Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I would strongly recommend rainbow over ccf for pediatrics.. ### Response: So to make sure that I have the situation in a nutshell: 3.5 y/o female with progressive weakness, intermittent episodes of loss of tone that are not accompanied by EEG changes, intermittent episodes of darker urine in the morning, and a diagnosis of oligoarticular JIA. Please correct anything that I got incorrect and I have some clarifying questions.-what is the state of her motor function now? Can she run, climb a ladder on the playground, fatigue quickly like walking around a store?-do the weakness episodes seem intermittent, like lasting for a few hours to days, or are they every single day.-does she have unsteadiness when reaching for objects? Having her hand seem to stumble past a cup or fork for example?-does she have any drooping of her eyelids? It would be to the point where the black of the pupil is obscured by the lid or she has to lean her head back to look at you.-following steroid injections did any of her other symptoms seem to get better? the weakness and seizure like episodes.-any family history of children passing away or having major medical issues. Do you, your spouse, or the child's siblings have any medical issues?-any issues during the pregnancy or delivery? Did she have to go to the NICU for any reason?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: According to what I found online, Mount Sinai has the only genetic test for porphyria. Trust me, I had a couple hundred dollars ready to spend on the genetic testing but everyone I spoke to who was versed in this stuff said it wouldnt make a difference. ### Response: TF is going on in here? What is wrong with all of you people? None of you are physicians, I doubt even medical professionals, and even the "best" "written" comments in here are absolute drivel. You are NOT being helpful. You are torturing someone while stoking a House, MD type fantasy.Dear OP, I sympathize with you. Dealing with a sick kid is trying and tough and this awful thread is NOT useful to your mind state NOR your health.A problem I have noticed in my short career has been clear communications to patients. I highly doubt after 4 hospitals, 14 specialists, and however many other physicians and staff that no one has come up with a diagnosis. What does this mean? I bet at minimum you had multiple different teams with multiple different personnel working on your daughter's case. It's possible the primary team wasn't doing their damn job of synthesizing all of the specialists information into easy to understand information and presenting that information to you. Even when we don't "know" what's going on, I can still call something idiopathic (as in I don't know) or I can throw out a variety of possible causes in what we call a differential diagnosis.To everyone saying "gEt GEnEtIC tEsTiNG". That's not even how any of this works. Even if we were to use "genetic testing" this would only confirm the diagnosis, NOT LEAD US TO THE DIAGNOSIS. Even then it is absolutely unnecessary for treatment in this case. Genetic testing is useful when we are performing family planning or working on research on illnesses. To my knowledge, and I'm open to any updates, bread and butter medicine does not YET have the tools to use genetic testing in the fashion many of you seem to think exists..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thats been our understanding. Genetic testing is like the final puzzle piece once all of the other testing is done, and narrows down the list of possible causes. The geneticist said there was a list about 30 things long that he thinks it could be, but wanted further testing before divulging them, which I get.We have seen 4 childrens hospitals but the specialists span. Weve seen 1 endocrinologist, 1 allergist, 4 neurologists, 3 rheumatologists (our new rheumy actually suggested another opinion since she was out of ideas too), 1 GI, 2 geneticists, 1 orthopedic surgeon, and 1 ophthalmologist. They were supposed to be coordinating on a team that diagnosis rare diseases, but when she remained asymptomatic, we held off. We didnt want to put her through anything more if the tests would be inconclusive, under the direction of the team. But red flags have been popping up over the past few months, and theres been a lack of response or a shrug. The atrophy was so bad in the knee last year that she could barely walk. The muscle/tissues/whatever it was never grew back, and she cant walk more than a few minutes. PT is concerned that with the loss of knee support, the ankle atrophy is going to be detrimental. Which is how I ended up here. Her pediatrician finally got neuro to call us and shell now be getting ultrasounds of both legs.I wanted to take a list to her doctor and say could it be any of these?Shes spent most of her life in constant pain, in doctors offices, and its just killing us. I want her to have a normal life, and if she cant, I just want to make it as pain free as possible.. ### Response: The most important thing I can recommend is finding a good PCP to make sure you have a medical home. That doctor should keep track of everything and keep the puzzle pieces together for you. I'm hoping that's already your pediatrician. From what you write, it seems like each specialist is stumped and is each trying to treat symptoms as they see it. Let's say we can't find what is going on, this is what we would be doing anyway. I say if things have been continuing to worsen, you may try another hospital system. I'm partial to Mayo, CHOP, and Children's National. On the other hand, you may have to consider that there isn't much to do but keep her comfortable. Palliative doctor's role are just that, keep people with chronic disease comfortable. That may include working with PTs, pain specialists, and whatever other tricks they have up there sleeves..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 'm not a doctor. Along with a suggestion, I just want to say how sorry I am to hear about your family going through this. I know how terrible I feel when our daughter just has a cold.Because I'm not a doctor, I don't have a diagnosis to suggest, but instead I want to suggest that you start collecting data, lots of data, then find your most analytical friend(s) and get them looking at it. They don't have to be a doctor; they're more likely to work in science, technology, engineering, business or law.What I'm suggesting you collect is literally everything your daughter eats, drinks, does and where she goes, including basic nutritional information what she's eating and drinking - carbohydrates, fats, etc. The same stuff that they put in big letters on most food packages.Along with that, put in what symptoms she had and how bad they were; devise a rating for her day if nothing else, where "5" is "it was a terrible day" to "1" is "she barely had any symptoms at all."This is going to be a complete pain in the ass.If it's a metabolic problem, there's a chance you'll see something like "when she has a high-carb, low-fat diet, she has a bad day" or "when she has a lot of fat, she does great" or some other permutation.If it's somehow an environmental problem, then maybe you'll see that "when she stays at grandma's house she's better than when she sleeps at home" or "if she doesn't go to school, she's better" or "she played in the basement today and she's a wreck."The doctors are clearly missing something, and maybe with some analysis you can find some clues to point them in the right direction. You may have the problem that they've already made up their mind about her and there's no changing it; in that case, you also need new doctors.Best wishes.. ### Response: Posts by unflaired users that claim legitimacy by virtue of professional medical experience are not allowed.If you are a medical professional who wishes to become a verified contributor to this subreddit, please message the moderators with a link to a picture of your medical ID, student ID, diploma, or other form of verification. Imgur.com is convenient, but you can host anywhere. Please block out personal information, such as your name and picture. You must include your reddit username in the photo!We do not accept digital forms of identification..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Rash EVERYWHERE? Please helpHello, so a little background. I am a 23yo F. I suffer from an ED and weigh approximately 80lbs and am 51. I was diagnosed with MCTD, scleroderma, dermatomyositis, and a grocery list of other things, but I feel those are most prevalent to the issues I am having. I also use marijuana regularly as well as vape. So. I moved to MI from MO last summer. Ever since about.. November 2021 I have been having skin issues. The skin is incredibly dry, most spots opened and scabbed and now they hurt and itch. No lotion I have tried (10+) seem to help. I have it on my legs, arms, chest, hip, back, face, behind/in my ears. Ive never had my skin look like this while living in MO. I have seen my PC and I have a rheumatology appointment end of April. I dont even want to imagine how much more this will progress. Does anyone know what this is? Or how I can manage it to minimize symptoms? Im at a loss. Please help! Skin rash. ### Response: Images do not allow us to see the extent and appearance of the eruption. A diagnosis is not possible. You are medically complex and you need dermatology care. I work closely with many rheumatologists and we have mutual respect. I would not count on a rheumatologist to manage your skin..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: What does high glucose in a CSF mean?28, Female, T1D 14 years, 59 165 lbs. I have upper extremity weakness in my legs and arms, worsening over the last year. Cant walk up stairs, all my tests come back inconclusive including genetic testing and nerve (I mean literally I have had an ENTIRE work up- MRIs, X-rays, blood work, neurology, spine clinic, rheumatology) so Im left with getting a triple muscle biopsy and had a spinal tap today. The only result that came from that was high glucose CSF and I cant find anything about what that signifies versus the low glucose.ETA: additional test results just came back showing high wbc and rbc in the fluid.. ### Response: Generally we're looking for low glucose in the CSF, as that's a sign that bacteria may be in there. There's usually a ratio between CSF and serum glucose (CSF is about 60% of serum), so I'd wonder if your serum glucose was just on the higher end when you got the LP done due to your T1DM..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Good to know. Im sure Ill hear back Monday, but additionally seeing the high WBC + RBC in the fluid made me nervous.. ### Response: How high for each?Reply Wbc 13, rbc 16.