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melvinmelvin

Legs swollen out of proportions (cellulities)

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am not after a concrete explanation of why/where, but perhaps a hint or so re what to think further about

late 60s, drink way too much, eat very healthy, have stopped smoking - alas a year too late

excellent blood pressure/pulse and eye sight, crapped down lungs

 

since spending lots of time in LoS I have experienced swollen legs 4 times

when I  say swollen I mean SWOLLEN, grotesque dimensions

 

first time, maybe 6 years ago, (right leg only) just went to an ordinary clinique off Sukhumvit BKK,

the chap took some blood samples - gave me a bag of pills and adviced not to eat watermelon and anything bird

went away after 2-3 weeks

 

2nd time, right leg, went to Samitivej, ultrasound-blood vessels-OK, pills and compression stocking,

3 weeks - fixed, this time the leg was HUGE

 

3rd time, early this year, mainly right leg, to a lesser degree left

gigantic proportions - liquid being pressed out through the skin - a real mess - looks just horrible

ultrasounds - all ok

fixed with some long term intrav. antibiotics treatment

thighs stone hard and so big that they press on the prostate and upsets normal pissing

treated art World Medical Centre in Nonthaburi

 

now again - both legs - size gigantic, lots of liquid being pressed out through the skin

legs look terrible below the knees - the  prostate totally confused - tough one

sitting down on the wc difficult to find penis and point it downwards in order to not piss all over the place

now I see people at Siriraj and am eating their pill mountains (antibiotics and this and that) - ultrasounds OK

it is slowly improving now

 

I have never heard any physician hinting at why this happens.

 

Have also consulted medics back home in Scandinavia re this,

same same - ultrasounds OK - don't know - compression stockings

 

last weekend at Siriraj a cardiologist came up with something half baked, pretty sharp and to the point guy

he noted excellent bp and pulse - did EKG - did ultrasound of heart and said:

 

heart pumping function is just fine, pumping of gassed up blood out is just good

the other side of the heart which is pumping shitty blood into the lungs for cleaning and uptake of new gas is struggling a bit,

has grown larger due to hard work - nothing wild though

due to crappy lungs the gas-exchange takes too long time - there is more dirty blood in the body below the lungs than what it should be (I think he said)

 

he suggested that there might be some link between this and the liquid reservoirs in the legs, he would need to think further etc etc

 

would guess  that I am not the only farang with this,

any idea re cause?

 

 

 

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Right sided heart failure (due to lung disease) can cause swelling of the legs though for the rxtent you describe would usually have to be pretty severe to be the sole cause.

Other possibilities are peripheral vascular disease and chronic venous insufficiency, both common in smokers. If peripheral vascular disease (decreased blood flow through the arteries) there would usually be leg pain on walking, which you do not mention, and decreased pulses which the doctors would pick up. If chronic venous stasis (decreased return of blood to the heart through veins due to weakened valves in the leg vein) it would be detectable through doppler ultrasound of the lrg veins. I can't really determine from what you say if this has been done or not. It can be difficult to do when large amount if swelling is present.

The two factors of right side heart failure and venous insufficiency can coexist. The right sided heart failure causes back up of blood and resistance to venous flow and weakened valves in leg veins adds to it resulting in blood vessels of the legs swelling up causing leakage of fluid to the tissues which in turn predisposes to cellulitis (tissue infection). If there is any degree of cirrhosis of the liver present (commmon in heavy drinkers) that will aggravate matters as that in itself creates resistance to blood flow from legs back to the heart.

A third possibility is deep vein thrombosis (DVT) but this would not present as equal symptoms in both legs it would be one leg only or at least one leg much worse than the other.

Doctors at Suriraj will not be unaware of these possibilities.

You have serious medical problems and from here on should avoid "ordinary clinics" and the like and stick to good hospitals.

Compression stockings, elevating legs, walking often (once able) and antibiotics until infection resolve and then once swelling has subsided a thorough evaluation of the circulatory function in your legs would be usual management. This last would be a doppler ultrasound and possible venogram (xray of veins after injection of a dye).

