Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: (EDIT Below Original Post ) I kinda wrote all of this in a rush this morning after talking to his critical care doctor and surprised to see how many have responded, thank you again, It really means so much.I been staying with him for 99% of the time in the hospital. I went home for one day out of 35 days.He was having issues all of this year, mostly without not being able to eat. We went to ER early June and test results came back okay (or so we were told)He became really sick and malnourished so we took him to ER again in Sept and they performed a CAT Scan. They found a Mass.Biopsy of the Mass diagnosed it as Stage 4 Lung Cancer and now he's been in the hospital for over 5 weeks.He had a cardiac arrest which lead to him being put on life support but they carried on with doing radiation to treat the mass and shrink itHe has SVC Syndrome, Pleural effusion (chest tube) Gastrointestinal tube present (Possibly getting a G-J) , HCC Lung Cancer and AFIB ( Atrial Flutter)Medications: (TBE) He's been/are onFor Pain: Morphine , fentanyl , Versed,Blood Thinners: Heparin, Zerelto, LovenoxBlood Pressures: Levophed, MidodrineDiuretics: Lasiks (oral)Lasiks (IV) 10mg to 20mg back to 10mg.Spironolactone (current)I really don't know what to do. They want us to tour LTAC facilities and we're scheduled to meet Palliative Care later on today..Chemo is an option but he might be too weak to do so..Idk if we should transfer hospitals to get second opinions or what.there isn't much I can do besides this. Being supportive and smiling.. Reaching out to people for help/opinions...This feeling of uselessness is overwhelming..EDITED (Additional information): Thank you for all the replies and upvotes... It means a ton. He's responsive and understands what's going on. We're able to communicate with him and he does mouth out his concerns. Even tho he hasn't really had significant improvement, He hasn't been getting worse and has been maintaining stability and he's doing a lot better than when he was first admitted into the hospital. I've understood for a while that his cancer isn't curable from a medical standpoint and that it's only possible to maintain it through treatment. He's expressed that no matter how small the chance is, he wants to continue fighting. We've had this talk several times throughout the years. Even now he expresses this. Which is why I'm trying to explore every realm of possibility. They trached him and He's been on Spontaneous mode (his respirator) for almost a week, and they did take him off the vent for 2-4 hours a day to get him used to breathing on his own. His diaphragm is really weak and he gets really anxious whenever this happens because of how different it feels but his vitals and oxygen levels always seem okay. He says he isn't in any pain, he just gets frustrated & anxious at times but that's understandable. He's just fighting really hard, we all are. We have an amazing support system from friends and family and there's a lot of people rooting for him. I just want him to have a 2nd chance at life and be able to live whatever time he has left to the fullest. I have access to some of his records through MyChart but the daily notes that nurses and docs input isn't all there. I wish I had more information to provide you all. https://i.imgur.com/rea1isQ.png. ### Response: Sorry to hear.(HCC stands for hepatocellular carcinoma, a kind of liver cancer. It can metastasize to the lung, which can be a cause for confusion. Or perhaps he has a lung cancer and the acronym you were provided isnt quite right. Probably not of much consequence to the following discussion.)If there is talk of LTAC and he is on versed, I am guessing he is still requiring mechanical ventilation?One cannot be precise without seeing all the data but the typical prognosis with this general picture is very poor. If someone is ill enough to die while in the hospital while receiving optimal care, the odds of complete recovery after resuscitation are low (in the neighborhood of 10%). In those who go to LTAC on a chronic ventilator, only a minority ever come off the vent (~30%), and there is a high short-term mortality in these patients even when stage IV cancer isnt in the mix. Stage IV cancer of any kind, with very very rare exception (some testicular cancer, etc), is not curable.Meeting with palliative care seems like a very good next step. If they do not suggest it themselves, I would ask for a family meeting with the palliative care docs, ICU docs, oncology and radiation oncology docs all in the room together. This is often the best way to get a complete picture of the current medical issues.If he is not currently able to make decisions for himself, as I suspect from information provided he is not, the main question for you and your family is: what is the minimum quality of life he would accept? Some would say that unless current therapies have a good chance of returning them to independent living with intact cognition, they would not want to be maintained alive by machines or treatments. Some would say that if they can think but require complete assistance, that would be enough. Some would say even being maintained in a state in which they have no awareness of the outside world is acceptable.The main question for his doctors is: what are the chances his current treatments will get him to that minimum qualify of life, whatever it is for him? If the treatments and supports offered have little chance of returning him to a state he would find acceptable, then one could view his current therapies as prolonging a state of suffering.Sorry again for what your family is going through..