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: My Arms Are Turning Blue, Please HelpTL;DR: I removed lab values, as they are no longer the most recent. I have normal skin underneath, to my knowledge, my skin just sheds blue - unaware as to why. I have neurologic and gastric issues, like already stated in edit one, so no need to retouch on that, just briefed about a new procedure I didnt know was going to be requested. I will update about the (dead) blue skin, the literal reason for the post in the first place, if ever discovered.No confirmed, or believed hematologic issues. I only shed blue skin? My skin recently came off, and its pink underneath like it used to be, for some reason it just comes off in blue heaps (random dead skin, I assume, but unsure as to why the color is blue). The veins are extremely bright, but thats about it underneath, I believe. I already have eczema/atopic dermatitis, I know that, but this still confuses me because it doesnt appear to be that. I plan on seeing my derm soon just in case.I thought Id add this information, only to discuss how thorough Ive tried to be, but none of which is the cause for it either. I have a whole host of neurological issues, migraines and OC as listed below, among other newly diagnosed issues, like tremors and possible nocturnal seizures (Im epileptic). Im going to be getting a VEEG done, as ordered by the newly epileptologist I just began seeing. My medications are being readjusted, and a hospital is the only safe way to do so.I also have gastric issues, like I said below.Bottom line, thank you all. If I ever figure out why Im shedding blue skin, Ill make sure to share.TL;DR: I took all suggestions as best I could. I was denied by hematology, rheumatology found no issue despite only slightly abnormal values (mainly NOT severe muscular degeneration that Ive now been made aware of, it didnt alarm him like I said), EKG and EEG requested are both normal. There have been newly diagnosed neurologic issues, but easily fixed with botox.Edit: Thank you to everyone who suggested various things that it could possibly be, and please know that I took your advice, both from this post, and the follow-up one I made awhile back, that Ive since deleted. Here is the in-depth follow-up that some had asked me to provide.Hematology: I was denied by two different hospitals, even though I had a thorough PCP referral, as both places said my issues werent possibly blood related. There were no other hematologic options in my area, so I decided I needed to move on from hematology completely, because I wasnt getting anywhere. Ive not been tested for any hemoglobinopathy as suggested on this post, or any other blood-related issue due to this.Rheumatology: This was the major one recommended on my other post, and I actually just went there a couple days ago after a successful (and surprisingly quick) referral. Despite my leg pain, color-changes and other various issues discussed below, the doctor doesnt believe its anything rheumatology related, either. A physician on the other post I had made, suggested getting a work-up and asking about APS (antiphospholipid syndrome), but I was only tested for possible muscle diseases to my knowledge. I havent received those results yet, but Im sure theyll be normal. Well see.Ive also recently had a redo of my heart echocardiogram done (which came out normal) because the last one was poorly imaged. My most recent (required) EEG was completely normal, but Ive been put on yet another epilepsy medication, unfortunately.The only thing Ive been diagnosed with, since when this was originally posted, has been migraines and occipital neuralgia, which I now receive injections for.Original Post:25F, 185lbs, white, non-smoker, non-drinker.TL;DR: major breathing difficulty, chest discomfort/pressure, (mainly) left leg heaviness/throbbing, odd blood consistency and possibly abnormal values.Hello, Im in quite a predicament. Ive now been labeled a zebra by a vein specialist, because no one can figure out the reasoning behind my current issues.For context, this is now seems to be a somewhat progressive issue, as different symptoms have arisen as time has gone on. I began not being able to breathe well sometime last year, but every time medical professionals take my O2 stats, it never goes below 98. However, its becoming increasingly harder within these last few months, especially taking deep breaths. After having some bad reflux episodes, I was told I had GERD, and then given some medication. However, Ive now been hospitalized twice for my severe breathing issues, both occasions in September, after my GERD diagnosis (and its well controlled/no reflux episodes), so I have a feeling its definitely a separate issue. My chest also feels as if theres a crushing force on it very frequently.I started getting severe leg pain, that made my (especially my left) calves feel heavy one minute, almost like carrying around tree trunks, and then pulsing/throbbing the next. I was scanned for blood clots in my left leg while at the ER, and everything came back normal. The same day I was scanned, a nurse noticed my left arm being a vibrant blue. The ER doctor then pointed out the fact hed noticed that it was also on my right arm at that point, as well. Ultrasounds have recently been done on both my arms, but those results also came back normal.My blood is now starting to be impacted as well I believe, as its appearing to have trouble stopping or clotting quickly. Im not sure if this issue is related to the color-changing or not. My blood will borderline gush out after blood draws/IV site wounds. My RBC has also been consistently high for awhile now, and my MCH and MCV are now dropping again. The values being abnormal arent by much or extremely significant, but Im not sure the reason for the abnormality either (again, reiterating the fact that Im not sure if its connected to the color-changing or not).. ### Response: Except for the bleeding, you're pretty much describing a sickle cell disease crisis. Did you ever have a hemoglobin electrophoresis test?EDIT: I saw the conversation further below. Some common traits for hemoglobinopathies are indeed low hemoglobin, high RBC and low MCV. I'd say you could catch about 80% based on these values (but then, electrophoresis is still required for final diagnosis, or DNA testing for alpha thalassemias). Anemias can be compensated for with high RBC counts. MCV, as in sickle cell anemia, may be normal since the sickeling occurs in the microcirculation at low PO2s.EDIT2:I'll give a short summary of things written below (including personal interpretation of what was written) for any physicians currently tuning in;Summary28F, non smoker, non drinker, not on birth controlFatigueSevere leg pain (excruciating), pulsing, throbbingSevere pain 'everywhere', especially shoulder bladesBlue discoloration in armsOxygenation is fineBoth arms and legs were scanned but no clots were foundNo history for excessive bleeding during surgery or tooth extractionsPeriods were heavy in the past, but no longerPictures could be interpreted as deep-tissue bleeding/bruising, but no discoloration has been described (cave too recent)No weight loss, fevers, infectionsLiver and spleen are normalLabNo full lab results on hemostasis (e.g. PT, APTT, Fibrinogen)Initially high RGB, normal MCV, hemoglobin. Now all three are decliningNormal d-dimer, normal plateletsNo hemoglobin electrophoresis was donePossibilities (in no particular order)(Acquired) Bleeding disorderThrombosisSickle-Hb C diseaseAnxiety...?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I have not, I dont even know what that is.. ### Response: No problem. Would you mind posting your history of values? Mainly hemoglobin, RBC, MCV.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Sure! Im going to hit the hay first since its 6 AM here and I havent slept yet, but when I get up, Ill get my bloodwork out.How do you want me to write it out on here? Like the reference ranges, and then my results?. ### Response: Screenshots are fine too btw.Otherwise, maybe like so? Dates aren't crucial, just give an indication of how far apart (e.g. months between or hours). If there's a missing value in one of the labs, just put a '-' so the values stay aligned vertically.RBC [ref], x, x, x, x MCV [ref], x, x, -, xI'd update your original post, and we'll go from there..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I updated it! I just separated it by the blood test, and it looks kind of chaotic I know, but I tried my best.Ill have to grab ahold of more of my bloodwork at my primarys office soon, so that theres not just three. ### Response: Hmm, these results neither confirm nor refute my first thought. But on seeing the photos they remind me more of deep-tissue bruises.Do they ever go away or change color at all? Was a tourniquet placed on your upper-right arm?Could you perhaps elaborate a bit on your bleeding history? Ever had any surgery or tooth extractions? Nose bleeds? How are your periods?Personally really looking forward to the comments of the hematologist..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Can alpha thalassemias present with normal hemoglobin, but chronically low ferritin? My hematologist suggested my hemoglobin was normal because I burn through ferritin so quickly. Like OP, my specialists have all but thrown in the towel after four years of treatments (for a diagnosis that has now been thrown out - Von Willebrands 2M).I have had high RBC and low MCV, normal HCT and HGB, low B12 and D (take weekly injection of the former, high dose oral supplement of the latter). Ive had two iron transfusions ~4 years ago. I can provide complete blood work for the last four years if that would help.. ### Response: Hemoglobinopathies (like thalassemias) produce red-cells that have a shorter life-span than regular 'normal' red cells. So yes, there is a high turnover and therefore higher demand of nutrients. However, there are other explanations as well. If you like further exploration I would suggest you make a new thread? Results from the last 4 years would give a tremendous head start..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I updated D-dimer and platelet results now that Im home to see my bloodwork. I apologize I keep replying, but since you made the list, I thought Id let you know, in case you end up not seeing it.. ### Response: Do you have a picture of your blue arms? Is it al over? Are the blue areas painful or itchy?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Theres a small sliver, same area on both sides, that is my pale skin. The rest of my arms are completely blue. Im currently trying to link photos, but I still am in the process of deleting photos, so that my already filled up iCloud storage will allow me to actually create a link lol.. ### Response: Would be really useful to see a picture! (Once youve had some sleep).


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Dont link through your iCloud to avoid being doxxed or anyone with nefarious intentions causing you more trouble.Edit: create an Imgur account (takes 2 seconds) and link. ### Response: Are you on any medications, otc stuff, supplements? Lots of exogenous substances can cause blue pigmentation (colloidal silver, amiodarone, minocycline to name a few)..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I put the data in that I was asked for, but I can totally do the whole thing, if you think itd be helpful! Quite a bit of my results are online, though, so Ill probably take some screenshots. Ill add it in the post too, once I do.. ### Response: Screenshots would be fine (and probably easier) as long as its readable..