You need to be under the care if a vascular specialust. Continuity of care is important, need to stop switching doctors/hospitals/clinics. If funds are limited Siriraj is best choice for Thonburi/Nonthaburi area. If you can afford it you can be seen by senior vascular docs from Siriraj at nearby private hospitals. If so let me know and I will give a suggested referral otherwise stick with Siriraj.

Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app

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thanks - I recognize several of the points you make

forgot  to say, this is not painful at all, can walk -  the challenge being the fitting of crocs on the feet

am comfortable using Siriraj, am seeing vascular specialist, later today actually,

and internal medicine/lung specialist re gas exchange and O2 saturation - will see him next week

 

Siriraj seems quite reasonable, main cost factor is the pill mountains

so far paying out of pocket rather than using insurance,

insurance covered me for a hefty 2.5 mill in Feb/Mar, prefer not to stress them

 

dopler/ultrasound of both legs have been done several times last 2 years without revealing anything special

 

the vascular chap is now waiting for the skin infection and size to be reduced to a state where it would be

meaningful to carry out another ultrasound variant, me standing rather than sitting or being horizontal

would guess that it would be postponed again today - still pretty big legs (improving though) and significant infection. 

 

thanks, think my understanding of this has improved - that was what I hoped for

 

(dont think there are nearby private hospitals of any size, there is Kasemrad (just down the road), but feel more comfortable

 with Siriraj both when it comes to expertise and equipment,

 and there is WMC in Nonthaburi - this is a quality place - but not really near

 

 so comfortable sticking with Siriraj)

 

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11 hours ago, Sheryl said:

Right sided heart failure (due to lung disease) can cause swelling of the legs though for the rxtent you describe would usually have to be pretty severe to be the sole cause.

Other possibilities are peripheral vascular disease and chronic venous insufficiency, both common in smokers. If peripheral vascular disease (decreased blood flow through the arteries) there would usually be leg pain on walking, which you do not mention, and decreased pulses which the doctors would pick up. If chronic venous stasis (decreased return of blood to the heart through veins due to weakened valves in the leg vein) it would be detectable through doppler ultrasound of the lrg veins. I can't really determine from what you say if this has been done or not. It can be difficult to do when large amount if swelling is present.

The two factors of right side heart failure and venous insufficiency can coexist. The right sided heart failure causes back up of blood and resistance to venous flow and weakened valves in leg veins adds to it resulting in blood vessels of the legs swelling up causing leakage of fluid to the tissues which in turn predisposes to cellulitis (tissue infection). If there is any degree of cirrhosis of the liver present (commmon in heavy drinkers) that will aggravate matters as that in itself creates resistance to blood flow from legs back to the heart.

A third possibility is deep vein thrombosis (DVT) but this would not present as equal symptoms in both legs it would be one leg only or at least one leg much worse than the other.

Doctors at Suriraj will not be unaware of these possibilities.

You have serious medical problems and from here on should avoid "ordinary clinics" and the like and stick to good hospitals.

Compression stockings, elevating legs, walking often (once able) and antibiotics until infection resolve and then once swelling has subsided a thorough evaluation of the circulatory function in your legs would be usual management. This last would be a doppler ultrasound and possible venogram (xray of veins after injection of a dye).

You need to be under the care if a vascular specialust. Continuity of care is important, need to stop switching doctors/hospitals/clinics. If funds are limited Siriraj is best choice for Thonburi/Nonthaburi area. If you can afford it you can be seen by senior vascular docs from Siriraj at nearby private hospitals. If so let me know and I will give a suggested referral otherwise stick with Siriraj.

Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app
 

 

again, thanks

I wonder if there might be smth I do not understand in your very last paragraph,

where you say    If you can afford it you can .......

Am I missing smth here?

What would be the possible advantage of meeting up with Siriraj medical staff at other hospitals than Siriraj???

