Instruction: Any pediatric GIs who are familiar with intussusception? Or something that presents as such symptomatically?Any pediatric GIs who are familiar with intussusception?My 15month old son who was full term at birth was diagnosed with a small bowel intussusception when my husband and I brought him to the emergency room yesterday, 12/21/2022. The ultrasound report read, There is a 1.1 x 0.9 cm small bowel small bowel intussusception in the left hemiabdomen near the umbilicus. No evidence of ileocolic intussusception in the right lower quadrant. No free fluid in the abdomen or pelvis.After this was found on ultrasound, after 2 hours, an ultrasound was repeated, and the intussusception was gone.I have to say I wasnt surprised by this diagnosis, and I am GLAD that it was found on ultrasound.Since my son was six weeks old, he has experienced what I intuitively thought was GI distress. He would scream inconsolably, turn red in the face, and grunt as if he were trying to bear down. This wasnt infrequent; it was all happening all the time. Every week we would visit the pediatrician and an urgent care 1-3 times. At these visits, they would tell my husband and me that it was colic or gas or fussiness. We tried different formulas with cutting everything out of my diet because he was getting breastmilk too. We tried gas drops, bicycles, probiotics, and the colic holds we were shown. You name it; we tried it.After six months of torture for my little guy, I finally said ENOUGH was ENOUGH, and I brought him to the emergency room. The imaging at the emergency room showed that he had a lot of gas in his abdomen, and it was recommended that we try a hypoallergenic formula. (Before this, my son was getting breastmilk supplemented with formula.) We switched to Similac alimentum. Once we discovered that all of the formula we had given our little guy was recalled, we changed to Nutramigen. Since being on the hypoallergenic formula, the CONSTANT crying and screaming had subsided but hadnt completely gone away.He would have bouts of inconsolable screaming that would last 20 minutes, and then he would calm down. Sometimes he would have bouts of screaming that would last 20 minutes, calm, and then crescendo into more extended periods of crying with bearing down, turning red in the face, shaking, and vomiting.With that said, I am looking for some guidance. Has any pediatric GI seen or heard of small bowel intussusception reoccurring for this time? The Emergency Room doctor said he couldnt answer this question because he sees the acute visit of patients. He recommended that we follow up with a pediatric GI surgeon and our pediatrician.I spoke with the pediatric GI Nurse Practitioner, and she said they do not perform surgeries on small bowl intussusceptions. She said that they only perform surgeries on small to large bowl intussusceptions. She also said that this should subside when he is 5 -- she said this as if I could look forward to relief for him in 3 1/2 years!!The pediatric GI Nurse Practitioner and the Emergency Room Physician told me that I should bring him to the ED anytime he presented the way he did when I brought him in when he was diagnosed. This cant is the answer. This is not sustainable for us or our child. Since he was 15 months old, we have brought him into the ED, pediatricians office, and urgent care countless times for the same issues. It just so happens that they FOUND the cause THIS time.I would like to know if anyone has guidance or familiarity with this. Some questions I have are, has anyone ever seen a re-occurring intussusception? If this is re-occurring, is our only option to keep bringing him to the ED? Could something else be missing? Who else should I talk to? What else should I do?I am so frustrated with all the conflicting information and advice I have been given over the last 15 months. I feel so discouraged and not heard.I am so worried and heartbroken seeing my son constantly go through this.Any suggestions would be helpful. I am following up with our pediatrician, and hopefully, they will FINALLY put in a referral to a pediatric GI. I am a registered nurse, so I have a general background in the medical field.

Output: Transient small bowel intuss is a common finding in kids with belly pain or GI distress.No, it essentially never needs intervention.Kids get it all the time when they have stomach bugs. You just don't have an ultrasound on their belly the whole time.This may or may not be related to his prior issues of belly pain at all.A possible, but unlikely possibility is some sort of pathologic lead point that causes recurrent intuss. Like a Mekels, a real bad Peyer's patch, vascular anomaly, or even less commonly malignancy. I know of these being implicated more so for recurrent ileocecal intuss, but I suppose there's no reason they can't occur higher up.I think referral to peds GI is appropriate.Another possibility is Deitls crisis. It's recurrent, transient UPJ obstruction that causes episodes of pain, similar to intuss. It's rare, but also underdiagnosed, because nobody fucking knows about it. Small kids that have it are actually experiencing renal colic, but can't communicate it, and are presumed to have actually have abdominal pain. It's something to consider in the child with chronic episodic belly pain that self resolves and has no other symptoms.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Any pediatric GIs who are familiar with intussusception? Or something that presents as such symptomatically?Any pediatric GIs who are familiar with intussusception?My 15month old son who was full term at birth was diagnosed with a small bowel intussusception when my husband and I brought him to the emergency room yesterday, 12/21/2022. The ultrasound report read, There is a 1.1 x 0.9 cm small bowel small bowel intussusception in the left hemiabdomen near the umbilicus. No evidence of ileocolic intussusception in the right lower quadrant. No free fluid in the abdomen or pelvis.After this was found on ultrasound, after 2 hours, an ultrasound was repeated, and the intussusception was gone.I have to say I wasnt surprised by this diagnosis, and I am GLAD that it was found on ultrasound.Since my son was six weeks old, he has experienced what I intuitively thought was GI distress. He would scream inconsolably, turn red in the face, and grunt as if he were trying to bear down. This wasnt infrequent; it was all happening all the time. Every week we would visit the pediatrician and an urgent care 1-3 times. At these visits, they would tell my husband and me that it was colic or gas or fussiness. We tried different formulas with cutting everything out of my diet because he was getting breastmilk too. We tried gas drops, bicycles, probiotics, and the colic holds we were shown. You name it; we tried it.After six months of torture for my little guy, I finally said ENOUGH was ENOUGH, and I brought him to the emergency room. The imaging at the emergency room showed that he had a lot of gas in his abdomen, and it was recommended that we try a hypoallergenic formula. (Before this, my son was getting breastmilk supplemented with formula.) We switched to Similac alimentum. Once we discovered that all of the formula we had given our little guy was recalled, we changed to Nutramigen. Since being on the hypoallergenic formula, the CONSTANT crying and screaming had subsided but hadnt completely gone away.He would have bouts of inconsolable screaming that would last 20 minutes, and then he would calm down. Sometimes he would have bouts of screaming that would last 20 minutes, calm, and then crescendo into more extended periods of crying with bearing down, turning red in the face, shaking, and vomiting.With that said, I am looking for some guidance. Has any pediatric GI seen or heard of small bowel intussusception reoccurring for this time? The Emergency Room doctor said he couldnt answer this question because he sees the acute visit of patients. He recommended that we follow up with a pediatric GI surgeon and our pediatrician.I spoke with the pediatric GI Nurse Practitioner, and she said they do not perform surgeries on small bowl intussusceptions. She said that they only perform surgeries on small to large bowl intussusceptions. She also said that this should subside when he is 5 -- she said this as if I could look forward to relief for him in 3 1/2 years!!The pediatric GI Nurse Practitioner and the Emergency Room Physician told me that I should bring him to the ED anytime he presented the way he did when I brought him in when he was diagnosed. This cant is the answer. This is not sustainable for us or our child. Since he was 15 months old, we have brought him into the ED, pediatricians office, and urgent care countless times for the same issues. It just so happens that they FOUND the cause THIS time.I would like to know if anyone has guidance or familiarity with this. Some questions I have are, has anyone ever seen a re-occurring intussusception? If this is re-occurring, is our only option to keep bringing him to the ED? Could something else be missing? Who else should I talk to? What else should I do?I am so frustrated with all the conflicting information and advice I have been given over the last 15 months. I feel so discouraged and not heard.I am so worried and heartbroken seeing my son constantly go through this.Any suggestions would be helpful. I am following up with our pediatrician, and hopefully, they will FINALLY put in a referral to a pediatric GI. I am a registered nurse, so I have a general background in the medical field.. ### Response: Transient small bowel intuss is a common finding in kids with belly pain or GI distress.No, it essentially never needs intervention.Kids get it all the time when they have stomach bugs. You just don't have an ultrasound on their belly the whole time.This may or may not be related to his prior issues of belly pain at all.A possible, but unlikely possibility is some sort of pathologic lead point that causes recurrent intuss. Like a Mekels, a real bad Peyer's patch, vascular anomaly, or even less commonly malignancy. I know of these being implicated more so for recurrent ileocecal intuss, but I suppose there's no reason they can't occur higher up.I think referral to peds GI is appropriate.Another possibility is Deitls crisis. It's recurrent, transient UPJ obstruction that causes episodes of pain, similar to intuss. It's rare, but also underdiagnosed, because nobody fucking knows about it. Small kids that have it are actually experiencing renal colic, but can't communicate it, and are presumed to have actually have abdominal pain. It's something to consider in the child with chronic episodic belly pain that self resolves and has no other symptoms..


Instruction: Pediatric Psych patient dosage9 F Caucasian 93 lbs 4ft 6?My daughter was prescribed Lexapro 5 mg and everything I'm reading online says it's not for children under 12. I reached out to her pediatrician and he says to contact them because it's their expertise. I've been trying but am not getting through. In the mean time, is this something I should hold off on giving her or is the dosage small enough?

Output: Its likely safe but there is limited evidence to show efficacy (limited number of trials). Id hold off until you speak to psych, 1-2 days while you wait to speak to a psychiatrist for more clarification wont make a difference. It takes 6 weeks of consistent use before you really start to see much in the way of improvement to begin with, for most patients.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Pediatric Psych patient dosage9 F Caucasian 93 lbs 4ft 6?My daughter was prescribed Lexapro 5 mg and everything I'm reading online says it's not for children under 12. I reached out to her pediatrician and he says to contact them because it's their expertise. I've been trying but am not getting through. In the mean time, is this something I should hold off on giving her or is the dosage small enough?. ### Response: Its likely safe but there is limited evidence to show efficacy (limited number of trials). Id hold off until you speak to psych, 1-2 days while you wait to speak to a psychiatrist for more clarification wont make a difference. It takes 6 weeks of consistent use before you really start to see much in the way of improvement to begin with, for most patients..