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I put it in my post! Theres a lot of screenshots lol, so beware, but its every test result Ive received most recently (September 11th).. ### Response: Is it just your arms that are blue? And the right started before the left?QYes, just my arms. The left one started turning blue before the right one, its the blood oddity that started in the right. My lips used to also occasionally turn blue months and months ago, but now its strictly my arms.Sorry it took so long to get back to you things have been crazy on my end with covid. Ive been thinking a lot about your case over the last few days. I think its really strange that its only your upper extremities that are changing color. Please keep an eye out for color changes on your legs or other body parts. Typically when there is some form of differential cyanosis (one part is blue and others arent) we think of cardiac defects and if its one specific limb poor perfusion. But given your age and normal echo a cardiac defect causing your symptoms is unlikely. My next best guess would be something like pernicious anemia/B12 deficiency. This could explain your developing anemia and some of your pain symptoms. The blue coloring could be due to easy bruising related to it. However given that you have microcytic anemia (small red blood cells) and we typically see a macrocytic anemia (big red blood cells) with pernicious anemia/B12 deficiency. But that doesnt necessarily rule out that as a cause for you symptoms. To evaluate this you would start by checking b12, folate levels. Like other have mentioned you could have a hemoglobinopathy causing the cyanosis and anemia which would be more consistent with your microcytosis. However I would have expected this to show up before now, have some known family history of anemia or bleeding disorders, and/or have cyanosis or bruising on more of your body than just your arms. My best guess would be some kind of vasculitis causing vasospasm in your arms giving them a cyanotic appearance. The vasculitis could also be causing the pain you experience in your legs. Your developing microcytic anemia could be early anemia of chronic disease with maybe a pinch of iron deficiency thrown in. Id recommend asking for a ferritin and iron level to evaluate the anemia more. In terms of vasculitis workup, its a bit out of my wheelhouse so Id recommend considering seeing a rheumatologist for further evaluation. Those docs typically (or at least the ones I have worked with) are more of the safari guides than other docs and specialize in zebras.Tl;dr: Possibly a vasculitis, consider rheumatology. Also could be B12 deficiency/pernicious anemia or hemoglobinopathy but less likely due to nerd stuff as above.*edit: Like to add that you should probably also consider seeing a hematologist as well if you havent..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you! I appreciate all this information greatly, and I will definitely take the advice. Im sorry things are bad with COVID right now, honestly I couldnt imagine what its like to be a doctor during this pandemic. Ive already had it myself, and my mother almost died from it. Its nasty stuff. Im praying for all of you.I went to the doctor today (my primary), and Ive been given a referral to hematology and cardiology, as most of my previous heart echo was suboptimally imaged and apparently the cardiologist remarked several times that he couldnt see hardly anything. Were making 100% sure its not my heart first, and then were going to hematology because Im having extreme bleeding issues again. I had blood drawn today for a new PT and PTT also and the tubes were filled up within seconds. The phlebotomist even remarked on the situation, and my blood appears to be almost the consistency of water. I was born at the hospital Im going to for hematology, so maybe there can be some connection if possible. Also, apparently on my last echo, it was remarked as me having trivial to mild mitral valve regurgitation but Im not quite positive what that is anyways, or if it is even something to question.Ill definitely be hitting up rheumatology next, especially if these dont pan out.. ### Response: Mitral valve is valve on the left side of your heart. The regurgitation means it leaks a little allowing some blood to flow backwards. I wouldnt think much about trivial to mild mitral regurgitation especially if it was a bad echo. I hope you find your answer. Please feel free to DM me at anytime if you have questions or concerns. Always happy to help.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Rheumatology- [49][female] Methotrexate and ColdMy mom is a patient of La county hospitals but does/t have a PCP only a specialty clinic doctor that she sees every 3 months so Im hoping to get some advice. She recently got a cold this past weekend, she tested for covid and had a negative result. She has a cough and is taking Acetaminophen from OTC. She is due to take Methotrexate today due to her Lupus treatment for her flare. Her doctor recently increased her dose to 10 pills weekly which I understand to be an immunosuppressant. How does this affect her if she has a cold? Should she skip until she gets better?. ### Response: That's a spectacular question,I wouldn't panic, I don't think it's radically dangerous but this does merit a phone call to the doctor's office. It's important and should be answered by someone who understands her particular history with lupus quite well.I say don't panic because it is not radically uncommon for people to take immunosuppressive drugs when they are in fact sick with an infection, that is the whole basis of taking steroids(the most iconic immunosuppressive drugs) when you have covid, it's looked at like a double-edged sword. So that's good with bad. In theory it could make her cold much more intense and last much longer than it would in a normal person .I don't know how bad her lupus flare is and if that's going to hurt her more withholding the drugs; or how bad her cold is, and if she's really going to fall apart, so I will refrain for making an explicit recommendation.I recommend you get this specialist to give the recommendation, but either way giving it or holding it, she will probably be okay for the meanwhile..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you! I feel much less panicked now. Ive tried getting a hold of her doctor but have not able to. Ill continue trying. On the lupus thread, Ive also seen that others have been told by their doctors to skip methotrexate when they had a cold. Ill let her know to skip and take it next week, when shes hopefully back to her normal self.. ### Response: I think that's probably an OK decision. Not my decision. I don't know her..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Chest/Neck CT/PET in preparation for lymph node biopsy for neurological/rheumatologic(?) symptoms, also showed lung nodule?Hello everyone! I just had a chest CT and neck CT with contrast to evaluate lymphadenopathy of the neck as well as potential lymph node activity of the chest, and to move towards a lymph node biopsy.This is what was found so far (also had an ER ultrasound showing multiple mildly enlarged lymph nodes in parotid, submandibular, levels 1 and 2 no fatty hilum)-Multiple nonenlarged reactive appearing cervical chain lymph nodes bilaterally. Asymmetric 0.9 cm left level 5 and 4/5 nodes, with preservation of the fatty hilum, likely reactive. Subcentimeter right retropharyngeal node similar to the recent cervical spine MR, with an elongated reactive appearance.My ENT, advised by the rheumatologist I am seeing, was somewhat hesitant on doing the biopsy before having a PET scan done because she stated a biopsy would interfere with a PET/CT for 12 weeks afterwards. The PET scan was recommended by the rheumatologist, as we do not have solid leads for the issues I am having and per his words can collect more sensitive data. I have symptoms progressing by the day, and would like to go ahead with the biopsy and forgo the PET scan also because of the high radiation dose. My questions are, does a biopsy really impact PET results for so long, and would it make sense to perform? Can I request the biopsy first instead? Also, would an excisional biopsy really be needed over a core needle biopsy?The CT also found a 4 mm right lower lobe nodule adjacent to pleura image versus subpleural atelectasis. Should i be concerned about this nodule or its location, and could it represent a rheumatologic disease process?I appreciate any advice! I am a mystery case to all the doctors I have seen and feel completely utterly hopeless.28F, 57, 172 lbs, Asian, No drug use or smoking of any kind, Current Medications include Levothyroxine, estrogen, and progesteronePrimary Issue- Multi system wide involvement including neurological, dermatologic, possible rheumatologist, endocrinologic- Severe neurological presentation of symptoms beginning as constant left-sided facial pain, progressing to tingling and cold, then constant numbness and deadness of sensation in peri orbital area, decreased corneal reflex, whole cheek, down to jaw, and through lips, combined with massive headaches in occipital temple and behind the eye, feels like face is falling off face and sagging. Loss of muscle in face and body as well as muscle twitching/pulsing in top and bottom eyelids (right and left) constant muscle twitching/aches/pain in random muscles throughout body. Recently spread of pain in parotid, submandibular, occipital, ear canal, left neck, supraclavicular areas with associated mildly enlarged and reactive lymph nodes, mostly on left but also bilaterally. Very recently tightness, compression, and loss of sensation in left front of foot and back of left calf which is still present.Many other non-neurological symptoms, have seen 60+ doctors.Duration: 2 years of worsening symptoms.. ### Response: Reactive lymph nodes are usually from some infection or inflammation and biopsy will likely not be helpful. Id say go for the PET first. The lung nodule does not seem worrisome. PET once again may be helpful to see if it is metabolically active.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Positive ANA test 1:1280, whats next?Hello im F 24 i weigh 110lbs and am 51 Ive been on a four month journey of trying to figure out whats wrong with me, had an oncology appointment recently as my physicians were suspicious for a lymphoma or leukemia. Had an ANA test along with a myriad of others and it came back positive 1:1280 speckled pattern. im being sent to a rheumatologistIm wondering what are the different things that can come from this positive test? and are petechiae something that happens with autoimmune diseases?ive had widespread lymph node swelling, with some hard immovable ones in my neck and underarmsdaily feversnight sweatsweight loss 10lbs in four monthspetechiae and bruisingred bumps in areas of lymph swellingfacial flushingburning sensation on skin face, neck, shoulders, armswidespread intense itchinessextreme fatigue, weaknessdizzinessupper abdominal pain & hip/lowback painand migrating pain that feels like growing pains in my bones throughout my body. ### Response: Could be lupus, maybe Sjogrens. Both can look like lymphoma and cause most of the symptoms youve listed. Rheum will test a battery of inflammatory markers, immunoglobulins and antibodies for a specific connective tissue disease (CTD). Many CTDs can cause petechiae and purpura due to vascular fragility and small vessel vasculitis. It can take some time to make these diagnoses..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Blood work off after MTX. Should I hold the next dose until Rheum consult?30F non-smoker 147 lb 5ft 2in tall, years long history of rheumatoid symptoms and indicative blood work. My degree is in clinical nutrition which means unfortunately I understand the basics of my blood work but am not sure what to do with it. My rheumatologist is out for a week.After 7 weeks of 10 mg oral methotrexate weekly with absolutely no contraindicated medications (sulfa, alcohol, etc) my blood work has come back. I'm just hoping for clarification on if these results are expected with methotrexate, or if I may want to hold a dose until Rheumatology is back in office next week.Creatinine has dropped to 0.51 and was 0.70 prior to treatment. BUN has risen to 24 and was 17 prior to treatment. CRP at 1.4, was 1.3 prior to treatment.If I can ask for any input just to ease my mind, I'd really appreciate it!. ### Response: I would not worry about these labs. They are inconsequentially different from prior.For your information - Creatinine is a measure of how well the kidneys are working. We worry more about kidney injury when it is high. BUN is not as specific and should be interpreted in the context of your creatinine. Your CRP is basically unchanged.Your rheumatologist would likely go more based off your symptoms in adjusting your meds, they are probably monitoring side effects of methotrexate so looking at blood counts for signs of low counts and liver function tests. Methotrexate is cleared through the kidneys so if there was a major change in your creatinine it may prompt a dose change. CRP and ESR are inflammatory markers that will be trended.Hope this helps!.