 

 

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Sounds good.

Thonburi hospital is right near Siriraj (almost walking distance) and many of the Siriraj profs have hours there, should you feel the need for quicker access or more time with the doc.

Otherwise carry on with Siriraj sounds like they are doing all the right things. Make sure vascular doc knows you are heavy drinker as, if the leg veins seem OK, resistance to returned blood flow due to liver scarring could be a factor and an ultrasound of the liver might be in order.

Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app

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24 minutes ago, Sheryl said:

Sounds good.

Thonburi hospital is right near Siriraj (almost walking distance) and many of the Siriraj profs have hours there, should you feel the need for quicker access or more time with the doc.

Otherwise carry on with Siriraj sounds like they are doing all the right things. Make sure vascular doc knows you are heavy drinker as, if the leg veins seem OK, resistance to returned blood flow due to liver scarring could be a factor and an ultrasound of the liver might be in order.

Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app
 

right, thanks - so I just forget that comment

going to Siriraj is entirely OK for me

time and access is not perceived as a constraint - they have time

 

saw  the vascular chap late afternoon today

he  checked surface temperature of lower legs, concluded OK can do the ultrasound now, infection is down

(right leg is visibly larger than left, right cellulitis looks like triple shait, awfull really.

 it is the left leg that produces all the liquid)

then

the ultrasound with me standing and a nurse pressing hard on the lower legs on physicians directions

the chap concludes:

veins in both legs OK, however, I do detect, in both legs, a minor reflux in the smallest vein around the ankle area

this is not a real problem and will not cause the swelling you have

My view is that we skip looking at veins for now and search further in the lung/heart area, I think the problem is there.

Keep on with compression stockings and medication - see you in 2 months and then he prescribed pills for 20 000.

 

then

off to the internal medicine lady, the first one I saw at Siriraj

she had had a look at my medical history from WMC this winter and entered some data into Siriraj records

She said that WMC says that the pressure in the area where the heart is pumping into the lungs are higher than it should be.

guess that compares to what the Siriraj cardiologist said, heart is working hard to pump shitty blood into the lungs.

she was overly pleased with bp and O2 saturation today, my bp is good but the saturation is a bit crappy actually - but it was rock bottom week and half ago when she arranged O2 feeding and the lung mechanic,

saturation today much better - but not good.

she prescribed another week of antibiotics - through with her

 

will see internal medicine/lung mechanic next week,

then will have to discuss what the vascular guy said and what the cardiologists said with him  - and stake out a meaningful course

forward,

could be a challenge - there are Thais around that speak better English than this guy

 

we'll see

 

 

 

 

 

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Further to your comment re liver; blood tests shows it has to work for its money,

(no surprise) however, test results are not way out of proportions though

 

ultrasound has been done in that area of the body, prostate-ok, kidneys-ok but one has a mini stone - treated with medication

some fat on liver observed - nothing alarming according to the medics

 

below I will list data from the invoice for my most recent visit to Siriraj

 

Amoxiclav tab 1 g (Curam)                             14 pcs               263 baht

Clindamycin cap 300 mg (Clinott-P)               20 pcs               250 baht

Daflon tab 500 mg (Diosmine+Hesperidin)     120 pcs               2400 baht

Reparil tab 20 mg                                        360 pcs              3150 baht

Vessel cap 250 LSU                                     240 pcs              15000 baht

 

do these drug prices seem OK? or would you say that they are inflated?

 

 

 

 

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I don't know. One would have to ask at a pharmacy for exact same brands and compare.

 

Government hospitals do not usually  inflate medication costs. However they are prescribing you imported brand names. If concerned about cost you should tell the doctors you prefer local generic brands. They may assume as a foreigner that you prefer western expensive brands.

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On 11/13/2018 at 6:06 AM, Sheryl said:

I don't know. One would have to ask at a pharmacy for exact same brands and compare.