Instruction: Thank you for your reply! She was given it starting on Saturday and seemed to do fine. I did end up getting through to someone and they said it was fine to give because she had been monitored while on it. I can't find any info as to why it's not recommended for children under 12 but they seem to find it appropriate, so I'm going to assume it should be?

Output: They dont recommend against it. Its just the lack of evidence and a strong benefit/risk analysis that prevents them from recommending it in patients under 12 at this point.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you for your reply! She was given it starting on Saturday and seemed to do fine. I did end up getting through to someone and they said it was fine to give because she had been monitored while on it. I can't find any info as to why it's not recommended for children under 12 but they seem to find it appropriate, so I'm going to assume it should be?. ### Response: They dont recommend against it. Its just the lack of evidence and a strong benefit/risk analysis that prevents them from recommending it in patients under 12 at this point..


Instruction: (Pediatrics) 24 month old white female with discordant bone age. 31" tall, 21 pounds. No meds, no surgeries.(Pediatrics) 24 month old white female with possible short stature. 31" tall, 21 pounds. No meds, no surgeries.My 2 year old hasn't been getting very tall as she's gotten older. She's dropped to the first percentile for height. Her first pediatrician wasn't overly concerned, but we saw a new pediatrician and she was concerned and had her x-rayed. I got the report back, but the doctor is out of the office so I won't be able to talk to her until next week.The radiology report says:FINDINGS: A single radiograph of the hand was provided for evaluation of bone age. The patient's chronological age is 24 months. The hand bone age according to the tables of Greulich and Pyle is approximately 2 years. The wrist bone age most closely approaches that of 1 year and 3 months. The standard deviation for the patient's chronological age is 4.64 months. No structural abnormalities are identified.IMPRESSION:Discordant bone age between the hand and wrist, but both are within 2 standard deviations of chronological age per the age and gender matched standards of Greulich and Pyle.Is the discrepancy worrisome?https://flic.kr/p/2nS9y6S

Output: Worrisome probably isnt the right term. It isnt indicative of anything dangerous.It can sometimes indicate a hormonal issue that requires endocrine referral.But will also say that pediatric endocrinologists and radiologist often disagree on bone ages.Bone ages are pretty subjective. Basically they x-ray the hand in a specific way and then compare it to a book with known bone ages and say eh, I think it looks like this one the most.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: (Pediatrics) 24 month old white female with discordant bone age. 31" tall, 21 pounds. No meds, no surgeries.(Pediatrics) 24 month old white female with possible short stature. 31" tall, 21 pounds. No meds, no surgeries.My 2 year old hasn't been getting very tall as she's gotten older. She's dropped to the first percentile for height. Her first pediatrician wasn't overly concerned, but we saw a new pediatrician and she was concerned and had her x-rayed. I got the report back, but the doctor is out of the office so I won't be able to talk to her until next week.The radiology report says:FINDINGS: A single radiograph of the hand was provided for evaluation of bone age. The patient's chronological age is 24 months. The hand bone age according to the tables of Greulich and Pyle is approximately 2 years. The wrist bone age most closely approaches that of 1 year and 3 months. The standard deviation for the patient's chronological age is 4.64 months. No structural abnormalities are identified.IMPRESSION:Discordant bone age between the hand and wrist, but both are within 2 standard deviations of chronological age per the age and gender matched standards of Greulich and Pyle.Is the discrepancy worrisome?https://flic.kr/p/2nS9y6S. ### Response: Worrisome probably isnt the right term. It isnt indicative of anything dangerous.It can sometimes indicate a hormonal issue that requires endocrine referral.But will also say that pediatric endocrinologists and radiologist often disagree on bone ages.Bone ages are pretty subjective. Basically they x-ray the hand in a specific way and then compare it to a book with known bone ages and say eh, I think it looks like this one the most..


Instruction: Disagree in what way? Just generally, or does one group tend to say bone age is more/less advanced than the other?

Output: Just generally. I dont do bone ages but have heard a few endocrinologists say I never listen to radiologys reads on bone ages. Then they proceed to do it themselves.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Disagree in what way? Just generally, or does one group tend to say bone age is more/less advanced than the other?. ### Response: Just generally. I dont do bone ages but have heard a few endocrinologists say I never listen to radiologys reads on bone ages. Then they proceed to do it themselves..


Instruction: 6 year old with hallucinations currently hospitilized. Is this autoimmune encephalopathy?Age: 6Sex: MaleLocation: New England, USAMy child has been in the hospital over the last week for suspected autoimmune encephalitis. I brought him to the ER on 4/11 per instruction from his pediatrician due to visual hallucinations. He was admitted after neurology came to the ER for a consult. The hallucinations have not been improving with treatment as of yet (4 days of IV steroids & 1 day of IV IG, see below for more specifics). I've been advised 90% of the labs will take a couple of weeks to get back. Is there anything else we should be considering? He's the happiest kid, he absolutely loves school and his friends and teachers and he can't wait to go home. He knows what he's seeing isn't real and I wish I could make it go away. Any insight/advice would be so appreciated. He's been a trooper throughout this process but it's not easy wondering every day what is going on. I can provide additional information if needed/requested.Assessment/Plan: Child is a 6 y.o. 5 m.o. male with PMH of hypnagogic hallucinations and asthma who presents for evaluation of 2 days of daytime hallucinations. Given acute onset of worsening visual hallucinations that started with nighttime awakenings on 4/7 and then progressed to daytime visual hallucinations on 4/10, we are concerned for autoimmune encephalitis. LTM EEG with left parasagittal and temporal spike wave epileptiform discharges, suggestive of underlying brain irritability. However, patient is very well appearing with no other classic features of autoimmune encephalitis- no encephalopathy, no weakness, no abnormal movements. Given that he is very well appearing and is not demonstrating significant decline from day to day, we will plan to first obtain CSF and brain MRI with contrast prior to starting immunosuppression. If CSF is bland, we would likely still recommend treating with immunosuppression given clinical concern and patient meeting diagnostic criteria for autoimmune encephalitis.EEG is abnormal but no definite seizures. Frequent and sleep activated left temporal and parasagittal spike and wave epileptiform discharges. Brain MRI normal. LP overall bland with 1 nucleated cell in tube 1, 2 nucleated cells in tube 2. Other labs pending but does have ANA positive at 1:320.Has been on IV steroids since 4/14 with no improvement in visual hallucinations. Will plan to continue steroids for total 5-day course and discuss case with our neuroimmunology colleagues. (This plan changed after neuroimmunology consult, began tapering steroids after 4th day to begin IV IG)Treatment:s/p 4-days of high dose IV methylprednisolone (30mg/kg daily)prednisone taper: 1mg/kg (max 60mg) prednisone tapering over 6 weeks (can roughly cut in half every 7 days) Week 1: 30mg daily Week 2: 15mg daily Week 3: 10mg daily Week 4: 5mg daily Offstart IVIG today for 2-days- IVIG 2g/kg divided over 2 days. Started on 4/17 treatment was well-toleratedResulted workup:EEG abnormal with frequent abundant spike wave epileptiform dischargesEEG continued to demonstrate frequent abundant left parasagittal and temporal spike wave epileptiform discharges -EEG from 4/12 -Frequent to abundant left parasagittal spike wave epileptiform discharges that occurred both independently and in brief 1-3 Hz runs lasting <10 seconds (BIRDS) -Occasional to abundant left temporal spike wave epileptiform discharges that occurred both independently and in brief 1-1.5 Hz runs lasting <10 seconds (BIRDS)quick brain MRI normalsedated brain MRI with contrast normal, incidental finding of likely arachnoid cystReassuring CBCd, BMP/Mg/Phos, LFT'sESR and CRP normalTSH elevated to 7.44, free T4 normal at 1.1B12 and folate normalRPR non-reactiveRhinovirus positiveCeruloplasmin normalUrine tox negativeUA normalANA positive 1:320, speckledSerum copper within normal rangeCSF opening pressure 15CSF cell count and total protein normalAnti-TPO antibodies negativeHIV 1/2 negativeCollected and pending: [] CSF culture [] CSF HSV PCR, CSF VZV PCR, CSF VZV IgM [] CSF oligoclonal bands, IgG index, beta-2 microglobulin, flow cytometry, cytology [] CSF autoimmune encephalopathy panel [] CSF anti-Glycine-R antibody [] Serum Glycine Receptor IgG [] Myelin oligodendrocyte glycoprotein [] 24 hour urine copper [] 24 hour urine porphyrins [] Double stranded DNA antibodies [] Antiphospholipid antibody panel [] Thyroglobulin antibody [] Serum MaTa Autoantibody test [] SPEP panel [] MS profile, serum and CXF [] IgG index/synthesis rate, serum and CSF [] EBV serology [] VZV IgG, IgM [] HSV PCR, HSV type 1,2 antibody [] Serum encephalopathy panel [] Mycoplasma IgM, IgG [] Lyme screen with reflex to immunoblot [] HSV PCR, serumMENTAL STATUS EXAM: Appearance: appropriately dressed Behavior: cooperative, eye contact good and pleasant Psychomotor Activity: normal Musculoskeletal: moves all extremities; no abnormal movements Station/Gait: normal Speech: regular rate, regular rhythm and regular volume Language: normal comprehension Mood: happy Affect: full range Thought Process: logical, linear and goal-directed Associations: no loosening of associations Thought Content: no delusions and no obsessions Perceptions/Experiences: visual hallucinations Orientation/Sensorium: alert Memory: immediate recall intact. Attention/Concentration: intact to observationImpression: Child is a cheerful and pleasant 6 yo boy, from X attending Kindergarten at X. He has a hx of mild OSA, hypogogic/hypnopompic hallucinations since early on, asthma, no prior past psychiatric history, presenting for worsening hallucinations since 4/10, admitted for medical work up on etiology. Psychiatry consulted for diagnostic clarification, support and medication management.4/14/23: Patient continues to be calm and cooperative, behaviorally appropriate for a 6-year-old boy. Continues to experience visual hallucinations, yesterday night described as "monsters," which patient is understandably afraid of. Most of patient's hallucinations are visual, vivid, and neutral with minimal emotional involvement. No auditory hallucinations. No clear seizure activity on EEG, other than minor blinking, clinical signs of seizure disorder not noted on physical exam. Pt age, onset, and symptoms are not typical of a primary psychotic disorder or normal development. We agree with pediatric neurology and primary team that the origin of hallucinations are organic. No emotional or behavioral dysregulation. Thus, we do not recommend scheduled psychotropic medications at this time. Pediatric neurology assess patient has underlying brain irritability from EEG findings (left parasagittal and temporal spike wave epileptiform discharges), likely secondary to encephalitis, as opposed to seizure disorder.