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Should I see a Rheumatologist?Hi I am 26F, 150lbs, currently only taking hormonal birth control (sprintec). I have been dealing with recurring hand and arm pain for the past four months or so. I'd estimate since the end of January 2023. It started as a sort of tingly feeling in my fingers with some pain around the proximal interphalangeal joint in all 10 of them. I wouldn't describe the tingling as numbness exactly, as it's not the pins and needles that others use to describe it, but it is constant. The pain is in both hands, but my right hand is worse as that is my dominant hand. As there is no specific moment I can remember when this started, I thought this might have been carpal tunnel or some other overuse injury from spending time knitting & crocheting as well as being on the computer 8-10 hours a day for my job/fun. I stopped knitting as much and when it didn't get better around a month in I stopped knitting completely. The pain does get worse when I use the computer and my phone so I am trying to limit the use of both and I have already switched to using a vertical mouse which didn't seem to make a difference. Specifically when I click the mouse with my right pointer finger I feel a pinch between my ring and pinky fingersI went to an orthopedic hand surgeon who said that he didn't think it was carpal tunnel as those are unusual symptoms for it and even more unusual to be experiencing the pain in both hands. He took X-rays that he said looked normal, and he ordered a bunch of blood tests for me including one for Rheumatoid factor. He also prescribed me physical therapy after I complained about still being in pain. The physical therapist did a bunch of intake tests that showed my grip strength and other strengths were on the low end, but normal and he seemed stumped on how to help me. After 3 sessions of in office physical therapy I did not seem to get better and if anything it's worse. As I now feel regular pain up my arms around my forearm and triceps (feels kind of like a tight stretching) in addition to the pain I described earlier. Also in the last couple of weeks I've experienced actual numbness in both of my pinkys, on seperate occasions. For the record I wasn't as diligent with the PT as I could have been, ie sometimes I would do exercises only once or twice a day instead of the recommended 2-3 times. I was diligent about the heat he recommended though.My blood tests came back all negative so the doctor said that he's at a loss, suggested I maybe make an appointment with a rheumatologist and prescribed me a 4mg medrol dose pack as a last ditch effort. During and after the prednisone I didn't really notice a change in pain levels. That coupled with the negative Rheumatoid Factor suggests to me that maybe there is no inflammation causing this? But I know that seronegative rheumatoid factor exists, hence why I'm now asking on reddit. Does it seem like this could be RA? Would it be worth it to go to the Rheumatologist for this? Was my doctor just wrong and it is some kind of overuse injury and I should just try a new orthopedic doctor? Maybe someone less specialized in the hands because the physical therapist suggested it might be a spinal issue since the pain is traveling up my arms. Should I just give up on doctors and try to be more diligent about the physical therapy on my own?For the record here are all the blood tests I got:CBC W/PLAT AUTOMATED DIFF - Only showed I have a slightly low red blood cell countANA PANELSEDIMENTATION RATEC-REACTIVE PROTEINRHEUMATOID FACTORURIC ACIDHLA-B27 ANTIGENCYCLIC CITRUL PEPTIDE ABSANACHOICE(R) SPECIFIC ANTIBODIES W/RFLX TO DSDNA. ### Response: Picture does not sound rheumatologic to me. In addition to the negative labs and imaging, most patients have relief with steroids on initial diagnosis of a rheumatologic condition. This tells me what is going on is unlikely autoimmune or inflammatory.Some ideas and thoughts on things that can cause pain/tingling/weakness in the arms and hands that I do have are have you ever had any neck trauma or whiplash? Has your B12 and thyroid been checked? Do you have any history of migraines?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: No neck trauma or whiplash and I'm not sure my B12 has ever been checked. I went to an endocrinologist last year because I found out I had a high level of thyroid peroxidase antibodies (166 iu/ml) after testing for a seperate concern, but my T3, T4, TSH were all normal so she said to come back in a year. I hadn't thought about it because the endo seemed very unconcerned, but do you think that could cause this?Also no real history of migraines, I remember I had 2 around when I started puberty and haven't had one since. My (older) siblings do occasionally have them though, not sure if that would matter.. ### Response: Hypothyroid can certainly cause some real muscle pain, joint pains and parasthesias (tingling in hands/feet). As a matter of fact, carpal tunnel syndrome is a common neuro symptom of hypothyroidism and is often reversible with thyroid hormone therapy.Get your thyroid checked. Id still also check B12..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 69M - prostate cancer? - what to expect?Hello, this is concerning my father (69M). He's 6'3" and about 15st. Anatomically this concerns this prostate, and geographically we're in the United Kingdom.He is a moderate regular drinker (2-3 small glasses wine most nights) but has never taken recreational drugs. He used to smoke but quit about 35 years ago.He has mild asthma and chronic sinus issues caused by nasal polyps that cause total nasal obstruction. He is awaiting followups for a cauterising surgery, but this seems unrelated.As part of routine bloods, my dad got a psa test about a month ago, which came back at 13.3, which is obviously elevated.His GP hasn't seen him in person and hasn't carried out a rectal exam, but instead referred him to urology. His urology referral was a telephone consult to tell him that he was being booked in for an MRI.He had the MRI (with contrast) last week and today was told that there was something suspicious on the left side of his prostate, and that he would need a biopsy. He hasn't had the biopsy yet.I understand that this is all geared towards a prostate cancer diagnosis, and I understand that at this stage, prostatitis is unlikely. All the clinicians with whom my dad has spoken have been very reticent when he has asked about cancer, but simultaneously tell him he might need a bone scan based on the outcome of the biopsy.I'm under no illusions that prostate cancer is high on the differential, but could benign prostatic hyperplasia still be on the cards? I understand that both conditions are diagnoses histologically, but it would be helpful to know whether PC and BPH look distinct on images?For background info - he has no urinary symptoms but has been losing weight steadily for about 3 years (maybe 4st in 3 years?). Assumption has been that he hasn't been eating much because his nasal polyps have robbed him of his sense of last largely. He also lost his wife (my mum) to breast cancer six months ago. He can't cook and eats rubbish, and also likely has depression.Any insight here would be useful in terms of differentials, outlook (based on the vagaries I've provided) and generally what to expect. I definitely feel that no clinical has been forthright with my father thus far. That's no criticism of the docs, but it hasn't helped him and has compounded his stress as he's gone straight to Google and catastrophised.. ### Response: Urologist. Impossible to provide much advice since he hasn't actually been diagnosed with prostate cancer and there are many nuances depending on what type / grade / stage of prostate cancer we are talking about. Certainly a chance you can have an elevated PSA and no prostate cancer even with an MRI. Only way to find out is biopsy. Results of that would determine what needs to be done.If he does have prostate cancer it is almost certainly localized to the prostate. Options would then be surgical prostate removal, radiation, or surveillance and waiting. Obviously I don't want to go into these with out a proper diagnosis. Biopsy happens in the office, takes about 15 min. Results take a week or two to come back..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: [Urology] 27M, Pee drops "leaks" after peeing. Embarrassed to visit a doctor.As the post says, I am 27M. After peeing few drops of pee leak out after peeing.As a "solution", i "rub" my penis to move any pee in the canal outside. I do it even from behind the testicles. However recently, it seems even that doesn't work out. As i still get few drops of pee afterward, especially when i sit down.I wanted to go to a doctor, however i am extremely embarrassed. And I am not even sure if there is anything that can be done at this point.The thing is: the reason i believe this is happening, is because when i was a kid, i inserted a thermometer in my urethra, it was deep enough that i felt it penetrating something and pee came out.However if i recall correctly nothing really changed after that incident and this leaking issue started happening about 5 to 8 years ago.. ### Response: To put your mind at ease, there is a VERY low likelihood that these issues are secondary to your "self-exploration" event that you journeyed on when you were younger. Additionally, there's absolutely no reason to be embarrassed about this. This is what us physicians do on a daily basis, and we do what we do because we love to help people (most of us, that is). And I promise, for every "embarrassing" event you think you might be bringing to the table, I guarantee all of us have seen much, much worse. But again, there's absolutely zero shame in what you're going through whatsoever. Get a referral to a urologist from your PCP; all they focus on is genitourinary tract issues, and they should hopefully be able to help you find an answer to what's going on..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Piggybacking... had this start happing to an extent sometime in my 30s or 40s, and figured this was just attributable to aging... Would a urologist visit typically be warranted if there's no other symptoms or related trauma that could have caused it?. ### Response: It's true that many men will develop these types of symptoms later in life due to something called BPH (benign prostatic hyperplasia), which is essentially when the prostate grows too large and starts "pinching" the urethra closed, which subsequently may lead to symptoms such as difficulty starting a stream or completely emptying when they go. However, your 30's is way too early for this to begin occurring. I would start with going to your PCP first so they can do a physical exam and ask more questions, and then they can help decide whether or not a urology consult is appropriate for you..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Cystocele76 old woman. Her nurse practitioner diagnosed her with cystocele. What kind of doctor would be the right doctor for cystocele? Would gynecologist be better option than an urologist since the patient is a woman?. ### Response: Luckily you don't have to choose: there are urogynaecologists out there, which are gynaecologists who specialize on urological and proctological issues in women. I'd go to one of those..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Does OB/gynecologist fit that category? Medicare physician finder doesn't even have the doctors category of urogynecologist on their web portal.. ### Response: Ah, I see. Sorry, I'm not in the united states. It's the right type of doctor, yes, but it doesn't tell you their sub-specialisation. Maybe look the ones you find via the portal up on the internet or call their office?