Question: To be answered by Dr. Ilir Sharka.

Hi. I hope you can see my last conversation with you or remember it. I'm the one who recently contacted you (two days ago) experiencing shortness of breath with exertion and rapid heart rate for three weeks. (Also lack of appetite, etc... asked if I should drive... hopefully that helps you remember if you can't see it)


I just had a really bad episode in the shower. So short of breath! I had to lie down on the floor to catch my breath before even getting dressed. I'm still recovering so still short of breath after about 30 mins.

My spouse was here and had to help me get dried off and lead me into the livingroom. I wasn't dizzy but the best I can describe it is that I was disoriented. I mean, my thinking was okay but I couldn't really get my bearings as far as walking. Had to walk really slowly with spouse's guidance and had a hard time walking in a straight line.

Sat down and had a hard time focusing with my eyes. Not blurry vision but a hard time making my eyes focus on a specific place - like spouse's face.

My pulse was 164 out of shower, which is not as high as it has been. My BP was fine 109/70. My pulse dropped down to normal (a little below my usual, actually) fairly quickly.

So do you think I should go to the ER? By the time I get there I will be completely recovered - just really tired probably. I will just have to wait all night and they will probably just send me home with no answers.

It's the same that has been happening only more severe SOB and the addition of the disorientation and difficulty focusing.

I was able to get an echo stress test scheduled for the day after tomorrow and my cardiology appointment was moved up to a week and a half from now - so not as long to wait.

Thank you for your advice. I am feeling much better right now - so, I just wanted to see if you thought an ER visit is appropriate even if I have recovered just because it was a more severe episode.

Thank you, Dr. Ilir. I felt better and went to bed, not to ER, so everything is just fine. I certainly did not want to go to the ER, so that worked out well. I do want to explain something and get your advice about how to communicate my symptoms to my cardiologist next Friday. I'm not sure if you remember, but I am getting short of breath with very minimal activity - everytime I do anything that requires much energy at all - even brushing my teeth. Showering is the most strenuous thing I do because I have, as you and others have suggested, limited my activity until I see my cardiologist. I understand the thought of the warm water having an impact. However, the showering requires a lot movemenent and activity, and also involves my arms over my head a lot (shampooing, rinsing, shampooing, rinsing again, conditioning, risnsing again) and having my hands above my head makes me have SOB very quickly. Of course, then there is all of the actual washing. So, I do feel that showers are the things that get me most short of breath primarily because it requires so much more energy than brushing my teeth or changing my clothes or taking the dog outside - all of which cause shortness of breath as well. (The warm water also componds the issue, I'm sure). Sometimes the showers make me less short of breath than others but they always are the most difficult things I do as far as that's concerned. But, what I do know for certain is that I am not having panic attacks. When these things occur (even with severity of last night) I do not feel anxious, fearful, like im dying, etc. I do not feel my heart racing, I am not trembling, I am simply very short of breath - like the air is going in but I am not getting enough oxygen. In fact, people have told me that I am "irrationally calm" about this whole situation as well as while I am actually experiencing the shortness of breath. I do think most people would be fearful during these intense episodes but, for whatever reason, I am really not. I have a paychology degree and I am a registered nurse. Here in the US, it is a big problem is that people (women most especially) are misdiagnosed with anxiety and panic attacks when they are having symptoms which should lead to further testing. This is especially true when it comes to cardiac or lung problems because the symptoms often mimic those of a panic attack. If the doctor does suspect panic attacks (in which case I really wish I could just bring him home and show him what exactly happens), that is okay. However, I do not want that to prevent me from getting an accurate diagnosis in a timely manner. I do not know how my cardiologist will be, but I do know that the appointments are scheduled in 20 minute blocks, back to back, so I would expect to only have 15 minutes or so to accurately describe my symptoms and convey what I have been experiencing. Do you have advice on how to avoid being misdiagnosed with panic attacks? I have seen this happen multiple times as a nurse and I don't want to experience it myself. I really wonder at this point if it is not lung related instead of cardiac because I am also a metalsmith, making jewelry, and breathe in a lot of chemicals and gasses. (I have not been doing this since the SOB started). So, I just need to have cardiac issues ruled out and then probably be evaluated by a lung speciaist. I just want to make sure I am not misdiagnosed with panic attacks or anxiety and kept from getting the full evaluation I need in order to figure out what is wrong physically. Do you have any suggestions? Perhaps I should even have my spouse video if i have another severe episode before the appointment to help the doctor see exactly how my synptoms present. It has just been a very long wait and I want to ensure that the doctor does not mistake something I say as being a indication that I am having panic attacks - thus preventing timely testing and diagnosis. Thank you so much for your advice!