Output: What were the CSF cell counts, protein, and glucose?

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 6 year old with hallucinations currently hospitilized. Is this autoimmune encephalopathy?Age: 6Sex: MaleLocation: New England, USAMy child has been in the hospital over the last week for suspected autoimmune encephalitis. I brought him to the ER on 4/11 per instruction from his pediatrician due to visual hallucinations. He was admitted after neurology came to the ER for a consult. The hallucinations have not been improving with treatment as of yet (4 days of IV steroids & 1 day of IV IG, see below for more specifics). I've been advised 90% of the labs will take a couple of weeks to get back. Is there anything else we should be considering? He's the happiest kid, he absolutely loves school and his friends and teachers and he can't wait to go home. He knows what he's seeing isn't real and I wish I could make it go away. Any insight/advice would be so appreciated. He's been a trooper throughout this process but it's not easy wondering every day what is going on. I can provide additional information if needed/requested.Assessment/Plan: Child is a 6 y.o. 5 m.o. male with PMH of hypnagogic hallucinations and asthma who presents for evaluation of 2 days of daytime hallucinations. Given acute onset of worsening visual hallucinations that started with nighttime awakenings on 4/7 and then progressed to daytime visual hallucinations on 4/10, we are concerned for autoimmune encephalitis. LTM EEG with left parasagittal and temporal spike wave epileptiform discharges, suggestive of underlying brain irritability. However, patient is very well appearing with no other classic features of autoimmune encephalitis- no encephalopathy, no weakness, no abnormal movements. Given that he is very well appearing and is not demonstrating significant decline from day to day, we will plan to first obtain CSF and brain MRI with contrast prior to starting immunosuppression. If CSF is bland, we would likely still recommend treating with immunosuppression given clinical concern and patient meeting diagnostic criteria for autoimmune encephalitis.EEG is abnormal but no definite seizures. Frequent and sleep activated left temporal and parasagittal spike and wave epileptiform discharges. Brain MRI normal. LP overall bland with 1 nucleated cell in tube 1, 2 nucleated cells in tube 2. Other labs pending but does have ANA positive at 1:320.Has been on IV steroids since 4/14 with no improvement in visual hallucinations. Will plan to continue steroids for total 5-day course and discuss case with our neuroimmunology colleagues. (This plan changed after neuroimmunology consult, began tapering steroids after 4th day to begin IV IG)Treatment:s/p 4-days of high dose IV methylprednisolone (30mg/kg daily)prednisone taper: 1mg/kg (max 60mg) prednisone tapering over 6 weeks (can roughly cut in half every 7 days) Week 1: 30mg daily Week 2: 15mg daily Week 3: 10mg daily Week 4: 5mg daily Offstart IVIG today for 2-days- IVIG 2g/kg divided over 2 days. Started on 4/17 treatment was well-toleratedResulted workup:EEG abnormal with frequent abundant spike wave epileptiform dischargesEEG continued to demonstrate frequent abundant left parasagittal and temporal spike wave epileptiform discharges -EEG from 4/12 -Frequent to abundant left parasagittal spike wave epileptiform discharges that occurred both independently and in brief 1-3 Hz runs lasting <10 seconds (BIRDS) -Occasional to abundant left temporal spike wave epileptiform discharges that occurred both independently and in brief 1-1.5 Hz runs lasting <10 seconds (BIRDS)quick brain MRI normalsedated brain MRI with contrast normal, incidental finding of likely arachnoid cystReassuring CBCd, BMP/Mg/Phos, LFT'sESR and CRP normalTSH elevated to 7.44, free T4 normal at 1.1B12 and folate normalRPR non-reactiveRhinovirus positiveCeruloplasmin normalUrine tox negativeUA normalANA positive 1:320, speckledSerum copper within normal rangeCSF opening pressure 15CSF cell count and total protein normalAnti-TPO antibodies negativeHIV 1/2 negativeCollected and pending: [] CSF culture [] CSF HSV PCR, CSF VZV PCR, CSF VZV IgM [] CSF oligoclonal bands, IgG index, beta-2 microglobulin, flow cytometry, cytology [] CSF autoimmune encephalopathy panel [] CSF anti-Glycine-R antibody [] Serum Glycine Receptor IgG [] Myelin oligodendrocyte glycoprotein [] 24 hour urine copper [] 24 hour urine porphyrins [] Double stranded DNA antibodies [] Antiphospholipid antibody panel [] Thyroglobulin antibody [] Serum MaTa Autoantibody test [] SPEP panel [] MS profile, serum and CXF [] IgG index/synthesis rate, serum and CSF [] EBV serology [] VZV IgG, IgM [] HSV PCR, HSV type 1,2 antibody [] Serum encephalopathy panel [] Mycoplasma IgM, IgG [] Lyme screen with reflex to immunoblot [] HSV PCR, serumMENTAL STATUS EXAM: Appearance: appropriately dressed Behavior: cooperative, eye contact good and pleasant Psychomotor Activity: normal Musculoskeletal: moves all extremities; no abnormal movements Station/Gait: normal Speech: regular rate, regular rhythm and regular volume Language: normal comprehension Mood: happy Affect: full range Thought Process: logical, linear and goal-directed Associations: no loosening of associations Thought Content: no delusions and no obsessions Perceptions/Experiences: visual hallucinations Orientation/Sensorium: alert Memory: immediate recall intact. Attention/Concentration: intact to observationImpression: Child is a cheerful and pleasant 6 yo boy, from X attending Kindergarten at X. He has a hx of mild OSA, hypogogic/hypnopompic hallucinations since early on, asthma, no prior past psychiatric history, presenting for worsening hallucinations since 4/10, admitted for medical work up on etiology. Psychiatry consulted for diagnostic clarification, support and medication management.4/14/23: Patient continues to be calm and cooperative, behaviorally appropriate for a 6-year-old boy. Continues to experience visual hallucinations, yesterday night described as "monsters," which patient is understandably afraid of. Most of patient's hallucinations are visual, vivid, and neutral with minimal emotional involvement. No auditory hallucinations. No clear seizure activity on EEG, other than minor blinking, clinical signs of seizure disorder not noted on physical exam. Pt age, onset, and symptoms are not typical of a primary psychotic disorder or normal development. We agree with pediatric neurology and primary team that the origin of hallucinations are organic. No emotional or behavioral dysregulation. Thus, we do not recommend scheduled psychotropic medications at this time. Pediatric neurology assess patient has underlying brain irritability from EEG findings (left parasagittal and temporal spike wave epileptiform discharges), likely secondary to encephalitis, as opposed to seizure disorder.. ### Response: What were the CSF cell counts, protein, and glucose?.


Instruction: 3y(f) Seeing Pediatric Pulmonologist - What to Expect and Genetic TestingMy (37F) daughter (3F) will be seeing a pediatric pulmonologist next week for suspected asthma. Her pediatrician has diagnosed it as "mild or intermittent" but from my observations, it is not mild and is getting worse. It was thought she had recurrent croup but we now suspect those croup episodes have actually been asthma attacks/flares. They only occur during viral illness, but each time she is sick she ends up in respiratory distress and needs an ER/hospital visit. She is prescribed albuterol, flovent, and decadron. Pediatrician agreed to allow us to only use flovent at onset of illness so it is not daily use.I don't know if there will be genetic testing performed, but I did sign a form agreeing to genetic testing.My question is, should I be thinking this is something beyond asthma and possibly genetic? Should I push for imaging and/or genetic testing?

Output: Peds ER doctor here, sounds very much like asthma. No, genetic testing is not done routinely at all, i suspect they make everyone sign that form before coming in so that they can streamline the process if they need to test patients for anything.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 3y(f) Seeing Pediatric Pulmonologist - What to Expect and Genetic TestingMy (37F) daughter (3F) will be seeing a pediatric pulmonologist next week for suspected asthma. Her pediatrician has diagnosed it as "mild or intermittent" but from my observations, it is not mild and is getting worse. It was thought she had recurrent croup but we now suspect those croup episodes have actually been asthma attacks/flares. They only occur during viral illness, but each time she is sick she ends up in respiratory distress and needs an ER/hospital visit. She is prescribed albuterol, flovent, and decadron. Pediatrician agreed to allow us to only use flovent at onset of illness so it is not daily use.I don't know if there will be genetic testing performed, but I did sign a form agreeing to genetic testing.My question is, should I be thinking this is something beyond asthma and possibly genetic? Should I push for imaging and/or genetic testing?. ### Response: Peds ER doctor here, sounds very much like asthma. No, genetic testing is not done routinely at all, i suspect they make everyone sign that form before coming in so that they can streamline the process if they need to test patients for anything..