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 27m - Urology/Andrology Question - successful Penile vein ligation and shockwave treatment contra indication? What happens to ligated veins ?Hello to all,I have been diagnosed with severe organic erectile dysfunction and am using PDE5I, injectable PGE1 (Alprostadil) and sometimes alpha-1-antagonists (doxazosin).I am suffering from organic erectile dysfunction and had a successful dorsal vein ligation (3 years ago - superfical and deep dorsal vein as well as two ectopic veins (which helped me to get erections with medication).Even though shock wave treatment might not be very promising I still want to try it and as I happen to live in a country where it is comparatively cheap I am about to do 10 sessions in 5 weeks.But I fear that it might "unblock" the vein ligation ?Hypothethically speaking - if the ligated veins where freed from their suture would they pop open again ? Or is there scar tissue built up which will continue to block the vein ?I fear the shockwaves might damage the "suture". Since I cannot happen to find information about that online maybe someone can help me out.Thank you and best,. ### Response: The suture themselves dissolve after a while. So 3 years later the veins are closed by scar tissue. Also, when a blood vessel is surgically closed, a longer segment of the vein eventually becomes "clogged". Sounds very unlikely that anything could break them open again, even if they should deliberately try.So I don't think you should worry about this specific complication. There's probably a lot of other possible complications though, I don't know much about this specific shock wave procedure. Sounds very experimental though. Do you know how it's supposed to help for ED?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Constant 9/10 flank pain Female 31Hello fellow people of reddit. I hope you are all doing better than I am currently.Overview: I had my first set of kidney stones in may of 2022. I had another set in July of 2022. In December of 2022 I started having constant pain in my flanks. Ive been to the emergency room several times since then. Ive seen urology, Ive seen my pcp, Ive seen the pain clinic, Ive seen a nephrologist. I have bloods done frequently as well as UAs. Ive been ignored and sent home every time when I seek help. Otc meds dont work and the narcotics just make me sick. I feel like Im going insane. Im Im so much pain on a constant basis. My mental health is starting to tank because of this. Any advice would be appreciated.I do have hypercalcemia, and hyperparathyroidism, and my nephrologist believes I could also have necrosis in my kidneys.I am 31, obese, 5 foot 3 inches tall. I have never smoked, dont drink, dont do drugs other than weed in gummy form every now and then.Current Meds are:Concerta, Propranolol, Losartian, Amlodipine, Nebulizer, Quvar, Alb inhalerHere are my most recent labs.UA:https://gyazo.com/d5f6f1fc96058f29dd17ea6d2e3126f9https://gyazo.com/fca06118e1b739c171942f1b3050492fCBC with Auto Differential:https://gyazo.com/940243c0ec3bb61963388832f51c2bd0CMP:https://gyazo.com/2586ac67b7574917dcb76db00ddf78ae. ### Response: The fact there is calcium oxalate in your urine, plus blood +++ indicates there may be a stone in the process of breaking up, and this is what is causing the pain for you (especially if you have a history of kidney stones). Looks like a slight UTI too, which isn't going to help..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thats what I said, but the only stone they can see is, according to them, no bigger than a grain of sand. The doctor I saw last night also said that I didn't have a UTI. I've had the crystals and blood in my urine every single UA since December.. ### Response: You don't have a raging UTI and your culture is negative from what I can see. But there are white blood cells in your urine, and bacteria (though no leucocytes/nitrates, which tend to be the classic uti markers). Plus, a high number of epithelial (skin) cells, which indicates sample contamination. So, not anything that warrants treating.And yes, kidney stones can literally be a grain of sand size and cause utter havoc..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Man, I wish the doctors here would understand that. Because every time Ive gone to the ER (which is a lot unfortunately because I cant deal with the pain and otc meds don't work on it) they just tell me Im being dramatic and to go home.. ### Response: I'm sorry to hear that. When I come across patients with pyelonephritis/renal colic etc, they tend to benefit somewhat from hot water bottles..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: My heating pad does help to a degree. Sometimes, it helps enough that I can sleep or do whatever it is I need to. And sometimes it does nothing.. ### Response: Do you have any imaging? Does the pain come and go? Where is it located? Is it the same as when you had kidney stones? What therapies have you tried, what did urologist say about the pain?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Nephrology says it's probable stones and/or renal papillary necrosis.s.ne. There's a constant dull ache and then like a colicky pain that gets really bad really fast. It feels very similar to past kidney stones. The pain is on both flanks and spreads to my side right above my hip.I've had a couple of CTs. The last one showed at least one itty bitty stone. There's a constant dull ache and then a colicky pain that gets really bad really fast. It feels very similar to past kidney stones.I've done heat, cold, narcotics, NSAIDS (which the nephrologist said to stop) Ive done physical therapy, exercise, and stretching.The urologist says he didn't see anything and that I'm being dramatic.My PCP says there is something wrong and to see urology.Nephrology says its probable stones and/or renal papillary necrosis.The pain clinic says Im being dramatic. ### Response: I agree that NSAIDS and opiates are not the way to manage this, and I believe your pain you are not "dramatic".How high is your calcium? Your hyperparathyroidism is possibly the most crucial thing to get under control. Chronic hypercalcemia obviously predisposes to stones, but also to a disease called nephrocalcinosis which can be painless but sometimes causes marked pain as small rocks of calcium get lodged in the draining portion of the kidney.The other not mutually exclusive possibility is you are having ureteral spasms, which are associated with hyperparathyroidism and hypercalcemia but no stones.So it is crucial to get your hyperparathyroidism under control. Even with "normal" calcium this can cause kidney problems and with hypercalcemia can cause kidney failure. If this is already under control then possibly it will get better once the ongoing calcium deposition improves. Dietary changes can also decrease calcium deposition, your nephrologist can advise on these.There are several medications available that are somewhat helpful for ureteral spasms including oxybutynin and tamsulosin but would focus on the underlying cause..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: My calcium bounces between 11.5 and 13.5. I have surgery to remove the overactive parathyroid glands at the end of next month. It was supposed to be this month but the hospital broke a needed machine the day before it.I will have to looked into the nephrocalcinosis, I haven't heard of it before.. ### Response: Holy smoking gun batman.Yes I suspect this surgery will help tremendously with your pain. If it was delayed long you should have been on a calcium lowering agent, though likely a little late to start now..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Fun fact my endocrinologist told me to take calcium and vit d.Im really hoping the surgery helps because I might just loose my mind if it doesnt. My calcium has been like this for about three years but I was always told it was fine until recently.. ### Response: I don't know the details so I can't really assess what is going on here, but in general we wouldn't let someone be that high for that long. Surgery is usually done fairly early and if not medical therapy offered, targeted at lowering not raising the calcium..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Unfortunately, I had a pcp that seemed to believe that everything was either due to menstruation, things I was doing, or that it was due to my low mental health or that I was lying. But he was the only one my insurance would cover. As soon as I switched doctors I got referrals and scans and procedures but that only happened in November of last year.The Ed always said it wasnt that high and it wasnt something to worry about.. ### Response: The ED is never going to treat hypercalcemia or really any chronic problems. It isn't acutely life threatening unless very high so not on their radar.They aren't mini-PCPS.Unfortunately people have poor access and get stuck in the ED visit spin cycle with care never moving forward. I think you are on a goodish path now though..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: The case of the constant invisible urine flood: neuro? Psych? Other?This is a bizarre one, so Im hoping for any ideas here.Pt (family member) is an 80 year old female residing in an assisted living facility with hx of benign essential tremor and recent dx of possible Parkinsonism (tremor, left side more than right. A&Ox4; No signs of dementia; MOCA 7.1 score 28/30. More hx and meds below) About three months ago, pt c/o urine constantly running down my legs. She reports that her clothing, shoes and socks get soaked with urine, to the extent that she leaves wet footprints when walking, and smells urine strongly in her room and on her clothing. She has been wearing adult incontinence briefs, but reports that the urine bypasses these briefs.Heres the problem. Family, caregivers, physicians, nurses, and therapists cannot see, smell, nor feel the urine. When pt says her pants are soaked, they appear and feel dry to the touch. Incontinence briefs also feel dry, and there is no sign of urine on pts bedclothes or clothing. She recently spent two weeks in an acute care hospital and another two weeks in a rehab hospital, and in that time, only one instance of urinary incontinence was noted and that was on admittance when it had been some time before she could be seen.She has seen a neurologist who prescribed Sinemet (carbidopa/levodopa) for her tremors. The neurologist mentioned that Sinemet can exacerbate incontinence, but didnt really address pts insistence that she is constantly having urine flow that soaks her legs and shoes but somehow bypasses the incontinence briefs leaving them dry.She has seen a urologist, who prescribed a bladder training regimen and voiding journal, but a bladder scan showed she is emptying her bladder just fine. Labs show no sign of UTI or other infectious or inflammatory process. Urology suggested this was more likely a sensory issue than a urology issue and referred back to the neurologist.Pt insists that her fellow assisted-living residents can also see and smell the urine, and has reported that she believes the caregivers are lying about not seeing it in order to be polite.Complicating this is that pt has a history of anxiety disorder, depression, sometimes exaggerating physical symptoms and deciding she has a grave condition of some sort until tests are done to rule it out. A psychologist has suggested she may have a personality disorder with emotional dysregulation and attention-seeking features as well.The fact is, though, this pt is miserable and 100% insistent that she is experiencing a constant flow of urine and sitting in wet clothes all the time. We cant get her in to the psychiatrist until late April.Are there ANY