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Very well said.I want add that if you look at the data for people who go to LTAC and are successfully liberated from the ventilator, and are alive and independent at 1 year... It's somewhere between 5-10 percent. It's a long road to get there, even without metastatic cancer.Something I'd like to add about the quality of life comment that I think is important to share with family members... Everyone has a quality of life minimum that they would accept. It's our jobs to tell the people we love what that minimum is while we are alive and healthy so that our love ones know what our wishes are. If (when) something happens to us, it's up to our love ones to state the decision we've previously made. There's always going to be emotions during this tough time, but guilt or regret should not be one of them.In Healthcare we commonly refer to the surrogate or next of kin as the "decision maker", but really the decision maker is always the patient. The surrogate is the party that speaks for the patient when they are unable to and brings the patients desires to light.. ### Response: HCC stands for hepatocellular carcinomaIn EPIC, a lot of diagnoses in the problem list are labeled with (HCC) after their name, like "Acute heart failure with reduced ejection fraction (HCC)". I have no idea what it means, but this is probably where OP got it from, and the pt probably doesn't have hepatocellular carcinoma.Edit: Just looked at OP's screenshot and you can see what I was talking about.Yes. Probably means the word salad pointed out by the other poster just before you. Never heard in a clinical context. Reason #649263 that epic sucks..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: HCCs are a method used in coding to show how "sick" a person is. It's used for Medicare reimbursement calculations for payers (insurance), incentive programs, etc. It's part of Risk Adjustment. Heirarchical condition code....or something like that. I can't even remember right now and I'm a certified Risk Adjustment coder.. ### Response: Is there any good reason that this stuff is exposed to actual healthcare workers?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Another aspect to note is that patients who see palliative care earlier have a much better prognosis - longer survival times and higher quality of life scores.. ### Response: Pulmonologist here. I am also the medical director of a hospice for the last 15 years. First, I am very sorry for the difficulty that you, your father, and your family are having to deal with. As a physician, and particularly in doing pulmonary/critical care as well as hospice, I have tried to help people through these tough situations for most of my career. Each case is individual and each patient is an individual with their own beliefs and values and dreams.Over the years, I've spoken to many dying patients and their families about their illness, and what I've tried to do is to give them the perspective of a physician in order that they can then use their own values and beliefs within the framework of a physician's perspective...using what we know and applying their own perspective.As a physician, my perspective on your father is that he is dying. Please don't take that as callous...it is not meant that way. Most people think of dying as a moment...and it certainly can be...car wreck, heart attack, massive stroke... those thinks can take a life in the blink of an eye. However, for many, if not most, people...dying is a process. It can be several hours or several weeks...or longer It begins when you know that nothing else can be done for the patient and all you are trying to do is maintain, and despite your best efforts, the trend is that the patient continues to decline. All patient's have good days and they have bad days, but for a dying patient, when you average it out, the trend is that they continue to worsen.It's at this point that I think it's important to find out what kind of death your father really wants. That can sound very brutal to some people...but remember, we're physicians and we experience this life and death everyday, and we see patients who die peacefully and comfortably and we see patient's who die alone and in horrible circumstances. With those experiences in mind and with our practicality, we begin to think about what we would want for ourselves. Ask any physician or nurse friend of yours...chances are they've thought about it a lot...far more than other people. They tend to know exactly how far they're willing to go before they just want comfort.From your post, you've spoken to your Dad about his care:He's expressed that no matter how small the chance is, he wants to continue fighting. We've had this talk serveral times throughout the years. Even now he expresses this. Which is why I'm trying to explore every realm of possibility.When he says "chance," what does he mean? Chance of a cure?...chance to go back home?...chance to get a little better and be off the ventilator? In other words, you need to know what his goals are. If his goal is cure, there is no chance. If his goal is going home to the way his life had been...there probably is little chance of that either, though there may be a chance to go home...I don't have enough information. But first, find out which of his goals are potentially achievable with his doctors. Once you know what goals are potentially achievable for your father, you and his doctors can talk about what would have to happen to achieve those goals.Eventually...at some point however, because of the nature of our existence, none of those goals will be achievable, and at that point it is reasonable to give your father permission to let go and to seek comfort in the final moments, days, or weeks of his life. I say that because many patients continue to fight because they think that's what they're suppose to do or because they think they'll be letting down their family if they let go. They endure unnecessary suffering because no one has offered them a path of comfort and acceptance or because they made a vow to fight on and they don't want to renege on a promise they made to someone.We all eventually die. Some of us will never know what hit us because it comes too quickly. For those of us who are struck with a terminal illness like cancer, the only benefit is that we may have enough time to get our personal affairs in order and make peace while having some control over the dying process. As a physician, I know how I'd want to die, however, I don't try to push that on any of my patients. There are definitely patients who don't want to do much at all and just want to enjoy what life they have left. There are other patients who can't die in peace without trying everything including investigational treatments. I respect them all but as a physician I have to make sure that they are making those decisions knowing all the facts and the possibilities and risks.Start by talking to your father about his goals and discussing those goals with your father and his doctors. Give your father permission to do what he wants whether it's letting go or fighting to his last breath. And make sure that in the end, his comfort and wishes guide what decisions you may have to make in his stead. I hope this helped a bit. As best as I can on a reddit post, I'd like to give you, your father, and your family a big hug and my wishes that you all will be comforted in the days ahead..