Instruction: Pediatric Abilify weaning schedule?Hi Reddit Docs, My 8yo (9 in April) son has been on Abilify for about a year, up to 15mg. Long story short we dont feel that it is making a difference and in fact hes getting worse, more physical/aggressive, even violent at times. Especially since we added clonidine again. (In addition hes being treated by a physician who specializes in ADHD, not a psychiatrist. He was diagnosed by a psychologist with ADHD, depression, and motor coordination development disorder. I had to see this Dr because he was diagnosed during the height of the pandemic and no psychiatrist was available. Basically threw different combinations of Vyvanse, guanfacine, clonidine, and Adderrall at him, hes currently on Adzenys, Abilify and just came off clonidine. Finally got him some Lexapro a few months ago and his baseline mood has improved but the outbursts are worse. Ive been trying again to get a psychiatrist with no luck. I currently have an emergency intake visit scheduled in 4 days with a social worker who is supposedly going to get us a faster referral visit.) What is the recommended taper schedule to come off the Abilify? Wanting to make sure current provider is giving us accurate info. Thank you!

Output: I am not sure what the guidelines for treating children are where you reside but to me this seems like a hodgepodge of medication. I would personally be very concerned to write out so many medications (some of which counteract each other).My first question would be what was the main problem with your son before he got medicated? Why did you seek help? Is there family history of psychiatric illness?The tapering really depends on the patient and the symptoms experienced. One could recommend to reduce 5mg every week (so 15mg, 10mg and finally 5mg before stopping). This can be further adjusted depending on any side effects. This can be also adjusted more finely if you have an oral solution instead of tablets.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Pediatric Abilify weaning schedule?Hi Reddit Docs, My 8yo (9 in April) son has been on Abilify for about a year, up to 15mg. Long story short we dont feel that it is making a difference and in fact hes getting worse, more physical/aggressive, even violent at times. Especially since we added clonidine again. (In addition hes being treated by a physician who specializes in ADHD, not a psychiatrist. He was diagnosed by a psychologist with ADHD, depression, and motor coordination development disorder. I had to see this Dr because he was diagnosed during the height of the pandemic and no psychiatrist was available. Basically threw different combinations of Vyvanse, guanfacine, clonidine, and Adderrall at him, hes currently on Adzenys, Abilify and just came off clonidine. Finally got him some Lexapro a few months ago and his baseline mood has improved but the outbursts are worse. Ive been trying again to get a psychiatrist with no luck. I currently have an emergency intake visit scheduled in 4 days with a social worker who is supposedly going to get us a faster referral visit.) What is the recommended taper schedule to come off the Abilify? Wanting to make sure current provider is giving us accurate info. Thank you!. ### Response: I am not sure what the guidelines for treating children are where you reside but to me this seems like a hodgepodge of medication. I would personally be very concerned to write out so many medications (some of which counteract each other).My first question would be what was the main problem with your son before he got medicated? Why did you seek help? Is there family history of psychiatric illness?The tapering really depends on the patient and the symptoms experienced. One could recommend to reduce 5mg every week (so 15mg, 10mg and finally 5mg before stopping). This can be further adjusted depending on any side effects. This can be also adjusted more finely if you have an oral solution instead of tablets..


Instruction: Pediatric4 y/o female, turning 5 next month. No significant PMH. Complaining of pin point pain around umbilical area that hurts more when I breathe in and out. Also complaining of GERD symptoms described it perfectly without knowing obviously when I eat my food and drink too, it goes down to my belly and then comes back up and I have to swallow it again.Started complaining of both these symptoms over the last 24 hours.No bulge can be noticed or palpated, even when coughing or taking deep breaths.What could this be?

Output: Gastric or duodenal ulcer, GERD, constipation. Would talk to pediatrician about it. Can do a trial with famotidine if it sounds like reflux to them with a more thorough history. If its a one off episode its unlikely to be anything to worry about if it self resolves. Look for food triggers and anything that helps or makes it worse in the mean time.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Pediatric4 y/o female, turning 5 next month. No significant PMH. Complaining of pin point pain around umbilical area that hurts more when I breathe in and out. Also complaining of GERD symptoms described it perfectly without knowing obviously when I eat my food and drink too, it goes down to my belly and then comes back up and I have to swallow it again.Started complaining of both these symptoms over the last 24 hours.No bulge can be noticed or palpated, even when coughing or taking deep breaths.What could this be?. ### Response: Gastric or duodenal ulcer, GERD, constipation. Would talk to pediatrician about it. Can do a trial with famotidine if it sounds like reflux to them with a more thorough history. If its a one off episode its unlikely to be anything to worry about if it self resolves. Look for food triggers and anything that helps or makes it worse in the mean time..


Instruction: Pediatric burnsMy daughter is 4 years old and was burned with hot water earlier today. She was taken to our local emergency room within about 20 minutes of the accident. The burns are on her chest/belly area covering approximately 65% of the front. The doctor did not specify but I believe it's 2nd degree burns as the top layer skin has came off. The er gave hycet plus gave her a prescription for hycet and silvadene cream. They gave some thin blue towels of hold over the burn area with instructions to not begin the cream or put anything else on it until it stops leaking fluid from the burn. Now she has blue towel fuzz stuck to the burn area and I was told not to wet the wound nor cover with anything else. I don't want to go against the er doctors instructions but I just have a bad feeling that this is going to end up infected. Do these instructions sound correct? Is there anything else I should be doing? Given the burn is on her chest I'm not sure I'm allowed to include a photo but if the mods allow it.

Output: This burn would likely meet criteria for inpatient management based on the described size and severity of the burn. Im surprised they would send you home. You should be able to lightly rinse the fibers off but every time you rinse it and if you have any abrasion, you risk destroying the epithelialization of new skin. There is a balance between dressing changes and allowing time for healing. Additionally moisture can increase the risk of infection. Generally speaking the fuzz is likely harmless, so you would have to use your judgement as to whether it needs to be removed based on the amount attached and any soiling or other factors present.If there is a significant amount, Id recommend a return to the emergency room for further management and discuss admission to the inpatient service or transfer to a burn center for further care. Burns often require more significant care than just the initial skin damage, especially if a significant portion of the trunk has been burned. In pediatric patients it is even more imperative to get proper care to ensure proper healing and limit future difficulties secondary to poor healing.They can be managed at home for minor burns, but if you are not comfortable with the care and it has not been described in enough detail that you feel comfortable, return to the ED. Your child will thank you in the future if you get proper care now. Its unfortunate that this may require an additional trip to the emergency room, but I wish you the best and hope your child has a speedy recovery.You may wish to try a different emergency room for a second opinion if you did not feel like you received adequate care at the first one.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Pediatric burnsMy daughter is 4 years old and was burned with hot water earlier today. She was taken to our local emergency room within about 20 minutes of the accident. The burns are on her chest/belly area covering approximately 65% of the front. The doctor did not specify but I believe it's 2nd degree burns as the top layer skin has came off. The er gave hycet plus gave her a prescription for hycet and silvadene cream. They gave some thin blue towels of hold over the burn area with instructions to not begin the cream or put anything else on it until it stops leaking fluid from the burn. Now she has blue towel fuzz stuck to the burn area and I was told not to wet the wound nor cover with anything else. I don't want to go against the er doctors instructions but I just have a bad feeling that this is going to end up infected. Do these instructions sound correct? Is there anything else I should be doing? Given the burn is on her chest I'm not sure I'm allowed to include a photo but if the mods allow it.. ### Response: This burn would likely meet criteria for inpatient management based on the described size and severity of the burn. Im surprised they would send you home. You should be able to lightly rinse the fibers off but every time you rinse it and if you have any abrasion, you risk destroying the epithelialization of new skin. There is a balance between dressing changes and allowing time for healing. Additionally moisture can increase the risk of infection. Generally speaking the fuzz is likely harmless, so you would have to use your judgement as to whether it needs to be removed based on the amount attached and any soiling or other factors present.If there is a significant amount, Id recommend a return to the emergency room for further management and discuss admission to the inpatient service or transfer to a burn center for further care. Burns often require more significant care than just the initial skin damage, especially if a significant portion of the trunk has been burned. In pediatric patients it is even more imperative to get proper care to ensure proper healing and limit future difficulties secondary to poor healing.They can be managed at home for minor burns, but if you are not comfortable with the care and it has not been described in enough detail that you feel comfortable, return to the ED. Your child will thank you in the future if you get proper care now. Its unfortunate that this may require an additional trip to the emergency room, but I wish you the best and hope your child has a speedy recovery.You may wish to try a different emergency room for a second opinion if you did not feel like you received adequate care at the first one..


Instruction: Pediatric lupus?My 11 y/o daughter had three weeks of low grade fever, headache, body ache, fatigue, nausea and low appetite. Multiple negative tests - covid (including antibody), mono, strep, flu, RSV. Had a positive urinalysis for bacteria and blood - did a round of Bactrim but the symptoms remained. Current meds for asthma - symbicort, xopenex as needed, singular.Doc ran some more blood tests - looks like some were autoimmune tests. Can I get some interpretation of these ANA titer results? Recommend seeing a pediatric rheumatologist?

Output: That's quite a high ANA titer (means very positive). Time to see a peds rheum.This is not the place to push Lyme pseudo-medicine.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Pediatric lupus?My 11 y/o daughter had three weeks of low grade fever, headache, body ache, fatigue, nausea and low appetite. Multiple negative tests - covid (including antibody), mono, strep, flu, RSV. Had a positive urinalysis for bacteria and blood - did a round of Bactrim but the symptoms remained. Current meds for asthma - symbicort, xopenex as needed, singular.Doc ran some more blood tests - looks like some were autoimmune tests. Can I get some interpretation of these ANA titer results? Recommend seeing a pediatric rheumatologist?. ### Response: That's quite a high ANA titer (means very positive). Time to see a peds rheum.This is not the place to push Lyme pseudo-medicine..