Thank you. That is very helpful. I have one more question and I think that should be the last one for awhile. Since I have my stress echo tomorrow, I happened to think... As I understand it, the stress echo is performed until you reach the target heart rate, which is 85% of your maximum heart rate. My maximum for my age is 220-42 = 178. So, 85% of that is 151. My heart rate gets to 150 just brushing my teeth. So, Iam likely not gping to be on the treadmill for very long at all before it stops. I would guess maybe a minute! Is that even going to be enough time to obtain the information needed? The echo of course will still show how my heart responded to the rise in heart rate but I would like to do it for longer so it will show what my heart does when it gets up to almost 170 with normal activities. I also don't even know how short of breath I will be after that little time. I'm sure I will be to a certain extent, but not nearly as much as I experience on a day to day basis. So, will this test even have time to show any abnormalities in heart rhythm, blood pressure, etc? What do you think it can show in that amount of time? It will not have a pulmonary component as that was not ordered, unfortunately. I suppose I will have to see a pulmonologist for any lung testing. Thanks again!

Hi! Stress echo today. You said you would be interested in the results. Well, they haven't been confirmed by the MD, but the preliminary report from the cardiac NP was that everything was normal! I pushed myself sooo hard. I dont know how I did it but I could hardly breathe at the end (never got dizzy, though) My pulse was 150 just from getting ready to leave this morning so when they told me that the cut off for me would be 151 I asked if I could just go until I couldn't take it anymore. I just wanted to give them as much information as possible. They agreed and I went for 7 minutes! I'm very stubborn though, and think that most people feeling the way I did would have have stopped much sooner. My pulse got up to 180 which, as you well know, is over my estimated maximum heart rate for my age. So, I did my best and my heart looks fine. No arrhythmias were noted, my heart was pumping well, EKG was good - everything looked normal. I also got the results of the 24 hour holter monitor. It says: The patient was in sinus rhythm throughout. No arrhythmias noted. Diagnosis: Tachycardia: unspecified. Yay! Of course, when I would get SOB, I was to record my activity in a diary. So, I suppose its obvious that the heart rate increases very much with minimal activity. I still have an appointment with my cardiologist next week. Do you think there is additional testing I should discuss with him or do you think it's time to stop considering cardiac problems?I do remember you recommended a tilt test. My PCP will be referring me to a pulmonologist next. Since I have the yearly specialist package, I might find someone on here to consult with in the meantime. I am fairly certain that they won't be as helpful as you have been! But, I will hope so. Thanks!

Hi, Dr. Iliri. Wow - I think I might know the cause of my problems. I wanted to ask you. When the symptoms began, my PCP ran many blood tests. She was especially interested in seeing what my ferrin level was. She then went on vacation before the reaults were back. Her nurse called me to tell me the results. She said that my ferritin level was 40 and that she had told the doctor who wanted the nurse to tell me to eat more iron rich foods. Well, I decided to look online today at my labs - so I could print them out and take them to the cardiology appointment. I discovered that my ferrtin is not 40. It is 4.0! I see that low ferritin causes every symptom I'm having - the SOB, the tachycardia, the low blood pressure, loss of appetite, even hair loss (which I havent told you about). I really think this might be the answer! What do you think? Would a4.0 would cause these significant issues? Also, what do you think the treatment would be with a ferritin of 4.0? Thank you.

Thank you. I am attaching all of my labs as you requested. You will see that my Hgb is only slightly low (actually higher than it normally is - when I haven't been having symptoms at all) so a very low ferritn with only slightly low hgb probably doesn't explain the symptoms after all, does it? I'm including everything (in screenshots) even though most results are absolutely fine. I think I've told you as well that my BP often gets low (very low considering my normal). When it is low (like today), I seem to have a more difficult time. I'm not sure if I've told you that oftentimes my pulse pressure is very narrow. Today my BP was 98/77 with a heart rate of 100, after nornal activity and then sitting for 5 minutes. I understand that a narrow pulse pressure oftentimes points to a problem with your heart to pump properly. However, wouldnt my stress echo have indicated that? (My BP 1 minute after the test was actually lower than it was before the test, but the pulse pressure wasnt narrow - I should have written the values down. Thanks so much again for your help! I hope I'm not asking too many questions! I thought Ihad asked the last one for awhile. I dont want to annoy you!

Well, it won't let me attach any additional files right now - but the only other abnormal findings are the ferritin, which is 4 as you know, and a very slightly low urine specific gravity. Also - FYI: there was no occult blood in my stool.