 

Government hospitals do not usually  inflate medication costs. However they are prescribing you imported brand names. If concerned about cost you should tell the doctors you prefer local generic brands. They may assume as a foreigner that you prefer western expensive brands.

ok, thanks - any significant difference between the two / imported vs generic ?

 

Edited by melvinmelvin

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Saw the internal med/lung chap this late afternoon (impressed by my BP and pulse)

I conveyed the findings of cardiologist and vascular as well as what was extracted from WMC files this winter.

 

Guess that agreed conclusion at Siriraj is that it is heart-right/lung interface that is the main cause here.

And the main culprit is COPD and the lungs.

 

Objective: treat lungs well (O2 at night) + some daily medication - ie delay progression of COPD

               my lung specialist in Norway says that it might be possible to improve lungs slightly

               if I have the guts and stamina to do some aerobic exercise, my heart is strong so heavy load may be OK

 

               keep a low sodium diet (which I do)

 

will see the lung guy again just before pii mai

and the vascular chap just after pii mai

 

(I think I understand to a certain extent what my lungs look like and how the inside tissue has changed

 so that the total surface through which O2 is absorbed is significantly smaller than in "good" lungs.

 

What is not clear to me is why this prevents/hinders the heart from pumping in blood.)

 

 

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On 11/13/2018 at 11:29 AM, melvinmelvin said:

Further to your comment re liver; blood tests shows it has to work for its money,

(no surprise) however, test results are not way out of proportions though

 

ultrasound has been done in that area of the body, prostate-ok, kidneys-ok but one has a mini stone - treated with medication

some fat on liver observed - nothing alarming according to the medics

 

below I will list data from the invoice for my most recent visit to Siriraj

 

Amoxiclav tab 1 g (Curam)                             14 pcs               263 baht

Clindamycin cap 300 mg (Clinott-P)               20 pcs               250 baht

Daflon tab 500 mg (Diosmine+Hesperidin)     120 pcs               2400 baht

Reparil tab 20 mg                                        360 pcs              3150 baht

Vessel cap 250 LSU                                     240 pcs              15000 baht

 

do these drug prices seem OK? or would you say that they are inflated?

 

 

 

 

Daflon 500mg, 30 pieces, 280 baht in CM.

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If you have Congestive Heart Failure,  "heavy load" is  not a good idea ,  aim for   moderative perceived exertion, stop if it is "heavy"

COPD  is emphysema and bronchitis combination, that  is progressive,    only treatment is managing  exacerbation and avoiding lung infections as best able,  maybe keep some  emergency inhalers on hands,  there are also long acting inhalers to   decrease exacerbations and for symptom management

 

your lungs are like an upside down tree, the oxygen and CO2 are exchanged in the leaves of the tree(the aveloli),   with emphysema your numbers of leaves is low hence, the bigger issue with COPD-emphysema is getting the CO2  out rather than the Oxygen in  .....   So pursed lip breathing to keep airways open and prevent CO2 trapped in the lower lungs with exhalation   and   diaphagm breathing,  as the lungs  have lost elasticity  and are overinflated and so the diaphagm is flattened and can't do it's job to created inhalation ....

 

sounds like you have a pulmonary heart valve problem from what you said , valve isn't  closing well,  blood  can't pump out of the heart ,  one can have COPD with no CHF   .......sorry if I am using medical terms

 

PS:  I don't see any  heart of lung meds  on your list  , but maybe that is not your full list

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thanks for engaging

I'm learning, days without any new knowledge are wasted days

I'll sleep and reflect on yours&Sheryl comments and see if I can muster some meaningful feedback

 

(haven't really thought much about this, or the body as such, until the last year and a half,

 since "I" have worked just fine without any severe problems, that has now changed)

 

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10 hours ago, chubby said:

 

 

 

10 hours ago, chubby said:

 

ONE

 

If you have Congestive Heart Failure,  "heavy load" is  not a good idea ,  aim for   moderative perceived exertion, stop if it is "heavy"