Instruction: Definitely in a tick borne illness area - Lyme tests are in these results too - but she was only reactive on one of the bands. I think that means shes negative?

Output: That means she's negative. Please don't listen to the internet panic about Lyme disease. It's easy to test for and straightforward to treat.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Definitely in a tick borne illness area - Lyme tests are in these results too - but she was only reactive on one of the bands. I think that means shes negative?. ### Response: That means she's negative. Please don't listen to the internet panic about Lyme disease. It's easy to test for and straightforward to treat..


Instruction: Pediatric Wellness Exam around PubertyI am trying to find a new pediatrician for my daughter (11y/f). We went to a local female pediatrician, who was nice, albeit a little rushed and pushy. We talked for a little while, and the pediatrician did ask if she had her period yet or not. She has not. Upon physical examination, with little notice (hey I'm going to do this, and then did it) the doctor pulled up my daughter's shirt and bra, and then pulled up her pants at the waistband to look at her vaginal area. My daughter was struggling to not let her do this and is now traumatized by the interaction and felt like she could have given a little more warning. I know that physicians are very busy and have many patients to see, but I feel like I've failed to protect my daughter from this. I would think a conversation asking if she is developing breast tissue or pubic hair would have been just as efficient without stressing my child. Or even saying what she is going to do before doing that kind of exam. Is this a normal practice on a wellness exam? My daughter will not be returning to this doctor.

Output: It is normal practice to check these areas, yes. Sounds like the doctor could have explained the process a bit better. At this age, I generally talk to the patient about what I'm going to do and why, then ask for their assent before proceeding.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Pediatric Wellness Exam around PubertyI am trying to find a new pediatrician for my daughter (11y/f). We went to a local female pediatrician, who was nice, albeit a little rushed and pushy. We talked for a little while, and the pediatrician did ask if she had her period yet or not. She has not. Upon physical examination, with little notice (hey I'm going to do this, and then did it) the doctor pulled up my daughter's shirt and bra, and then pulled up her pants at the waistband to look at her vaginal area. My daughter was struggling to not let her do this and is now traumatized by the interaction and felt like she could have given a little more warning. I know that physicians are very busy and have many patients to see, but I feel like I've failed to protect my daughter from this. I would think a conversation asking if she is developing breast tissue or pubic hair would have been just as efficient without stressing my child. Or even saying what she is going to do before doing that kind of exam. Is this a normal practice on a wellness exam? My daughter will not be returning to this doctor.. ### Response: It is normal practice to check these areas, yes. Sounds like the doctor could have explained the process a bit better. At this age, I generally talk to the patient about what I'm going to do and why, then ask for their assent before proceeding..


Instruction: 7yo old with Hashimotos and Lichen SclerosisMy apologies for such a vague request but Im searching for any answers of how these two are connected or if we should be traveling out of state for second opinions. My daughter was diagnosed in the past year with both conditions. We live in the US (Nevada). She currently sees a pediatric endocrinologist and a pediatric urologist (we do not have a pediatric gynecologist where I live and our pediatric dermatologist is a male and my daughter wasnt comfortable seeing him).My issue is that everywhere we take her they comment on how rare her conditions are or how they havent treated it before. To me, that doesnt mean they are incompetent or she is receiving poor treatment, I just wonder if there are people who do treat these conditions more frequently and if it is worth our time to seek second opinions.Definitely not rich, but could most likely cover basic assessments if need be.Thank you in advance!

Output: If someone has one autoimmune condition, they are at increased risk of developing other autoimmune conditions. These are both autoimmune conditions but unrelated except for the autoimmune diathesis. No comment on the thyroid disease, but skin biopsy results are definitive and treatment of lichen sclerosus is usually straightforward.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 7yo old with Hashimotos and Lichen SclerosisMy apologies for such a vague request but Im searching for any answers of how these two are connected or if we should be traveling out of state for second opinions. My daughter was diagnosed in the past year with both conditions. We live in the US (Nevada). She currently sees a pediatric endocrinologist and a pediatric urologist (we do not have a pediatric gynecologist where I live and our pediatric dermatologist is a male and my daughter wasnt comfortable seeing him).My issue is that everywhere we take her they comment on how rare her conditions are or how they havent treated it before. To me, that doesnt mean they are incompetent or she is receiving poor treatment, I just wonder if there are people who do treat these conditions more frequently and if it is worth our time to seek second opinions.Definitely not rich, but could most likely cover basic assessments if need be.Thank you in advance!. ### Response: If someone has one autoimmune condition, they are at increased risk of developing other autoimmune conditions. These are both autoimmune conditions but unrelated except for the autoimmune diathesis. No comment on the thyroid disease, but skin biopsy results are definitive and treatment of lichen sclerosus is usually straightforward..


Instruction: For my son.Age: 8 months old Weight and height: 20 pounds and 2 foot No medications being taken No smoking No current medical issues Location of complaint: headIll start with saying we took him immediately to the ER and got seen by a neurosurgeon at a pediatric hospital afterwards. They said he was good to go after observing him for a few hours and said his CT scan was clear of any bleeding or fractures by both the ER and neurosurgeon at at the pediatric hospital.I was at work and my wife called me and told my son fell back off of the couch, which is about a foot and half up off the floor (which is hard tile, there is a rug there as well about a quarter of an inch thick if that.)She picked him up and then said he was crying but then he stopped and his eyes rolled to the back of his head, he started bubbling at his mouth and got stiff. Wasnt responding to anything. I work at the hospital where we brought him into the ED at and I saw him, I was moving him but he wasnt responding either so they called in a code and gave him 2.5mg diastate to help him out. After they gave him that, I saw him start moving and making noises. Afterwards they took a CT scan on him which, at that point, I was informed by one of the doctors there it was clear from any fractures or bleeds. However, I was also told that since there wasnt a radiologist there the doctor told me she couldnt say for sure. At this point, they send us to the pediatric hospital where he was seen by the neurosurgeon, who told us she didnt see anything either and it looked clear to her as well. Afterwards we were three from about 10:30-5:00 pm. During the time we waited he fell asleep and ate like normal, didnt throw up or anything. Neurosurgeon came back and did some other tests, he grabbed some keys she had and played with them like he normally does with things. From there, they discharged us and said to watch him over the next 48 hours for any changes in behavior or anything out the norm. Neurosurgeon stated she doesnt think he had a seizure but doesnt know for sure since the scan was done about 20-25 minutes after he arrived and wasnt sure if it was done too early. For a bit of a better timeline of events, he fell about 8:59 a.m. and arrived at the hospital about 9:05 a.mSo after we got home hes been completely normal. Even today hes been fine. He has a regular check up in about two weeks but I want to do a follow up and wanted your alls advice due to the fact of how he was immediately after the fall, since that seemed to be the part that had most of the providers a little stumped. I did on searching on google (I know) to see if I could find anything similar to the situation but found nothing that seemed similar to it. They way a nurse and the neurosurgeon explained what it was, that it couldve been he had response to the trauma of the pain and that his was reaction was what made him go into that state. I apologize for the long read but there was no short version that had enough info. But, if theres a question that anyone needs answered for more context please let me know.

Output: t's hard to say if he seized or not. Seizure after head injury isn't super rare. You can have seizure in absence of bleeds or fractures. The timing or findings of the CT has no bearing on whether he seized.He may have been concussed. Concussion is a clinical diagnosis, and is not something that is diagnosed by imaging.I frankly would be shocked if he had seizures or concussion from the fall, as described. I've seen >100 babies with falls like this, none have had serious injury.I've seen many infants and toddlers with falls from 2nd story window/balconies. I don't recall any ever having serious head injury.But yeah, likely either a weird pain response, or concussion. Or there is more to this story than an 18" fall onto carpeted floor.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: For my son.Age: 8 months old Weight and height: 20 pounds and 2 foot No medications being taken No smoking No current medical issues Location of complaint: headIll start with saying we took him immediately to the ER and got seen by a neurosurgeon at a pediatric hospital afterwards. They said he was good to go after observing him for a few hours and said his CT scan was clear of any bleeding or fractures by both the ER and neurosurgeon at at the pediatric hospital.I was at work and my wife called me and told my son fell back off of the couch, which is about a foot and half up off the floor (which is hard tile, there is a rug there as well about a quarter of an inch thick if that.)She picked him up and then said he was crying but then he stopped and his eyes rolled to the back of his head, he started bubbling at his mouth and got stiff. Wasnt responding to anything. I work at the hospital where we brought him into the ED at and I saw him, I was moving him but he wasnt responding either so they called in a code and gave him 2.5mg diastate to help him out. After they gave him that, I saw him start moving and making noises. Afterwards they took a CT scan on him which, at that point, I was informed by one of the doctors there it was clear from any fractures or bleeds. However, I was also told that since there wasnt a radiologist there the doctor told me she couldnt say for sure. At this point, they send us to the pediatric hospital where he was seen by the neurosurgeon, who told us she didnt see anything either and it looked clear to her as well. Afterwards we were three from about 10:30-5:00 pm. During the time we waited he fell asleep and ate like normal, didnt throw up or anything. Neurosurgeon came back and did some other tests, he grabbed some keys she had and played with them like he normally does with things. From there, they discharged us and said to watch him over the next 48 hours for any changes in behavior or anything out the norm. Neurosurgeon stated she doesnt think he had a seizure but doesnt know for sure since the scan was done about 20-25 minutes after he arrived and wasnt sure if it was done too early. For a bit of a better timeline of events, he fell about 8:59 a.m. and arrived at the hospital about 9:05 a.mSo after we got home hes been completely normal. Even today hes been fine. He has a regular check up in about two weeks but I want to do a follow up and wanted your alls advice due to the fact of how he was immediately after the fall, since that seemed to be the part that had most of the providers a little stumped. I did on searching on google (I know) to see if I could find anything similar to the situation but found nothing that seemed similar to it. They way a nurse and the neurosurgeon explained what it was, that it couldve been he had response to the trauma of the pain and that his was reaction was what made him go into that state. I apologize for the long read but there was no short version that had enough info. But, if theres a question that anyone needs answered for more context please let me know.. ### Response: t's hard to say if he seized or not. Seizure after head injury isn't super rare. You can have seizure in absence of bleeds or fractures. The timing or findings of the CT has no bearing on whether he seized.He may have been concussed. Concussion is a clinical diagnosis, and is not something that is diagnosed by imaging.I frankly would be shocked if he had seizures or concussion from the fall, as described. I've seen >100 babies with falls like this, none have had serious injury.I've seen many infants and toddlers with falls from 2nd story window/balconies. I don't recall any ever having serious head injury.But yeah, likely either a weird pain response, or concussion. Or there is more to this story than an 18" fall onto carpeted floor..


