or drinking.
I will be happy to help you further.
Wishing good health to your relative.
Thanks.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (15 hours later)
Thanks doc. He is my dad. Yes he has swallowing difficulty and also reflux while eating and he also coughs while eating or drinking. Appreciate your detailed reply. Thanks again.
doctor
Answered by Dr. Kaushal Bhavsar (8 minutes later)
Brief Answer:
Get done sputum culture and sensitivity report.

Detailed Answer:
Thanks for your follow up question on HCM.
Aspiration pneumonia is common in old age people with CNS (central nervous system) disorders.
So the bacterias causing the aspiration pneumonia are different then bacterias causing simple community acquired pneumonia.
He is having fever spikes even after antibiotics.
This suggests that treatment is not appropriate.
Treatment of pneumonia should be guided according to the causative organism.
So get done sputum culture to isolate the causative organism.
And sensitivity to guide the effective antibiotic therapy.
He needs anaerobic coverage.
Tell me
1. Does he have sputum (expectoration)?
2. Sputum culture and sensitivity done or not?
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 (2 hours later)
01 Yes he has sputum (expectoration) - In fact he does not close his mouth completely and most of the time he drolls.
02. AFB was done which was negative but sputum culture and sensitivity not done. Do you advise me to get them done?

Thanks for your help and advise.

XXXX
doctor
Answered by Dr. Kaushal Bhavsar (9 minutes later)
Brief Answer:
Get done sputum culture and sensitivity.

Detailed Answer:
Thanks for your follow up question on HCM.
He is having aspiration pneumonia for sure.
And it is not routine community acquired pneumonia (CAP) .
Causative organism, severity, prognosis etc are different then CAP.
PPossibility of gram negative and anaerobic bacterial infection is more.
And ceftum 250 is not going to help because it doesn't cover these bacterias.
So sputum culture and sensitivity should be done to isolate the causative organism and for guiding appropriate antibiotic treatment.
Do you feel he is not improving rather worsening on current medicine?
Does he feel more weakness, fever and decreased oral intake after ceftum?
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 (38 minutes later)
Doctor

His problem is he gets fever more or less every week just for four hours. Funnily it subsides with paracetomol single dose.

I will not say he has not improved after fifteen days of ceftum 250 twice a day in the sense he is coughing less and his food intake is better. But he is weak which I was attributing to antibiotics. But fever has not stopped occuring every week it is more or less periodical like on friday afternoons or sunday afternoons. Do you think a sputum culture and sensitivity is going to help?

I do not want him to take a bronchioscopy because frankly he is too old for that. Is there a way to determine what foreign particle is in his lungs without the bronchioscopy test?

Thanks
XXXX
doctor
Answered by Dr. Kaushal Bhavsar (1 hour later)
Brief Answer:
For sputum culture and sensitivity, bronchoscopy is not needed.

Detailed Answer:
Thanks for your follow up question on HCM.
I can understand your concern about old age and invasive procedure like bronchoscopy.
Sputum culture and sensitivity will not need bronchoscopy.
If patient is not having sputum (expectoration) then we need bronchoscopy and lavage to obtain secretions.
Since he is having cough with expectoration, we can send sputum culture and sensitivity directly without bronchoscopy.
And fever is an indication of continued infection.
So his infection is still there.
So better to get done sputum culture and sensitivity report.
About aspirated material, food particles are the most common materials.
Please let me know
1. Was he a smoker?
2. Have you undergone CT thorax?
3. Have you measured the temperature during fever spikes? Does he have chills with fever?
Please reply me answers of above asked questions, so that I can guide you better.
I will be happy to help you further.
Wishing good health to your father.
Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (4 days later)
Doctor,

I got my dad's sputum culture and sensitivity. It reads as follows: Biochemical reactions: Indole ; Negative. Voques Prosker: Positive. TSI:Acid butt/acid slant Motility. Methyl Red: Negative. Citrate: Positive. Motility: Non motile Final Identification of Organism grown : Kiebsiella pneumoniae. Antibiogram: Sensitive to : Amikacin, Ceftroiaxone, Ciprofloxacin, Co-Trimoxazole, Imipenem, Levofioxacin, Piperacillin-Tazobactam, Tobramycin. Moderately sensitiave to: Meropenem. Resistant to: Amoxyclav, Ampicillin, Cefaazolin, Cefoxiin, Cefuroime. His temperature spikes to 102 and settles gradully with paracetomol. Can you please give me your adice? Thanks XXXX
doctor
Answered by Dr. Kaushal Bhavsar (1 hour later)
Brief Answer:
Klebsiella pneumonia is gram negative bacterias.

