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PULMONARY HYPERTENSION, STOKE with normal PFT and CT.

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I am a 51 year old female who had been tested for pulmonary hypertension about 7 years old patientago and the RHC was negative. I since have had multiple strokes for unknown reasons. I saw a cardiologist last March who did a stress echo and the pressures went up to 60. He said my problem was in my lungs so he sent me to a pulmonologist who repeated pulmonary function studies. All was normal except a 20% drop in the Diffusion Capacity(69%). He was 100% convinced I do have PH and sent me to the previous PH doc who repeated the echo and did a CT of chest. My pressures were about 45-50 and otherwise normal. Normal CT. He said I don't have PH and felt no need to repeat the RHC. Now I am lost as to what to do. I get very short of breath and wonder if it is the Diffusion being low causing this and what do I do next if anything? I never smoked.


Category: Pulmonologist

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Category: Allergy and Immunologist
Dr. Jacob George Pulinilkunnathil is online now

Expert:  Dr. Jacob George Pulinilkunnathil replied 4 Days.

Hello.
Thank you for posting you query at DoctorSpring.com
Can i have the answers of the following questions. It will help me to understand your disease better.
1- why was a rhc done 7 years old patientback? What were the symptoms then?
2- how did the symptoms progress?
3- do you have any shortness of breath on walking up a flight of stairs or are you too breathless even to brush your teeth or take a bath?
4- what were the disabilities that you faced when you had multiple episodes of stroke?
5- why did you prefer to see a cardio instead of neurologist for stroke?
6-can you please send me any blood investigation reports, ct reports or ct films and the pulmonary function test report?
7- do you smoke? Are you married? Do you have any children/any history of recurrent abortions?
8-Any past history of pain and swelling of legs?
9- any consumption of contraceptive pills or hormone therapy?
Once you answer my questions, i can guide you further.
Thank you.
Wish you good health.
Dr. Jacob George P
MD, FCCP, IDCCM


Patient replied :

I had the RHC done at the time(2007) because during a routine echo, the pressures were around 40 and I had some shortness of breath. The mean pressure at the time of the RHC was 18. He repeated the RHC again in 2009 and the mean was 21. symptoms seem to have progressed slowly over the years. Sometimes I feel almost normal and then I can go for many monthes being very short of breath. Stairs are very difficult, carrying groceries, making a bed cause me to be very short of breath but I have no issues with everyday things. I still work(I am an RN and have had to go part time because of this). No disabilities from the strokes. I had a TIA so I had an MRI at the time which showed the previous strokes. I was not aware I had them. I had seen the neurologist first. He felt it the strokes were not caused by my BP so he sent me to the cardiologist to rule out any other cardiac issue. I never smoked. I have had recurrent miscarriages along with three live births. All bloodwork for rheum/immun have been negative including Lupus testing. No pain or swelling in legs No birth control for about 15-20 years old patientor hormone therapy I gave chemotherapy for 15 years old patientwith no protection so I have often wondered if that is what is affecting my lungs. The PH doc repeated the PFT's and again, all was normal but the Diffusion was 72%( at the other hospital it was 69%). He says that is insignificant which I can't understand since the pulmonologist says otherwise. The PH doc is a Rheumatologist. The Pulmonologist was at another hospital and away on vacation but I will try to upload some tests from the rheumatologist. Not sure if I can figure that out.
I will submit my answers and then try to figure it out! Thank you


Expert:  Dr. Jacob George Pulinilkunnathil replied 3 Days.

Hello.
I had the RHC done at the time(2007) because during a routine echo, the pressures were around 40 and I had some shortness of breath. The mean pressure at the time of the RHC was 18. He repeated the RHC again in 2009 and the mean was 21. :-
Echo was suggestive of mild PH initially, which was normal on follow up. assuming the techiniques were normal, the only explanation would be a small pulmonary embolism in 2007, that was absent in 2009 and completely resolved.

Symptoms seem to have progressed slowly over the years. Sometimes I feel almost normal and then I can go for many months being very short of breath. -
I assume there is no diurnal or seasonal variation, and now you feel that symptoms are being progressive.

No disabilities from the strokes. I had a TIA so I had an MRI at the time which showed the previous strokes. I was not aware I had them.:-
Mri showing multiple strokes means you are prone for clotting. however, i am not convinced how there are no associated symptoms. would like to have a review reporting of old MRI films to rule out any mis diagnosis of infarction/ its differentials.

I never smoked. I have had recurrent miscarriages along with three live births. All bloodwork for rheum/immun have been negative including Lupus testing.:-
warrants the same now again. you have symptoms of clotting, evidence of clotting and miscarriages- hence i would look again for autoimmune diseases, and suggest anticoagulation for minimum 6 months.
I gave chemotherapy for 15 years old patientwith no protection so I have often wondered if that is what is affecting my lungs. :- unlikely.
The PH doc repeated the PFT's and again, all was normal but the Diffusion was 70%. He says that is insignificant which I can't understand since the pulmonologist says otherwise. The PH doc is a Rheumatologist :-
A redution in DLCO can be seen in pulmonary fibrosis,other interstitial lung diseases, COPD, cardiac dysfunction, pulmonary embolism, PH due to whatever causes or even anemia.
FIbrosis, COPD, ILD have been ruled out by a normal spirometry, cardiac dysfunction ruled out by echo. so only anemia, Pul embolism and PH are in my list. I realise that we have a CTPA saying there is no PE, and pulmonary arteries are normal, with no evidence of recent or chronic Emboli. still a v/q scan as a follow up might be beneficial.please discuss it with your pulmonologist. you have a decline of fev1 of around 50 ml / year, which is a bit high.
From all these, putting things together, i still would like to rule out anemia, Pul embolism/ PH.
From all i have right now, i too will opt that i have no evidence to say that there is PH. however the pft and blood investigations need further workup
Regards
Dr. JACOB GEORGE P
MD, FCCP IDCCM


Dr. Jacob George Pulinilkunnathil
Category: Allergy and Immunologist
Experience: 
Residency, Post Graduation: MD, Respiratory Medicine, J L N Medical College, Ajmer, Rajasthan (2012).
Medical School, Internship: MBBS, Government Medical College, Kottayam, 2001-07 
Indian Diploma in Critical Care Medicine (IDCCM) - Medical Trust Hospital, 2013-2014.
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