Instruction: Trans (FTM) invasive exam at endocrinology visit *repost **is this common practice??4 years ago i had visited a pediatric endocrinologist for my first dose of T after 2 years of therapy. i had done everything i needed to, i was excited, i was desperate the endocrinologist did everything routine blood tests, usual physical examinations during the physical, it was quite apparent that i did have excess hair and signs of hyperandrogenism. the blood work even indicated that my cholesterol was high. the day of my follow-up he had asked me to wear a gown so he can check down there i dont remember ever getting a reason why but he did let my mom stay in the room and brought a chaperone. i was desperate so i let him do it. it haunted me for a while.4 years later. i had learned that that examination apparently isnt routine via my friends and this examination was never reported in any of my records so i decided to give him a call about it to express my concerns. he told me that people who have hyperandrogenism, their clit grows so he wanted to check for signs of that and anything that can indicate for signs of a tumor, that is causing it so that he would order a CT scan if he suspected iti still dont know how a physical examination can make that clear but i felt pressured today so i just agreed just like i did 4 years ago he even admitted to checking several patients clits for a baseline for T but he said he doesnt do it anymore because its uncomfortable or has a (female) nurse do it if he feels its necessary.i still dont have an answer im afraid i gave consent that day under false pretenses i feel strange just leaving this alone even though i dont think he had any ill intentions.should i ask for another opinion? or am i making this a bigger problem than it is?

Output: Sounds like they were assessing for clitoromegaly and they werent very sensitive to your needs or reading the room. I dont think this is common for FTM physical exams, especially when youre displaying signs of hyperandrogenism.What I can say is that my guess is a pediatric endocrinologist is definitely more likely to assess genitalia because they are the ones that first pick up on hormonal imbalances caused by tumors or abnormal genitalia so it may actually be within their scope. I think they were being thorough during a time when trans care was evolving given that they brought a chaperone. If they did a full pelvic exam then that would certainly raise some red flags.I think your being uncomfortable was warranted and I dont think what they did is standard practice. However, Im not sure Id pursue it anymore given that a genitalia exam in some cases might be appropriate. Again, if penetration occurred then Id be more worried. Today, this would typically be monitored by a Gyn as part of a multidisciplinary team.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Trans (FTM) invasive exam at endocrinology visit *repost **is this common practice??4 years ago i had visited a pediatric endocrinologist for my first dose of T after 2 years of therapy. i had done everything i needed to, i was excited, i was desperate the endocrinologist did everything routine blood tests, usual physical examinations during the physical, it was quite apparent that i did have excess hair and signs of hyperandrogenism. the blood work even indicated that my cholesterol was high. the day of my follow-up he had asked me to wear a gown so he can check down there i dont remember ever getting a reason why but he did let my mom stay in the room and brought a chaperone. i was desperate so i let him do it. it haunted me for a while.4 years later. i had learned that that examination apparently isnt routine via my friends and this examination was never reported in any of my records so i decided to give him a call about it to express my concerns. he told me that people who have hyperandrogenism, their clit grows so he wanted to check for signs of that and anything that can indicate for signs of a tumor, that is causing it so that he would order a CT scan if he suspected iti still dont know how a physical examination can make that clear but i felt pressured today so i just agreed just like i did 4 years ago he even admitted to checking several patients clits for a baseline for T but he said he doesnt do it anymore because its uncomfortable or has a (female) nurse do it if he feels its necessary.i still dont have an answer im afraid i gave consent that day under false pretenses i feel strange just leaving this alone even though i dont think he had any ill intentions.should i ask for another opinion? or am i making this a bigger problem than it is?. ### Response: Sounds like they were assessing for clitoromegaly and they werent very sensitive to your needs or reading the room. I dont think this is common for FTM physical exams, especially when youre displaying signs of hyperandrogenism.What I can say is that my guess is a pediatric endocrinologist is definitely more likely to assess genitalia because they are the ones that first pick up on hormonal imbalances caused by tumors or abnormal genitalia so it may actually be within their scope. I think they were being thorough during a time when trans care was evolving given that they brought a chaperone. If they did a full pelvic exam then that would certainly raise some red flags.I think your being uncomfortable was warranted and I dont think what they did is standard practice. However, Im not sure Id pursue it anymore given that a genitalia exam in some cases might be appropriate. Again, if penetration occurred then Id be more worried. Today, this would typically be monitored by a Gyn as part of a multidisciplinary team..


Instruction: What exactly do percentiles mean for pediatrics?I took my two year old for his appointment today he weighed 32.2 lbs/90th percentile and his height was 34.5/63rd percentile.I know this might sound bad, but does this mean my child is on the short and chunky side? Only asking because I didnt mention his diet and the doctor never brought it up except to cut out juices and switch to 2% or 1% milk for him.. but didnt seem concerned with his weight and said his teeth were great.I shouldve asked, but my son was trying to get into everything, it got hectic and it completely slipped my mind to ask

Output: He's on the heavier side for kids his age. He's still taller than average, though, so in general he's just a bigger than average 2yo.Switching to low-fat milk and avoiding sugary beverages are standard things that we suggest at this age, so I wouldn't read into the pediatrician talking about those. That's the recommendation for every kid!

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: What exactly do percentiles mean for pediatrics?I took my two year old for his appointment today he weighed 32.2 lbs/90th percentile and his height was 34.5/63rd percentile.I know this might sound bad, but does this mean my child is on the short and chunky side? Only asking because I didnt mention his diet and the doctor never brought it up except to cut out juices and switch to 2% or 1% milk for him.. but didnt seem concerned with his weight and said his teeth were great.I shouldve asked, but my son was trying to get into everything, it got hectic and it completely slipped my mind to ask. ### Response: He's on the heavier side for kids his age. He's still taller than average, though, so in general he's just a bigger than average 2yo.Switching to low-fat milk and avoiding sugary beverages are standard things that we suggest at this age, so I wouldn't read into the pediatrician talking about those. That's the recommendation for every kid!.


Instruction: The only time percentiles posed a problem for my kiddos was when they were used to detect a head growth problem in one of my kiddos  extra imaging was requested and there was an actual reason for the extreme jump off of the datum points off of the growth curve.Would it be fair to suggest that growth curves and percentiles are used to detect changes in growth?

Output: Yes, that's a good way to explain it. When we're watching from visit to visit, we're looking at the trend in percentile over time.50th percentile would be exactly average, 90% percentile means in a room of 100 kids his age hes heavier than 90 of them.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: The only time percentiles posed a problem for my kiddos was when they were used to detect a head growth problem in one of my kiddos  extra imaging was requested and there was an actual reason for the extreme jump off of the datum points off of the growth curve.Would it be fair to suggest that growth curves and percentiles are used to detect changes in growth?. ### Response: Yes, that's a good way to explain it. When we're watching from visit to visit, we're looking at the trend in percentile over time.50th percentile would be exactly average, 90% percentile means in a room of 100 kids his age hes heavier than 90 of them..


Instruction: low neutrophils high lymphocytes pediatricMy son is 3 years old. Got a ton of blood work for his weight I guess. He's 27lbs. He has high energy and no concerns other than occasional constipation. The blood work came back with low neutrophils 21% and high lymphocytes 71% (which has me sick to my stomach thanks to Google. WBC, RBC and hemoglobin is normal. Hematocrit is low 32.9% with the range min of 34%. His neutrophils absolute is 1.56 which is in range but on the low end of the range that says the min is 1.50. Lymphocytes absolute is in range. All morphology is normal. His ferritin is low at 23 with the standard low being 36. Everything else is normal. They did a lipid panel which I didn't have him fast as no one informed me. And his triglycerides were pretty high at 238mg/dl. He had half a sugar cookie an hour before and I was feeding the other half during his blood draw to distract him. VLDL was high at 48mg. Everything was normal on lipid. Carbon dioxide was low at 17.0mm.