Detailed Answer:
Thanks for your follow up question on HCM.
So he is having pneumonia due to infection with klebsiella pneumonia. It is gram negative bacterias.
And sensitivity pattern suggest that this organism is resistant to cefuroxime.
I want to confirm one thing.
Ceftum contains cefuroxime or not?
Is he having chills associated with fever spikes?
Please reply me answers of above asked questions, so that I can guide you better.
I will be happy to help you further.
Wishing good health to your father.
Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (9 hours later)
Hello Doctor

Yes Ceftum contains cefuroxime.

He has chills with fever spikes. Malaria, dengue have been tested and negative. This seems to be his chronic problem.

Thanks
XXX

doctor
Answered by Dr. Kaushal Bhavsar (13 minutes later)
Brief Answer:
Chronic means since how many days?

Detailed Answer:
Thanks for your follow up question on HCM.
Initially you said he is having this problem since 15 days. Now you are saying that it is chronic problem.
So please let me know
1. Chronic means since how many days?
2. Which symptoms he is having chronically? Is he having chronic cough or chronic fever with chills?
And you should stop cefuroxime as it is resistant.
Please reply me answers of above asked questions, so that I can guide you better.
I will be happy to help you further.
Wishing good health to your father.
Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (1 hour later)
Doctor

He has been getting fever on and off since last October. Fever always spikes to 102 and starts coming down gradually. It starts like this - first he will have cough and will not eat and suddenly he will have high temperature. Temperature does not last more than half a day. If he spits he gets lot of phlegm. But he does not spit regularly. I said it is chronic because this has been happening more or less every ten days. Yes I have stopped Ceftum.

Thanks
XXXX
doctor
Answered by Dr. Kaushal Bhavsar (25 minutes later)
Brief Answer:
He must be having reflux since long time.

Detailed Answer:
Thanks for your follow up question on HCM.
So he is having on - off fever since 7 months with occasional cough and a lot of mucus expectoration.
This clearly suggest that he is having aspiration pneumonia since almost 7 months.
Antibiotics will treat his pneumonia for short period.
But if he continues to have aspirations, chances of recurrent pneumonia are very high.
And this is the story since last 7 months.
So we need to treat his cause for aspiration, to prevent recurrence of aspiration pneumonia.
At present you should start dual antibiotics for him.
Levofloxacin and co-trimoxazole.
Please let me know
1. His body weight, so that I can give you exact dosing of these antibiotics.
2. Is he taking anything for reflux disease?
3. Which drugs he is taking for parkinsonism?
Please reply me answers of above asked questions, so that I can guide you better.
I will be happy to help you further.
Wishing good health to your father.
Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (2 hours later)
Doctor

He is on Ropark 0.25 four tablets thrice a day.
He is also taking Stolin P 500 twice a day and Cognix Plus once a day.
Besides he is also given DesvalER once a day.
His body weight is 45 kgs.

How can we prevent aspirations?

Thanks
XXXX
doctor
Answered by Dr. Kaushal Bhavsar (26 minutes later)
Brief Answer:
He is not taking any drug for acid reflux.

Detailed Answer:
Thanks for your question on HCM.
I have gone through the drug list.
All these drugs are for neurological improvement and prevention of dementia. I don't know what stolin P is having. So please let me know the content of stolin P.
All these drugs cause GERD (gastroesophageal reflux disease) and it is the common cause for aspiration pneumonia.
So we need to start treatment for GERD.
So start proton pump inhibitors and prokinetic drugs.
Combination of pantoprazole and levosulperide is available in the market.
You need to give this twice daily before lunch and dinner.
Does he have coughing while eating or swallowing? Is it more with liquids or solids?
What is his diet?
We need to modify all these things for prevention of aspiration, so please let me know the answers of above asked questions.
I will be happy to help you further.
Wishing good health to your father.
Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Kaushal Bhavsar

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What does this x-ray report of lungs indicate?

Brief Answer: Possibility of aspiration pneumonia is more. Detailed Answer: Thanks for your question on HCM. I can understand your relative's situation and problem. Possibility of pneumonia is more in his case because of x ray report and his symptoms like recurrent fever. He is also having parkinsonism, so possibility of aspiration pneumonia is more. And aspiration pneumonia is more on right side due to position of right bronchus. Right sided main bronchus is in line with trachea and it is short and wide. So aspirated particles can easily lodge in right sided lung and cause pneumonia. Mixed (aerobic and anaerobic) infection is more common in such cases. He may need additional antibiotic. Please let me know if he has swallowing difficulty or reflux while eating or coughing while eating or drinking. I will be happy to help you further. Wishing good health to your relative. Thanks.