Which Specialist to Consult for Persistent Shortness of Breath?

If you are experiencing difficulty breathing, you should see a pulmonologist?

Hello, my mother is 73 years old.
Six months ago, she started experiencing shortness of breath (even while walking on flat ground), but she does not cough.
She underwent X-rays, a resting electrocardiogram, pulmonary function tests, and echocardiography in the cardiology department, but no significant abnormalities were found.
Thyroid tests were also normal.
A physician suggested a nuclear scan, and later, she was diagnosed with cervical cancer and underwent chemoradiation, without further evaluation for her shortness of breath.
After completing radiation therapy, her shortness of breath worsened (sometimes she experiences it even while lying flat).
Since the echocardiogram was done six months ago, the cardiologist performed another echocardiogram, which showed her heart condition to be good.
Blood tests indicated anemia (due to previous chemoradiation), and the cardiologist believes the shortness of breath is likely due to the anemia.
However, the hematologist considers the anemia to be "chronic anemia" and does not recommend a blood transfusion, suggesting instead that it may be related to kidney function (with creatinine levels at 1.9).
They recommended seeing a nephrologist for evaluation.
Now, we are unsure which specialty to consult next due to the frequency of tests.
Could you provide some guidance? Thank you for your response.

DJFHJDJFJ, 40~49 year old female. Ask Date: 2017/02/20

Dr. Chen Taicheng reply Family Medicine

There are many causes of shortness of breath, and it is important to prioritize the exclusion of heart and lung issues.
Regarding the heart, conditions such as heart failure (common in the elderly), arrhythmias (such as atrial fibrillation, also common in older adults), myocardial ischemia, and valve problems can all lead to shortness of breath.
As for the lungs, conditions like asthma, chronic obstructive pulmonary disease (COPD) (primarily caused by smoking, secondhand smoke, air pollution, or kitchen fumes), as well as other rare interstitial lung diseases or pulmonary embolism, can also cause dyspnea.
Cardiologists take these factors into account, using X-rays, electrocardiograms, pulmonary function tests, and echocardiograms to rule out the aforementioned diseases.
Additionally, hypothyroidism (which has been ruled out) can also contribute to shortness of breath.
Poor kidney function can lead to anemia (which your mother currently has, although anemia can be caused by other factors), electrolyte imbalances, acidosis, and edema, all of which can contribute to the sensation of breathlessness.
Furthermore, as people age, decreased muscle endurance may also cause shortness of breath even when walking on flat ground.
Post-chemotherapy, physical condition may worsen, exacerbating the feeling of breathlessness.
The recommended order for consultations is: Pulmonology (to thoroughly rule out asthma, COPD, and other lung diseases) → Nephrology (to monitor kidney function and correct anemia or other electrolyte and acid-base imbalances).
Attention to nutrition and physical rehabilitation should help improve the situation.
Wishing you good health, Dr.
Chen Tai-Cheng from Taoyuan Hospital Family Medicine Department is concerned about you.

Reply Date: 2017/02/20

More Info

When dealing with persistent shortness of breath, especially in a patient with a complex medical history like your mother, it is crucial to take a systematic approach to identify the underlying cause. Given the information you've provided, your mother has undergone various tests, including imaging and heart evaluations, which have not revealed any significant abnormalities. However, her symptoms have worsened, particularly after undergoing chemotherapy and radiation for cervical cancer.

Recommended Specialist Consultations
1. Pulmonologist: Since your mother is experiencing shortness of breath, a pulmonologist (lung specialist) should be one of the first specialists to consult. They can perform a comprehensive evaluation of lung function, including advanced pulmonary function tests, imaging studies like a CT scan of the chest, and possibly a bronchoscopy if indicated. Given that her symptoms have intensified, it is essential to rule out any pulmonary complications, such as radiation pneumonitis, which can occur after radiation therapy.

2. Hematologist: Since there is a mention of anemia, consulting a hematologist is also advisable. Anemia can significantly contribute to fatigue and shortness of breath, especially in elderly patients. The hematologist can evaluate the type of anemia and determine if further treatment is necessary. They can also assess whether the anemia is related to her cancer treatment or if there are other underlying causes.

3. Nephrologist: Given the elevated creatinine level (1.9), which indicates potential kidney dysfunction, a nephrologist should be consulted. Kidney issues can lead to fluid overload, which may manifest as shortness of breath. The nephrologist can assess her kidney function and determine if any interventions are needed.

4. Oncologist: Since your mother has a history of cervical cancer and has recently undergone treatment, it is essential to keep her oncologist in the loop. They can provide insights into whether her current symptoms could be related to her cancer treatment or if there are any additional oncological evaluations needed.

Additional Considerations
- Multidisciplinary Approach: Given the complexity of your mother's case, a multidisciplinary approach may be beneficial. This involves coordinating care among the various specialists to ensure that all aspects of her health are being addressed.

- Symptom Management: In the meantime, managing her symptoms is crucial. If her shortness of breath is severe, supplemental oxygen may be considered, especially if her oxygen saturation levels are low.

- Follow-Up: Regular follow-up appointments with the specialists are essential to monitor her condition and adjust treatment plans as necessary.

- Patient Advocacy: Given the frequency of her medical appointments and the complexity of her case, it may be helpful to have a family member or caregiver accompany her to appointments. They can help advocate for her needs and ensure that all concerns are addressed.

Conclusion
In summary, your mother should be evaluated by a pulmonologist for her respiratory symptoms, a hematologist for her anemia, and a nephrologist for her kidney function. Keeping her oncologist informed is also crucial due to her cancer history. A coordinated, multidisciplinary approach will provide the best chance of identifying the underlying cause of her persistent shortness of breath and improving her overall quality of life.

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