Output: First off keep in mind the percentages always have to add up to 100. So either the neutrophils are low because the lymphocytes are high, or the lymphocytes look high because the neutrophils are low. So he's got one problem, not two. Based on the other values my guess is that it's probably the low neutrophils but I'd have to see the absolute numbers.His iron is a little low but otherwise everything else is normal. Do you have a hard time getting him to eat meat? Because it's likely just dietary.In general, I really recommend against googling labs because it always comes up with scary stuff. Those aren't cancer values if that's what you're worried about. Could be he's fighting off an infection, could be related to a malabsorption issue or dietary deficiency, could just be normal for him.If it were my patient or my child I would think it's not likely a big deal, but would want to recheck at some point in the next few months to see if it changes. Keeping in mind I'm a family doctor and not a pediatrician, so they may have a slightly different plan.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: low neutrophils high lymphocytes pediatricMy son is 3 years old. Got a ton of blood work for his weight I guess. He's 27lbs. He has high energy and no concerns other than occasional constipation. The blood work came back with low neutrophils 21% and high lymphocytes 71% (which has me sick to my stomach thanks to Google. WBC, RBC and hemoglobin is normal. Hematocrit is low 32.9% with the range min of 34%. His neutrophils absolute is 1.56 which is in range but on the low end of the range that says the min is 1.50. Lymphocytes absolute is in range. All morphology is normal. His ferritin is low at 23 with the standard low being 36. Everything else is normal. They did a lipid panel which I didn't have him fast as no one informed me. And his triglycerides were pretty high at 238mg/dl. He had half a sugar cookie an hour before and I was feeding the other half during his blood draw to distract him. VLDL was high at 48mg. Everything was normal on lipid. Carbon dioxide was low at 17.0mm.. ### Response: First off keep in mind the percentages always have to add up to 100. So either the neutrophils are low because the lymphocytes are high, or the lymphocytes look high because the neutrophils are low. So he's got one problem, not two. Based on the other values my guess is that it's probably the low neutrophils but I'd have to see the absolute numbers.His iron is a little low but otherwise everything else is normal. Do you have a hard time getting him to eat meat? Because it's likely just dietary.In general, I really recommend against googling labs because it always comes up with scary stuff. Those aren't cancer values if that's what you're worried about. Could be he's fighting off an infection, could be related to a malabsorption issue or dietary deficiency, could just be normal for him.If it were my patient or my child I would think it's not likely a big deal, but would want to recheck at some point in the next few months to see if it changes. Keeping in mind I'm a family doctor and not a pediatrician, so they may have a slightly different plan..


Instruction: Neutrophils Absolute Your Value 1.56 103/uL Standard Range 1.50 - 8.50 103/uL Lymphocytes Absolute Your Value 5.26 103/uL Standard Range 2.70 - 10.50 103/uL Monocytes Absolute Your Value 0.44 103/uL Standard Range 0.10 - 1.10 103/uL Eosinophils Absolute Your Value 0.15 103/uL Standard Range 0.00 - 0.90 103/uL Basophil Absolute Your Value 0.00 103/uL Standard Range 0.00 - 0.20 103/uL Bands Absolute Your Value 0.00 103/uL Standard Range 0.00 - 2.10 103/uL

Output: Honestly that doesn't really look awful. Mild neutropenia. Not particularly scary.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Neutrophils Absolute Your Value 1.56 103/uL Standard Range 1.50 - 8.50 103/uL Lymphocytes Absolute Your Value 5.26 103/uL Standard Range 2.70 - 10.50 103/uL Monocytes Absolute Your Value 0.44 103/uL Standard Range 0.10 - 1.10 103/uL Eosinophils Absolute Your Value 0.15 103/uL Standard Range 0.00 - 0.90 103/uL Basophil Absolute Your Value 0.00 103/uL Standard Range 0.00 - 0.20 103/uL Bands Absolute Your Value 0.00 103/uL Standard Range 0.00 - 2.10 103/uL. ### Response: Honestly that doesn't really look awful. Mild neutropenia. Not particularly scary..


Instruction: Ascites 4 weeks post-op, acute renal failureUpdate: Over 5L of fluid was drained from my dads abdomen today. The fluid was high in creatinine and consistent with urine. He initially felt much better, but then started experiencing extreme pain, likely from muscle spasms due to the drastic change in his body over the course if only 2 hours. His O2 dropped to 86 due to the pain. He is now medicated for pain and sleeping on and off. We are hoping that his status will improve over the next few days. Thank you to everyone that commented.70M, 6ft even, 205 lbs, Barrett's esophagus, eczemaHistory of heavy smoking decades ago that was reduced to once or twice per day in the 1980s. Uses edibles/microdosing to manage anxiety and depression.Regular medications include acid reducers for well-monitored esophagus and fish oils and supplements for controlled eczema. Very active lifestyle for age including managing half acre yard, frequent 15 to 20 mile bike rides when weather permits, strength training at gym multiple times per week.January 12th, dad underwent robot assisted prostate removal. Lymph nodes were clear and there was one area where cancer had spread one millimeter into outside tissues. No radiation is recommended at this time. He was disharged home with a catheter. The catheter was removed one week later, but about 18 hours after it was removed, he was having trouble urinating and developed severe pain. He went to the ER cathed again. He was determined to have continued swelling in his urethra.A few days later, a cystogram with his surgeon revealed a small tear in his bladder where his bladder and urethra meet. His surgeon said that he expects the tear to heal on its own.My dad was admitted to the ER today for increasing discomfort in his abdominal area with pain and diarrhea. When I showed up, I noticed that his abdomen was visibly distended. CT confirmed ascites. Nothing else to note other than a 2 mm calcification in a kidney and cirrhosis. He is a recovered alcoholic that hasn't touched alcohol in 37 years. Labs shows some RBCs and WBCs in his urine. Also indicated acute kidney failure. BUN 56 mg/dL, creatinine 4.54 mg/dL, eGFR-Cr 13 mL/min/1.73m2.It is a lymphatic leak? Maybe urine leak caused it? If so, what next?

Output: In a patient with cirrhosis and new onset renal failure with swelling by the prostatic urethra, your dad appears to be at risk for urinary retention because of how much inflammation and swelling there is by the pelvis at the neck of the urethra. A simple noninvasive bladder scan can be done at the urologist's office after he voids or is allowed to empty his bladder completely , called a "post void residual". If there is more than 300-450 cc (every doc has their own cutoff) after a reasonable attempt to empty every last drop, he is considered to have urinary retention. This can cause urine to flow backwards and cause backpressure into the kidneys, effectively causing hydronephrosis (which can be picked up on a renal ultrasound (ultrasound of kidneys), or CT scan of the abdomen. Obstructive uropathy is this condition and can be source of renal failureAlso, ascites is not uncommon in decompensated cirrhosis. Make sure your dad is on a low salt diet. Also it is important to check a Complete metabolic panel or hepatic function panel to see his albumin level. Low albumin can contribute to ascites. Your dad could be in what we call hepatorenal syndrome if his cirrhosis is not under control and can lead to renal failure and death.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Ascites 4 weeks post-op, acute renal failureUpdate: Over 5L of fluid was drained from my dads abdomen today. The fluid was high in creatinine and consistent with urine. He initially felt much better, but then started experiencing extreme pain, likely from muscle spasms due to the drastic change in his body over the course if only 2 hours. His O2 dropped to 86 due to the pain. He is now medicated for pain and sleeping on and off. We are hoping that his status will improve over the next few days. Thank you to everyone that commented.70M, 6ft even, 205 lbs, Barrett's esophagus, eczemaHistory of heavy smoking decades ago that was reduced to once or twice per day in the 1980s. Uses edibles/microdosing to manage anxiety and depression.Regular medications include acid reducers for well-monitored esophagus and fish oils and supplements for controlled eczema. Very active lifestyle for age including managing half acre yard, frequent 15 to 20 mile bike rides when weather permits, strength training at gym multiple times per week.January 12th, dad underwent robot assisted prostate removal. Lymph nodes were clear and there was one area where cancer had spread one millimeter into outside tissues. No radiation is recommended at this time. He was disharged home with a catheter. The catheter was removed one week later, but about 18 hours after it was removed, he was having trouble urinating and developed severe pain. He went to the ER cathed again. He was determined to have continued swelling in his urethra.A few days later, a cystogram with his surgeon revealed a small tear in his bladder where his bladder and urethra meet. His surgeon said that he expects the tear to heal on its own.My dad was admitted to the ER today for increasing discomfort in his abdominal area with pain and diarrhea. When I showed up, I noticed that his abdomen was visibly distended. CT confirmed ascites. Nothing else to note other than a 2 mm calcification in a kidney and cirrhosis. He is a recovered alcoholic that hasn't touched alcohol in 37 years. Labs shows some RBCs and WBCs in his urine. Also indicated acute kidney failure. BUN 56 mg/dL, creatinine 4.54 mg/dL, eGFR-Cr 13 mL/min/1.73m2.It is a lymphatic leak? Maybe urine leak caused it? If so, what next?. ### Response: In a patient with cirrhosis and new onset renal failure with swelling by the prostatic urethra, your dad appears to be at risk for urinary retention because of how much inflammation and swelling there is by the pelvis at the neck of the urethra. A simple noninvasive bladder scan can be done at the urologist's office after he voids or is allowed to empty his bladder completely , called a "post void residual". If there is more than 300-450 cc (every doc has their own cutoff) after a reasonable attempt to empty every last drop, he is considered to have urinary retention. This can cause urine to flow backwards and cause backpressure into the kidneys, effectively causing hydronephrosis (which can be picked up on a renal ultrasound (ultrasound of kidneys), or CT scan of the abdomen. Obstructive uropathy is this condition and can be source of renal failureAlso, ascites is not uncommon in decompensated cirrhosis. Make sure your dad is on a low salt diet. Also it is important to check a Complete metabolic panel or hepatic function panel to see his albumin level. Low albumin can contribute to ascites. Your dad could be in what we call hepatorenal syndrome if his cirrhosis is not under control and can lead to renal failure and death..


Instruction: What would cause someone to spiral into acsites when they have not touched alcohol in 37 years? He quit drinking when he was only 33 years old and hasn't had a drop since. He has never had any issues with his liver before.I will put his CT impressions, but I don't recall seeing anything about hydronephrosis.

Output: low albumin levels coupled with changes in portal pressure can cause this too, as can increased salt in diet or from IV fluids he had received during surgery. You mentioned the CT had findings of cirrhosis. Cirrhosis physiology is complex and would need complete liver function panel, INR, Tbili, serum albumin, Na levels to fully evaluate severity

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: What would cause someone to spiral into acsites when they have not touched alcohol in 37 years? He quit drinking when he was only 33 years old and hasn't had a drop since. He has never had any issues with his liver before.I will put his CT impressions, but I don't recall seeing anything about hydronephrosis.. ### Response: low albumin levels coupled with changes in portal pressure can cause this too, as can increased salt in diet or from IV fluids he had received during surgery. You mentioned the CT had findings of cirrhosis. Cirrhosis physiology is complex and would need complete liver function panel, INR, Tbili, serum albumin, Na levels to fully evaluate severity.