ideas of what we may be missing to explain this from a neurological/sensory standpoint or another place to look? I have been really trying to advocate for this pt but its very difficult when the problem seems to be invisible for everyone but her. On the chance this is not psychosomatic, Id really like to make sure weve considered all options and are not just blowing her off because of her mental health issues.No alcohol, no drugs other than prescribed, no marijuana, no tobacco/nicotine use.Meds: Sinemet 25/100 2 tabs tid (Parkinsonism) Bupropion 75mg qam (depression) Liothyronine 5mcg tid (hypothyroid) Levothyroxine 50mcg qam (hypothyroid) Trazodone 50mg qpm (sleep) Buspirone 5mg bid (anxiety) Alprazolam 0.5mg qpm (anxiety/sleep) Ibandronate 150mg q30day (osteoporosis)Surgical/other hx: Hysterectomy/bilateral oophorectomy ~40 years ago Pregnancy: G2P2 ~50 years ago Melanoma removal, L knee, ~5 years agoLabs:CBC shows minor anemia beginning the day after starting Sinemet but seems to be resolving.BMP normal except for elevated AST (last values from Jan 2023 to Mar 2023 were 88, 71, 144, 156, 162, 91, 101 in chronological order.)Imaging:MRI Lumbar spine w and w/o contrast 2/1/2023: they didnt think it had anything that would explain constant urine flow but I can post the report if needed.CT head 1/30/2023: impression was: 1. No acute intracranial abnormality.2. Atherosclerosis.. ### Response: I would guess these are vivid hallucinaties, resultibg in a delusion. These can be caused by her combination of meds ( levodopa, bupropion and trazodone can cause agitatie and confusion in eldery patients). Did it start after starting levodopa? Parkiinson itself can cause vivid hallucinations too,but often parkinsons is more advanced then. And it could also be caused by depression. Older people often have these kind of delusions when they have psychotic depression.I would go back to the neurologist or psychiatrist for an evaluation. Probably stopping some meds should be tried, or antipsychotics compatible with parkinsons like clozapine added. But ask her doctors first what and how..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Oh, I forgot to answer your question: No, this started quite awhile before she started levodopa and buspar.She had been taking bupropion, trazodone, and alprazolam for years, but spent a few weeks in an inpatient psychiatric facility specifically focusing on elderly patients (edit: for depression/SI) about 9 months ago, and the psychiatrist there doubled her bupropion from 75mg qd to 150mg qd.The urinary problem started about three or four months after that. Two months ago, she was hospitalized for increasing tremor and weakness, at which time a consulting psychiatrist said to titrate her off the bupropion as he felt it was contributing to her anxiety levels. At that time, her bupropion dosage was cut in half to the 75mg she is currently on.The increasing tremor and weakness were determined to have been simple deconditioning due to self-isolating, turning away physical therapists, and not moving around much at all. She went from acute care to an intensive inpatient rehab facility and very quickly (about 2 weeks) regained much of her strength and a decrease in tremors.Thank you so much! We are trying to wean her off bupropion for that exact reason (not hallucinations specifically, but because it can exacerbate anxiety), so thats good to know. We just saw the neurologist yesterday but he sort of waved it away and suggested we discuss med interactions with the pharmacist.Further complicating matters is that shes tried pretty much every SSRI and SSNRI for depression and has had bad reactions to all of them, so bupropion at the time was thought to be a sort of last-ditch effort and seemed to be working for her. Since it also works on dopamine, the neurologist was completely unconcerned about it, but admitted that comprehensive med review was not in his wheelhouse.We did specifically ask the neurologist if this could be related to the Parkinsonism and he said he didnt think so because of the rest of how her condition appears.So, it sounds like I should continue trying to get her into the psychiatrist sooner? So far her other doctors dont seem to think theres a problem that they can speak to.. ### Response: For depression with psychotic symptoms, like these hallucinations/delusion, often tricyclic antidepressants are used, so probably meds she has not tried yet or maybe a few decades ago when they were more common.Personally i would try to get an appointment as soon as possible, because something is clearly not right and she is suffering probably.That could be a psychiatrist specialised in the eldery or (another?) neurologist. Consulting a pharmacist with an interest in psychopharmacology however also a good idea in the meantime.Armchair diagnosis is easy, but i could be very wrong and there is something else going on. This is just some thoughts that came to mind.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Child urology: Double kidney, megaurether, uretheroceleFemale, 10 months old, 70 cm, 7.5 kgHi all,I am searching for second opinions and experiences for my 10 months old daughter.She was born with a double kidney whose upper part is polycystic and thus not working properly. The urether of this part became a megaureter, probably because it ends in an ureterocele in the bladder.Her first surgery was when she was 1 month old. They cut into the ureterocele so the urine can flow into the bladder. However, at this point they thought she had only one urether for both systems and thus there had been enough urine to guarantee sufficient flow. When she had a persistent infection with Klebsiella pneumonia, we were referred to specialists who saw the second urether and, 2 weeks later, her second surgery was done to make a urostoma, so the basically standing urine from the megaureter could flow directly outside. The ureter is smaller now and except that she receives prophylactic treatment with antibiotics, everything is normal. But the stoma has to be closed of course. Now there are 2 options:connect the ureter from the dysplastic part of the double system with the healthy ureter from the healthy partcut out the dysplastic part of the double system and part of its ureter, leaving the other part and the ureterocele where they are, as there is no refluxOur doctors recommend option 1), as the surgery is shorter (90 minutes vs 3 hrs) and less invasive (opening up the existing hole from the stoma a bit more vs making an additional cut close to the lungs) and the healthy kidney part is not damaged (vs certain loss of at least 7% function). The only risk is that the connection of the two ureters leaks, which is rare and easily fixed they say.These are all compelling arguments, but we were also told that option 2) is the more common one. Does anyone have experience with similar cases? What's her best option in your opinion?Thank you very much for any feedback!. ### Response: !redditsilver.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Is it normal for a Urology PA to try to prescribe antidepressants/SSRIs?(Posting this again to fix some things that I needed to fix in this) Age: 24Sex: FemaleHeight: 5'1"Weight: 100Race: CaucasianDuration of complaint: urinary issues for about a year, suspected interstitial cystitis. Appointment was todayLocation on body: urethra/bladderCurrent medications: N/ANo recreational drugs, non-smoker, non-drinkerI had a very uncomfortable urology appointment today and while one of my doctors confirmed this was really weird I kind of would like to hear from other doctors unrelated to the situation.I went in because my gyno suspects that I have interstitial cystitis.I'd like to mention he's very very specific with me about what will happen. He knows that I rely on a really precise description of what the plan is (I have really bad anxiety and sensory issues). So it was weird to me when I went in and the PA immediately scoffed and said "it's never interstitial cystitis. They just claim that and send you off our way". Then she insisted on pelvic floor massage which I am unable to do and I said no to because my gyno and I went over all the options and he didn't think that was even on the board of necessary ideas. She pushed and said that "I injured my shoulder and got pelvic massage therapy and it fixed my shoulder".She claimed she had read all of my charts and medical background and asked if I was taking anything for the pain. I thought she meant Tylenol and said no because it doesn't work. She then started listing off amitriptyline and two other antidepressants/SSRIs. Then cymbalta. I got confused and told her I'm already taking savella and she asked me "what for? What does that do?"Shouldn't she know what that does? It just sent off a really red flag for me because those are usually meds that you need to involve a psychiatrist for. And if she had read my file and is messing with those kinds of meds why would she mess with my antidepressant that is package insert for pain and depression? She also would've seen that I'm prescribed tramadol.She also got really snotty when she asked if I had been surgically diagnosed when I said I had endometriosis which also would have been in my file/medical history. It also seems like any message from my gyno she just threw in the trash pile and came in with her mind made up that he was full of it.I guess I just need to know what to do. If this is normal and she just was kind of awful then okay but it really didn't feel normal. Do I tell someone about this? Who do I tell? She told me "then just go back to your gyno and see what he says" and (as I expected he would) he's sending me to another urologist, I imagine he's wondering why there was a problem.Edit: she also asked me about a bunch of food and drinks, I answered honestly that I just drink water with an occasional soda and about my food habits. Then she sent me home with a list of food to stop eating and all of it is stuff I point blank told her I don't eat. I'm just really upset because I had to drive a long way to get there, do things that will set me back anxiety-wise for days and she didn't even listen to that.Edit 2: There's also the unfortunate fact that the more stressed I got by her ignoring me and getting really pushy the more I started to stim. And she decided the best thing to do was start IGNORING me (I was still speaking to her, just no eye contact and moving my fingers) and only speak to my mother. I was then completely invisible.. ### Response: That sounds like a mix of multiple bad things. Theres a strong whiff of functional medicine (read: quackery) in massage for everything and weird food restrictions. Theres stigma against psychiatric treatment and mental illness. And theres ignorance.Theres nothing wrong with a urology PA managing antidepressants if he or she actually has expertise in those medications, but that isnt what happened here. This PA might be right about it not being interstitial cystitis, but even if so behaved so badly that youd want a second opinion anyway..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Definitely getting a second opinion, hopefully with someone that actually is interested in sitting down and talking things out instead of whatever this whole mess was.Thank you for letting me know that it's not unusual for urology PAs to work with those meds in general. ### Response: I think it actually is unusual. Its not unprofessional or absolutely a bad thing, but its unusual.Its not only psychiatrists who manage psychiatric medications, but most of the other doctors (and PAs and NPs) who do it are generalists, so probably family our internal medicine primary care doctors and the occasional gynecologist who does primary care..