COPD  is emphysema and bronchitis combination, that  is progressive,    only treatment is managing  exacerbation and avoiding lung infections as best able,  maybe keep some  emergency inhalers on hands,  there are also long acting inhalers to   decrease exacerbations and for symptom management

3

 

 

 

10 hours ago, chubby said:

TWO

your lungs are like an upside down tree, the oxygen and CO2 are exchanged in the leaves of the tree(the aveloli),   with emphysema your numbers of leaves is low hence, the bigger issue with COPD-emphysema is getting the CO2  out rather than the Oxygen in  .....   So pursed lip breathing to keep airways open and prevent CO2 trapped in the lower lungs with exhalation   and   diaphagm breathing,  as the lungs  have lost elasticity  and are overinflated and so the diaphagm is flattened and can't do it's job to created inhalation ....

THREE

sounds like you have a pulmonary heart valve problem from what you said , valve isn't  closing well,  blood  can't pump out of the heart ,  one can have COPD with no CHF   .......sorry if I am using medical terms

FOUR

PS:  I don't see any  heart of lung meds  on your list  , but maybe that is not your full list

13

 

Thanks again, I have inserted paragraph numbers above, as a reference:

 

to ONE

OK, not sure about the term re failure you use.

However, what I can say is that all cardiologists (quite a number in LoS and Norway) say that I have an OK

and strong heart. (My guess is that the slow CO2 cleaning reached (or passed rather) some kind of threshold last year which

resulted in pressure increase and tougher working conditions for the right side)

My internal medicine/lung guy and his cardiologist (have followed me for 30 years) - top notch researchers,

are strong believers in aerobics. Because it can improve lungs, "some". But high effort would be necessary.

Like wise, cardiologist at Siriraj said, exercise fine. No hint at taking it easy.

Anyway, I do understand what you say re treatment and I have the stuff available.

And I am focused on that.

My body worked reasonably well until about Xmas last year and not so well when I collapsed last February.

 

June this summer I did this oxygen/flight test at 2 different hospitals, conclusion 2 lit/min during longer flights,

elaborate tests with different gas mixtures and lots of blood tests.

There was also a practical load test, me walking at high speed up and down corridors under constant

measurement of O2 saturation for 20 minutes.

They were utterly surprised that I could at that speed and that I was not even close to tired afterward.

So maybe "I" works relatively well with relatively low saturation.

 

Now, on fairly good days I measure 94% in the morning, normally 93-92 %.

That works for me. If I manage to keep it at 93/92 I can spend the days with my hobbies and lead a meaningful life.

 

to TWO:

Yes, mostly understood. I try to make that kind of breathing routine.

(my "normal" breathing before was both in and out through nose with closed mouth and slow slow,

 so slow that CPAPs O2 concentrators got confused, trying to make the new way to breath routine now.)

 

to THREE:

Might be some X-communication here.

My understanding is that the cardiologists say, heart is pumping out (fresh/gassed up blood to the body) just fine,

the challenge is pumping used blood into the lungs.

 

to FOUR:

right,

the two first drugs are for killing the infection in the legs, temporary, will finish early next week.

the three last ones are from the vascular surgeon - sorting out cellulitis / swelling,

temporary stuff, will see him again early January.

I just listed these three because I was curious re cost, these drugs would have been cost free for me in Norway,

so was kinda taken back when I got a bill for 20 000.

 

I do take some heart related drugs, Pradaxa - Atorvastatin - Actavis - IsoptinRetard

(I normally bring supply for 13 months from Norway (free))

The cardiologist at Siriraj gave me Furetic # 40 mg (Furosemide),

my understanding was that this was temporary, I have for another 4 days or say, and thats it.

 

 

lungs; Relvar and Incruse, the lung guy at Siriraj said ; very good this is the best drug on the market

and I have 2-3 different inhalators for use if I feel the need.

(this I also bring in large supplies cost free from Norway)

 

As said,

swelling down O2 saturation at 93/92 I am relatively OK and can do the stuff I want to do.

 

 

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