Instruction: Thank you. I just got off the phone with his surgeon, and we were able to talk for about 30 minutes. He feels that there is a continued bladder leak and that we are likely to find that the fluid collection is high in creatinine. They are putting a drain in tomorrow and they'll test the fluid. If this is the case, his kidney function is likely not as poor as it appears, as his body is reabsorbing creatinine through his peritoneum. I did ask him to run a liver panel out of an abundance of caution and he agreed.

Output: If that's the case, then this is a Urinoma I believe. Still though a creatinine of 4.54 and BUN of 56 is quite high but you're dad's urologist is right that creatinine can be inflated in this rare but unique scenario. BUN would be expectedly a bit higher if his creatinine were that high but not always. Cystatin C measurement can be another surrogate used to indirectly measure his true GFR. That hole wont repair itself unless the urologist diverts the urine elsewhere and hence the drain is needed. Bladder wont heal if there's continuous flow of any liquid, in this case urine, through the hole.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you. I just got off the phone with his surgeon, and we were able to talk for about 30 minutes. He feels that there is a continued bladder leak and that we are likely to find that the fluid collection is high in creatinine. They are putting a drain in tomorrow and they'll test the fluid. If this is the case, his kidney function is likely not as poor as it appears, as his body is reabsorbing creatinine through his peritoneum. I did ask him to run a liver panel out of an abundance of caution and he agreed.. ### Response: If that's the case, then this is a Urinoma I believe. Still though a creatinine of 4.54 and BUN of 56 is quite high but you're dad's urologist is right that creatinine can be inflated in this rare but unique scenario. BUN would be expectedly a bit higher if his creatinine were that high but not always. Cystatin C measurement can be another surrogate used to indirectly measure his true GFR. That hole wont repair itself unless the urologist diverts the urine elsewhere and hence the drain is needed. Bladder wont heal if there's continuous flow of any liquid, in this case urine, through the hole..


Instruction: Thank you for your input. I feel significantly more at ease. Hopefully, this is truely just the continued leakage. When my dad's labs came through electronically, I was initally shocked and alarmed. Now I feel cautiously optimistic.His urologist us going to mess with catheter sizing and try to inflate the balloon a bit more to put a bit of a stretch and seal up that leak. He'll give it two more weeks to see if the fistula can repair itself before going in for a corrective surgery.

Output: I'd be worried about a bladder leak given the bladder injury. Need to aspirate and sample that fluid before writing it off as simple ascities, imho.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you for your input. I feel significantly more at ease. Hopefully, this is truely just the continued leakage. When my dad's labs came through electronically, I was initally shocked and alarmed. Now I feel cautiously optimistic.His urologist us going to mess with catheter sizing and try to inflate the balloon a bit more to put a bit of a stretch and seal up that leak. He'll give it two more weeks to see if the fistula can repair itself before going in for a corrective surgery.. ### Response: I'd be worried about a bladder leak given the bladder injury. Need to aspirate and sample that fluid before writing it off as simple ascities, imho..


Instruction: They are putting a drain in tomorrow morning, so we will find out what thr fluid is then. I feel extremely frustrated right now that there isn't more of a sense of urgency.

Output: Either the fluid is persistent leak from the tear which seems somewhat likely. The other possibility is obviously cirrhosis with ascites. As a prior heavy alcohol user, long-term smoker likely some degree of poor lifestyle habits (ie dietary) and his age he has more than enough risk factors to develop cirrhosis.Either way, sampling the fluid will give the necessary info

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: They are putting a drain in tomorrow morning, so we will find out what thr fluid is then. I feel extremely frustrated right now that there isn't more of a sense of urgency.. ### Response: Either the fluid is persistent leak from the tear which seems somewhat likely. The other possibility is obviously cirrhosis with ascites. As a prior heavy alcohol user, long-term smoker likely some degree of poor lifestyle habits (ie dietary) and his age he has more than enough risk factors to develop cirrhosis.Either way, sampling the fluid will give the necessary info.


Instruction: My husbands diagnosis. Please help. I posted a few months ago about this and you were all so helpful.Pt: 41 y/o male, former marine, non smoker, very occasional drinker, 170 lbs 60.My husbands official diagnosis is Metastatic renal cell carcinoma, which spread to his lungs. They went in and took the tumor off the kidney (he has horseshoe kidney so he only technically has one) and he was very optimistic about getting it all from that area. Said his body encapsulated the tumor and they didnt see anything else on his kidney. They said there were nodes in his lungs, but that they werent treating and just want to keep an eye on until mid December, then talk about what to do if they grow. The problem is, he is weak and is having trouble breathing.No chemo, no radiation, no immunotherapy yet or maybe at all. Is this normal?His lymph nodes have been so swollen I can see them under his collar bone, and in his neck. Im worried. Is metastatic a automatic stage 4 diagnosis?Is his prognosis good? His oncologist and doctor seem to think so, but they wont really speak on anything early on. They said we would meet in December and talk more then. What do I do now?My husband isnt able to work, and is taking time off from getting his degree. He can barely walk around without being winded. I have picked up extra shifts at work, so I dont get to see him and how hes doing. I just want to know if I should trust what they are telling us, or ask for them to check him again since hes so weak. Help? Im losing my mind.Thank you. I appreciate you all so very much.

Output: Dont wait, call the oncology office now and let them know these concerns, they may need to start other treatments sooner.See a palliative care doctor ASAP. They are experts in cancer pain. Some cancer treatment centers also have anesthesiologists or rehab doctors who are experts in cancer pain.Oncologists are experts in the extreme complexities of treating cancers. There is a lot more to having cancer, and it's best to have an interdisciplinary team.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: My husbands diagnosis. Please help. I posted a few months ago about this and you were all so helpful.Pt: 41 y/o male, former marine, non smoker, very occasional drinker, 170 lbs 60.My husbands official diagnosis is Metastatic renal cell carcinoma, which spread to his lungs. They went in and took the tumor off the kidney (he has horseshoe kidney so he only technically has one) and he was very optimistic about getting it all from that area. Said his body encapsulated the tumor and they didnt see anything else on his kidney. They said there were nodes in his lungs, but that they werent treating and just want to keep an eye on until mid December, then talk about what to do if they grow. The problem is, he is weak and is having trouble breathing.No chemo, no radiation, no immunotherapy yet or maybe at all. Is this normal?His lymph nodes have been so swollen I can see them under his collar bone, and in his neck. Im worried. Is metastatic a automatic stage 4 diagnosis?Is his prognosis good? His oncologist and doctor seem to think so, but they wont really speak on anything early on. They said we would meet in December and talk more then. What do I do now?My husband isnt able to work, and is taking time off from getting his degree. He can barely walk around without being winded. I have picked up extra shifts at work, so I dont get to see him and how hes doing. I just want to know if I should trust what they are telling us, or ask for them to check him again since hes so weak. Help? Im losing my mind.Thank you. I appreciate you all so very much.. ### Response: Dont wait, call the oncology office now and let them know these concerns, they may need to start other treatments sooner.See a palliative care doctor ASAP. They are experts in cancer pain. Some cancer treatment centers also have anesthesiologists or rehab doctors who are experts in cancer pain.Oncologists are experts in the extreme complexities of treating cancers. There is a lot more to having cancer, and it's best to have an interdisciplinary team..


Instruction: He definitely needs to be checked out sooner rather than later, so if the oncologists cant see him urgently then he should still see primary care, or failing that, go to ED where they can check him over and perhaps even do a CT to establish whats going on with his nodes / progression.

Output: Yea an ER doc can check to make Sure he hasnt developed a PE (blood clot in the lungs) which is common and cancer and causes shortness of breath. The CT will also see if the cancer is bigger. Just be sure to go to an ED thats affiliated with his oncologist so they can see the images

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: He definitely needs to be checked out sooner rather than later, so if the oncologists cant see him urgently then he should still see primary care, or failing that, go to ED where they can check him over and perhaps even do a CT to establish whats going on with his nodes / progression.. ### Response: Yea an ER doc can check to make Sure he hasnt developed a PE (blood clot in the lungs) which is common and cancer and causes shortness of breath. The CT will also see if the cancer is bigger. Just be sure to go to an ED thats affiliated with his oncologist so they can see the images.


Instruction: Pts horseshoe kidney would handle it better than an. NSAID for, say, minor pain. But metastasizing cancer pain is of a much higher order. Hell be initially given Norco, probably transition to higher-order opiates via a learned palliative oncology Al pain specialist.

Output: That is an outrageously inappropriate pain regimen for a young person with advanced cancer.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Pts horseshoe kidney would handle it better than an. NSAID for, say, minor pain. But metastasizing cancer pain is of a much higher order. Hell be initially given Norco, probably transition to higher-order opiates via a learned palliative oncology Al pain specialist.. ### Response: That is an outrageously inappropriate pain regimen for a young person with advanced cancer..


Instruction: I agree. I was shocked. Its hard as his wife to watch him suffer. The man never complains, and if he says in hurts, it hurts.

Output: I'm seeing a lot more tylenol/NSAID management for post operative patients (c-sections, hernias, hysterectomies, etc). However we always give narcs for breakthrough. The cancer patients are the exception, particularly the stage 4 ones. They still get non narcotic pain alternatives but that's in combination with narcs.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I agree. I was shocked. Its hard as his wife to watch him suffer. The man never complains, and if he says in hurts, it hurts.. ### Response: I'm seeing a lot more tylenol/NSAID management for post operative patients (c-sections, hernias, hysterectomies, etc). However we always give narcs for breakthrough. The cancer patients are the exception, particularly the stage 4 ones. They still get non narcotic pain alternatives but that's in combination with narcs..