Dr. Sagar Ramesh Makode
Cardiology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
My son has blurry before a few months for which the concerned doctor gave him an injection in his eye and prescribed Prednisone, with which he picked up shortness of breath and, at times, chest pain. The doctors there did a few tests, including ECG and 24-hours Holter test. Initially, the potency of medicine was 60, then 50, 40, 30, 20, and now it is reduced to 15 and will be further reduced to 10 within a week. I am attaching herewith all the reports and ECG for your reference, with a request to please advise us that he is on the right treatment or not.
Hello,
Welcome to icliniq.com.
Now to comment on whether his current treatment course is accurate or not, I need to know the diagnosis made there for the blurriness because there are many reasons for the blurriness in vision. So please attach if you have his clinical notes or discharge summary. Regarding the tests attached (attachment removed to protect patient identity), they are fine with some minor issues. There are minor abnormalities like slight elevation in liver enzyme ALT and was coming down in the subsequent report. Also, HbA1c was slightly elevated, but fasting sugar was fine, which suggests some elevation in blood sugar in the last few months probably related to Prednisone. So, there is nothing to worry about it. Also, his ECG (electrocardiography) is normal, and Holter showed some extra beats, which may cause random chest pain, but these are fine to have and not a matter of concern. Also, chest pain may be related to gastric reflux caused by Prednisone. He should also be on antacids for the same. If shortness of breath is significant, it would need further evaluation as none of the tests explain it. Mild form of weakness and subsequent shortness of breath may be related to illness and treatment side effects, sedentary lifestyle-related to illness, etc. Overall, I do not see any alarming abnormalities in the results and hope to get things better. Has he noticed an improvement in vision with treatment? If yes, then it would be a good sign.
Patient's Query
Thank you doctor,
We will get in touch with our son regarding the diagnosis of blurriness and will update you.
Hello,
Welcome back to icliniq.com.
You are welcome. Keep in touch for further doubts.
Patient's Query
Hi doctor,
We checked with our son, and he says that the doctor has told us that he got exposed to any TB patient during his life, which has tricked his immune system, which results in an attack on the back of his eyes, causing inflammation. As regards the improvement in blurriness, he says that there is a slight improvement. If you have any further advice, let us know, as it will be of great help.
Hello,
Welcome back to icliniq.com.
For the mentioned problem, treatment is fine, and also the tapering of Prednisone is proper. Now regarding this issue, it is important to have regular follow with an ophthalmologist for eye examination and vision assessment. This is to keep track over the inflammation and to assess the need to add another immune suppressant. Vision improvement is a gradual process and may take some time, but regular and advised direct follow up with an ophthalmologist are extremely important. The treating ophthalmologist would be in the best position to advise regarding adding any new medications. If he is not on any antacids, then he should on one like Pantoprazole or Rabeprazole for a week or two. If he notices any fever, loss of weight, loss of appetite, cough, and worsening in vision, they should not be neglected as these may indicate reactivation of tuberculosis. In this period of COVID-19, avoiding contact and prevention assumes much more importance in his case as he is on immunosuppressant medication. COVID-19 may take a severe course in such patients. Avoid uncooked foods.
Patient's Query
Thank you doctor,
Thanks for all the advice, and I will implement the same. It was a pleasure interacting with you.
Hello,
Welcome back to icliniq.com.
You are welocme. keep in touch for further doubts.
Patient's Query
Thank you doctor,
The concerned doctor referred his file to a Rheumatologist who advised him to take two additional medicines Methotrexate 10 mg (once a week) and Sandoz-Folic (Folic Acid 5 mg), for six days only. I am getting a little worried about why they are consulting a Rheumatologist and, on top, asking him to take Methotrexate. Please advise.
Hello,
Welcome back to icliniq.com.
Do you have any notes from the treating doctor mentioning his examination findings and possible diagnosis? Is not there any improvement on steroids? Does he have any other bodily symptoms like joint pains, backaches, cough, or other symptoms? If we were to analyze the situation, we have only two things: his blurring of vision and medications. So, doctor notes and thought process would be very helpful in giving you some meaningful opinion. Now, Methotrexate's addition of Methotrexate means hiking up the immunosuppressant, which is probably because doctor has seen signs of inadequate response on examination or inadequate relief in terms of symptoms. Or the doctor thinks that he will need medication for a longer period, and steroids cannot be continued for a longer period. This is a usual protocol of adding some other agents after steroids are tapered off to maintain immunosuppression and taper it off after a few months. Folate is given along with Methotrexate to reduce its side effects. Now seeing his treatment, it appears that doctor is thinking on the line of autoimmune disease, where our own immunity attacks the body. And frequently, this is associated with the autoimmune process elsewhere in the body like joints, thyroid, lungs, etc. So, he probably wanted a rheumatologist to screen him and ascertain anything wrong elsewhere in the body. Also, rheumatologist are the specialist for autoimmune disorders, and he can guide regarding the treatment. So rheumatologist will probably advise him for autoimmune blood profiles like ANA, dsDNA and other tests, serum ACE level, chest x-ray or CT scan, etc. Also, yoga is said to suppress allergy and autoimmunity, so there is no harm in doing it if it is feasible. So, he may go ahead with Methotrexate and seek a rheumatologist's opinion, who would be better positioned to guide regarding the future course and ascertain the cause for this as I guess confirm diagnosis is not yet made.
Patient's Query
Thank you doctor,
I will get in touch with my son and will see if he can get the doctor's notes. Rheumatologist has advised for blood test every month as indicated by you. I will also advise my son to do some yoga exercises that may help him.
Helo,
Welcome back to icliniq.com.
You are welcome. Keep in touch for further doubts.
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