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Yeah the savella is for my fibromyalgia and depression, I've cycled through stuff like elavil (ultimately dismissed as an option when I was 14ish) and cymbalta (horrible reaction) so I don't find that so weird. I guess maybe it put me on edge because I've had bad experiences with a lot of those? I'm very touchy about messing with those when I'm settled in one because it's hard physically and mentally and I really don't feel safe unless my psychiatrist is involvedI've gotten the "what's it for" question a lot it was more the "what is that" that got me because I thought it was a pretty well known med. ### Response: Sorry this is short. No signal. Speed read the issue. Only have to say.... Cymbalta is a powerful antidepressant which has use in resistant stress incontinence , that is leaking on exercise usually later in life.Amitriptyline has a big role in bladder control mostly for nocturia, peeing at night. It is used at doses much less than when used 50 years ago as an antidepressant but I like to correct people who complain theyve been put on an antidepressant when the dose is 50mg instead of the 300mg it was then. It was a poor antidepressant but people said that their bladders were better.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: That's interesting. But also odd because I told her I'm not having incontinence. ### Response: Precisely. It doesnt really make sense so maybe another opinion.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: My (72M) father was sent off for a number of urology tests, are these standard procedure?72M, 160 lb. He has had frequent urinary urgency for years now, untreated. Recently has gotten much worse, and the need to urinate has been waking him up 5+ times each night. When he does urinate, he has trouble emptying his bladder.I scheduled an appointment for him with a urologist and the urologist prescribed Flomax to him. This was today. The urologist sent off for a number of tests:PSACreatinineUrinalysisAlso, these procedures:Transurethral cystoscopyRenal ultrasound and ultrasound of the urinary tractI'm wondering about the cystoscopy - as this is what my father is most fearful of. I spoke with the urologist and he said this is to see if there are issues that need to be addressed by surgery that the Flomax can't help cure. I'm still not sure what this is done for and if this is standard procedure? Would it be better to just see how he responds to the Flomax and perform the procedure if he doesn't? Or is there value in doing this anyways?. ### Response: Flomax was given as due to the likelihood of benign prostatic hyperplasia, and pretty much every guy has an already enlarging prostate when they're above 60 anyway.The cystoscopy is to look into the urinary bladder for any issues that may not be due to the prostate (prostate would still be the number one source of problems in this age group regardless). All these tests should cover all the bases for the probable urinary tract issues for his age..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Seeking information regarding dads renal cell carcinoma. Any urologists here?My dad has been having serious issues with vomiting, nausea, and weight loss. They ended up doing abdominal CT because colonoscopy and upper GI scope were normal. There was an incidental finding of a 2 cm heterogenous(I think???) lesion on one kidney. Per radiology report, it says renal cell carcinoma until proven otherwise.Today we saw the urological surgeon who said due to size of tumor and my dads age, hes a candidate for ablation and theyll give him a referral.The appointment was very rushed and I (29 F) went in with my dad because he has a history of TBI and has a hard time remembering/relaying medical info. We basically were just told that its cancer (which I figured from reading rad report) and that it can be ablated very quickly and the doctor then basically told my dad to drop his pants for a prostate exam so I made a swift exit.My questions lie in whether more imaging needs to be done on my dad to make sure theres not other cancer somewhere? The doc said most likely stage one but theyve only done the abd CT and nothing else?? I understand its a small tumor but does that automatically mean theres no metastasis?? I dont understand how they know that its only stage I without additional testing or imaging? Can anyone give me insight here about this process?We will be following up with that physician where I will be asking for clarification. It was such a whirlwind of an appt and I just didnt feel prepared to ask necessary questions.. ### Response: From the information provided, this is not standard of care - but giving us the image files (upload to e.g. dicomlibrary and CT report would be very helpful.Here is NCCN's very helpful patient guideline for kidney cancer.A suspicious 2 cm lesion on a kidney often, but not always is renal cell carcinoma. A 2 cm renal cell carcinoma that's confined to the kidney is usually pretty harmless and very unlikely to relapse or metastasize.The problem is that 1) staging is incomplete and 2) you won't have histology going along with this to confirm that it is indeed renal cell carcinoma and 3) your father has concerning symptoms that are as of yet unexplained.Initial evaluation and staging vitally includes comprehensive labs (CBC, metabolic panel, LDH), abdominal CT with and without contrast, chest CT (or at least, but that's discouraged in the guidelines, chest X-ray) and a thorough physical examination and history.If there are any alarming signs on history or examination, additional imaging must be done. I'd consider vomiting, nausea and weight loss to be alarming. At least brain imaging (preferably MRI) should be done to exclude brain metastases imho.Also, when not performing a partial nephrectomy, which would be preferable to ablation if possible, an initial core needle biopsy to secure histologic diagnosis is recommended. Otherwise you won't ever know what kind of 2 cm mass they burned. The NCCN guidelines stateBiopsy of small lesions confirms a diagnosis of malignancy for surveillance, cryosurgery, and radiofrequency ablation strategies. Ablative techniques may require multiple treatments to achieve the same local oncologic outcomes as conventional surgery..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I did an in home vinegar test yesterday and the area he was referring to did NOT react. I did have a single spot react, but not the one he was referring too. The vinegar test has a high false positive rate so I'll talk to him about that, but still, the visible areas he could have been talking about DID NOT react.I want this guy to be sure i have HPV before he charges me to cut shit that's been there forever. I can take care of a skin tag for under $5 at home. And while I know it's incredibly common to have hpv I want him to be sure if I'm going to have to disclose that with future partners. Maybe I should see a dermatologist?What are some questions I can ask to make sure he's right?. ### Response: Easiest and cheapest way is to post a picture here and Ill check it for you. Its a clinical diagnosis and honestly not that difficult to determine.Edit. Also, if you have had unprotected sex with > 1 partner, chances are you have been exposed to the virus..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: http://imgur.com/a/lhCk8a4Again, its been there my entire life, including the skin bridge. I always assumed they were caused by the same shitty circumcision.To your edit: I've never had unprotected sex. That includes oral (not fun).. ### Response: Doesnt look like a wart and your history doesnt really support that diagnosis either..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Bleeding vs. clotting risk - When is heparin bridging appropriate?Hi all, I am just a simple-minded EMT, trying to understand this concept for a family member who recently underwent surgery.The family member has chronic a-fib, which has been well managed with warfarin. He needed a trans-urethral resection of a bladder tumor (TURBT). His cardiologist said he should not be off warfarin for more than 72 hours, and his urology surgeon said to stop the warfarin 48 hours in advance of the surgery (meaning the plan was to resume the warfarin 24 hours after surgery). After the surgery, the surgeon said he was not able to cauterize all of the 'wound' (I am not sure the correct term here), so my family member had a good amount of hematuria, though the surgeon said it was not a life-threatening amount.He was supposed to take aspirin after being discharged, but they ended up admitting him due to a good amount of clotting in the bladder, which required daily irrigation. I am not sure if the nurses ever ended up giving him aspirin or heparin while he was off the warfarin. The surgeon seemed very concerned about the bleeding, and said that my family member could not go back on his blood thinners for another 48 hours after the initially planned resumption (which would result in a total of 5 days off the blood thinners).Now my question is, isn't it easier to fix a bit of bleeding than a blood clot (which could cause CVA, AMI, or PE)? Wouldn't it be better to keep him on blood thinners and handle the bleeding, than to risk a deadly clot?We would ask his surgeon, but it's sort of a foregone conclusion at this point as my family member has already been discharged. So, this is just for my personal education. Thanks for your insight.. ### Response: isn't it easier to fix a bit of bleedingGeneral surgeon here. No, it's not always easier. Sometimes the tissues are just oozy, and you can't just throw a simple suture in or cauterize it and make it stop. Sometimes, the more you cauterize something thats oozy and inflamed, the more it oozes and bleeds on you. Sometimes, you just need to let the body do its thing and form a clot. So either you stop blood thinners for as small a window as possible, and accept the risk of developing a clot elsewhere, or you keep them on blood thinners and just let them ooze and ooze and ooze, potentially requiring blood transfusions, which then opens them up to other risks. Others may have other viewpoints, but this is from a surgical view..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you.Do you always do a heparin bridge or is this contraindicated under certain situations?Does a patient history of a-fib affect the outcome of the risk calculus?. ### Response: When considering the decisions here, you need to weigh the benefits and risks of anticoagulation.His stroke risk from afib can be estimated with the CHADS2-VASC score. Look this calculator up online. Most people stand an annualized risk of 2-11% of experiencing stroke. On a day to day basis, that risk is super small. Like 0.001% chance of having a stroke every day he's off anticoagulation, and even that is probably an overestimate of his stroke risk.The risks of bleeding are obvious. He's bleeding into his GU tract. This could occlude his bladder. He could bleed into the wound bed in ways that make his recovery worse. The chance of bleeding while anticoagulated is 100%.The last nail in the coffin is that we have multiple large and well-designed trials (BRIDGE and PERIOP2) that show no benefit to bridging pre or postoperatively in any population we've looked at this far, including mechanical valves in the post-op setting.At this point the only cases where bridging might be worth it is acute DVT/PE within 3 months of surgery, and maybe mechanical mitral valve..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: What monitoring is usually needed when taking a patient off anti-coagulation therapy for surgery? e.g. CT scan, d-dimer?For reference, this family member's CHADS2-VASC score is 4.Thank you for your help. The CHADS2-VASC calculator definitely improved my understanding.. ### Response: No monitoring is needed. The idea now is to resume anticoagulation once appropriate from a surgical standpoint. Not uncommon to wait anywhere from 5-14 days post-op to resume anticoagulation depending on how bloody the procedure was..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I (f25) recently was referred to the one stop urology specialist clinic for tests, but the specialist I saw refused to do any of the tests I was booked in for based on my age.Hi there! I am F25, around 8st (I don't weigh myself due to history of anorexia nervosa), don't drink, smoke cigarettes (have cut down, do not smoke heavily), don't use recreational drugs, and live in England. Previous diagnosis fibromyalgia ~5 years ago, ASD, c-PTSD, juvenile arthritis (age 14). I am prescribed quetiapine XL 200mg once p/day, naproxen as and when needed, promethazine hydrochloride as and when needed, cocodamol as and when needed. I also take a probiotic, vitamin D, iron, vitamin c, and a multivitamin all as supplements once p/day.I have recently been having a lot of medical issues, which my GP is trying to have investigated. I have petechiae all over both arms after sun exposure, internal pain in the chest, and incontinence with internal pain in the kidney area. Also, a year or so ago I had blood tests done which indicated my kidney function was lower than normal. I also have a lot of other symptoms, but these are presumably to do with fibromyalgia, so I won't list them. The incontinence gets worse in the evening and at night, where I am needing to urinate every 10-15 minutes. Pretty much every time I drink anything, I need to urinate straight after. GP sent a urine sample away for lab analysis, which showed microscopic blood in the sample, and protein. I was referred for an emergency CT scan due to the intense pain, which flares up and is not constant, but the hospital declined to do one (due to not having space, I think). I was then referred to the urology clinic for a four hour appointment.When I arrived at my appointment, I was told I would have an ultrasound, a flexible cystoscopy, blood tests, urine test, and flow rate test. After going back into the waiting room, I was shortly called back into the doctor's office. He told me that he would no longer be performing any of the tests I had been booked in for, except for an ultrasound. He did a stick test of my urine sample and told me I had no blood in it, but the blood from my previous sample was microscopic and was only found in the lab analysis, NOT in the initial stick test. I was told that, because of my age, I could not possibly have any health issues, and that he had people with possible bladder cancer who he could be seeing but wasn't able to as I was "taking up [his] time, when others need it more," despite my time being booked in. He explained that the only issue I could have was kidney stones, and also dismissed my pain further when he found out I have fibromyalgia.I then went in for my ultrasound, which came back as no kidney stones. I was then called in and, to the doctor's surprise, told that I don't have stones (which I already knew and had tried to explain - I have had kidney stones in the past, and my recent issues have not been consistent with my previous experience). He said "I'm a surgeon, I look for problems to treat. You don't have stones, so I can't treat you." I asked why I am having incontinence issues, and he said "probably because you are a woman. It's common in women," and when I asked what I'm supposed to do about the awful pain for which painkillers barely touch the side, his best advice was "get pregnant. Pregnancy often cures all sorts of illnesses." I was almost in tears at this point. My response was "I just had a miscarriage in December. I've had two miscarriages," and he said "try again." I said "I don't want to," but he insisted this was the best idea. I also explained that my GP had said there could possibly be an inflammatory issue, and he said it wasn't possible to have inflammation without kidney stones or an infection. He also implied that my fibromyalgia is not real because he "prefers not to label patients if [he has] no real evidence." He also stated that the only reason he was going to do any other tests in the first place was because if he didn't it would be "sod's law" and I'd actually have something wrong.I feel at such a loss. I was so devastated after my appointment, and still ended up being in there for 3.5 hours even though he refused to do any of the tests. Fortunately I had my partner with me, who was able to support me whilst I was sobbing in the waiting room. It's been such a long journey to find a GP who takes my complaints seriously, and have had years of doctors being dismissive. I genuinely thought I might begin to have some answers after the appointment, but I now feel like I'm just five steps back.Is it normal to be refused tests based on age and gender? Is anything he said to me actually true, as I feel like it was all completely dismissive? Should I request to see someone else, or will the same thing happen again? I'm honestly devastated, and concerned for my health. Any advice is welcome, I just want to know what the best way to proceed is, and if there is anything specific that I should be emphasising with doctors in the future to be taken more seriously. I tend to mask and come across as very polite, but maybe it would benefit me better if I acted less positive and worked harder on getting across the severity of the pain? Also, am I able to request any specific blood tests? If so, what would be recommended?Thank you so much for reading, apologies for the long post.. ### Response: Medically he may or may not have been justified in not doing all the initial tests - one-stop clinics usually book you in assuming youll need everything even if thats unlikely to be the case. And your urologist is probably a better judge of that than the GP.However, the way you were spoken to is bizarre and clearly inappropriate. Id suggest you contact the PALS service for the hospital you were at and ask your GP to re-refer you to urology - perhaps another urologists outpatient clinic. PALS may also be able to help with that..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: [8 F] Higher WBC than RBC?My 8 year old daughter had labs and her WBC was 8.8 thousand and RBC 4.76. These are both in normal range, but is it actually ok if there are more WBC than red?We do have two doc appts this week for follow up, but my pediatrician did not notate anything about this in the system notes, only made a note for her to increase zinc intake based on her slightly low zinc.She has a variety of other health symptoms that we havent figure out also, but Im just curious if this is specifically alarming.Im sure Im over thinking it. I definitely have some medical anxiety since my mother passed last year, which I completely acknowledge. Thanks for any input!EDIT TO ADD: Conditions- bladder area pain (working with urology), abdominal pain, sometimes has protein in urine, burning feet/neuropathy (new symptom- one month), urine leakage during daytime, pale/flushed face, general malaise. ### Response: The units on them are different - the red cells are in millions per cubic millimeter, the white cells are in thousands. Everyone has way more red cells than white. When it comes to the specific numbers on labs, we don't compare them like that..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: What about having 57% lymphocytes? Is that ok too?. ### Response: Yes, totally fine..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Urology or dermatologyAge: 28Sex: maleHeight: 170cm (5'7)Weight: 66kg (145 lb)Race: AsianDuration: several monthLocation: Singapore. Condition is on penisNo other health issueNo medicationMy husband has a little bump on his penis for several month. It's several mm wide, there's a hole in the middle, and can see some black stuff inside. The black stuff is shaped like a thin disk. It does not hurt or itch or anything.We are planning to see a doctor in Singapore to check it out, but I don't know if we should book a urology doctor or dermatology doctor. Any advice? We don't have a general doctor.Thanks in advance!. ### Response: Both specialties would be a good choice..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Concerned over 'Spironolactone' Rx for acne as a maleHello, (30y/o male).I was recently seen by an NP at a Urology center and during my visit my acne was brought up. She just got done some time working in dermatology. I had stated I was not comfortable with something like Acutane since I am trying to have kids and honestly that medication seems very scary to me from a health standpoint. She Rx me something called 'spironolactone'. Coincidentally I was seeing a male health specialist (an NP) the next day and he also brought up my acne and suggested 'spironolactone' out of the blue..Before I picked this up from the Pharmacy I googled it, because I like to know about medications and nowhere does it say this medication is safe or FDA approved for men. It's apparently outstanding for female acne, but as an androgen blocker, is not intended for use in men, and in fact a clinical study showed 100mg of daily use for 3 months in a group of 18 men, 8 of them developed significant gynecomastia..I called and canceled my Rx for spironolactone. I wanted to get an MDs opinion on this. I am a lay person so maybe I was just dramatic here. I am quite confused why two entirely different NPs, practicing in different states, would both suggest spironolactone (100mg a day) for acne in men..Patient History:Pituitary tumor which impacts my testosterone levels (sub 100) so am on 100mg of T a week. I have cut this down and am weaning completely off of it because I am currently 0.00 10x6 for sperm. NP just started me on 5mg of 'finasteride' (for acne due to DHT conversion maybe?) and HCG (0.75mg a week) to try and get that up. Another NP started me on Clomid and suggested I finished off the HCG (*I know, its not ideal to have two providers dictating care for the same thing - but NP #1 didnt know I was at a 0 and wanted to determine if I needed something like Clomid after the analysis came back but I dont see her again for 2 months).*I will say the IM testosterone has changed my life. I cannot explain how much better I feel. Its so profound I almost want to cry. Its like seeing in color for the first time in 20 years. I am sad / nervous to get off of it, but its for a purpose so I can handle that.. ### Response: I have never heard of spironolactone being used for men's acne. Without good evidence, I use it frequently in women..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Reoccurring UTIHi just looking for some advice and what to know looking forward. Before Christmas I had a UTI for approximately 2 weeks, during this time I tried one course of nitrofurantoin (100mg twice daily) which didnt help at all, then two courses of pivmecillinam (200mg three times a day, with a loading dose of 400mg both times) which also didnt help. Eventually I was referred to urology who did bloods (normal), urine dip (positive for protein and blood) and ultrasound of kidneys bladder and ovaries. Scans came back completely normal and the urologist then prescribed ciprofloxacin 500mg twice daily for a week. The cipro seemed to have worked and I was fine over Christmas, but potentially still had some dysuria/frequency though a lot less than before. In the past few days symptoms have come back to the extent that they were before the cipro.Im going to pick up a new prescription for ciprofloxacin in an hour or so and its a 5 day course. Should I be concerned and see a urologist? Or is this just a UTI that wasnt fully treated so has come back?21F, Mixed African-American/White, 60mg fluoxetine daily, 75mg desogesterel daily, 40mg propranolol up to three times daily. ### Response: you should probably see your urologist again who may want to do a full urinalysis and culture/sensitivity test..