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you for the supportive information. I really appreciate the time you took to type this out.He's responsive and understands what's going on. We're able to communicate with him and he does mouth out his concerns. Even tho he hasn't really had significant improvement, He hasn't been getting worse and has been maintaining stability and he's doing alot better than when he was first admitted into the hospital. I've understood for a while that his cancer isn't curable from a medical standpoint and that it's only possible to maintain it through treatment.He's expressed that no matter how small the chance is, he wants to continue fighting. We've had this talk serveral times throughout the years. Even now he expresses this. Which is why I'm trying to explore every realm of possibility.They trached him and He's been on Spontaneous mode (his respirator) for almost a week, and they did take him off the vent for 2-4 hours a day to get him used to breathe on his own. His diaphragm is really weak and he gets really anxious whenever this happens because of how different it feels but his vitals and oxygen levels always seem okay.He says he isn't in any pain, he just gets frustrated & anxious at times but that's understandable. He's just fighting really hard, we all are. We have an amazing support system from friends and family and there's alot of people rooting for him. I just want him to have a 2nd chance at life and be able to live whatever time he has left to the fullest.I have access to some of his records through MyChart but the daily notes that nurses and docs input isn't all there. I wish I had more information to provide you all.https://i.imgur.com/rea1isQ.pngI kinda wrote all of this in a rush this morning after talking to his critical care doctor and surprised to see how many over responded, thank you again, It really means so much.. ### Response: I'm sorry you are going through this.Your father is going to die. I'm no oncologist, but this seems like he won't get into a situation where he can be treated with chemo or other targeted therapy (I assume they looked at that through his biopsy).A second option can help informing treatment decisions and with accepting this terrible news, but looking how to make sure your father is comfortable for the coming period seems like a good idea..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Hi all, I'm looking for some assistance for what my next steps are, as I'm just a grad student and not a medical professional.TLDR: 48/F with late stage liver failure and diabetes. Estimated 3-6 months to live. She suddenly is not lucid after stopping most treatment and starting an SSRI. I want to know if this sounds like encephalopathy, and if it does, can it be caused by these treatments?My mom (48/F/caucasian) is currently in the hospital for late stage liver failure. The current prognosis is that 10% is functioning, which is complicated by her diabetes. Last month she was in the hospital with 20% liver function, and had a second toe removed (the first was amputated in 2019).I brought her back in after my dad called complaining about how she can no longer stand, speak coherently, stop crying, and was in constant pain, which we were told was encephalopathy. Since she was removed from the ICU, a family member has been here for the entirety of visitation hours everyday to help her eat, get to the bathroom, etc, so we have witnessed this whole process. After a week or so of treatment with diuretics, she was lucid, starting walking, ate all of her food plus snacks, etc, though still in pain. She was able to verbalize that.Due to the IV teatments they were giving her, she accumulated 40 lbs of fluids in her legs and and abdomen, which they said couldn't drain due to her hemoglobin levels/blood pressure. It started weeping from her legs as a yellow liquid, and eventually she developed dozens of sores on her leg bandages and the legs swelled to 3x their regular size. She was in excruciating pain plus itching, which from what I've read to pretty standard. That all said, she was still able to verbalize this and was lucid.5 days ago, she was told by the hospitalist that there is nothing they can do, and instead of palliative care, she should now be in hospice care. She was incredibly upset by this, but was still lucid. At that time, the palliative care doctor prescribed her an SSRI (not sure which one, they would not tell me) and the hospitalist stopped all other treatment other than blood pressure medicine, insulin before meals, oxycodone upon request, and benedryl for itching upon request.The timeline since then is as follows:Friday, she started receiving the SSRI. She was still lucid, calling people, and complaining of pain.Saturday, she stopped eating, speaking, or drinking anything. She just lays in bed, and if you ask her a question she stares blankly at you. She will nod sometimes to questions. She ate very little, and only when urged to.Sunday, she was about the same. Barely ate and doesn't speak at all.Today, Monday 3/15: she is still the same, and hadn't had any sort of fluid since the previous family member left at 6p the day before and I arrived this morning. She has had no bowel movements in 24 hours. The palliative care representative prescribed ritalin to make her more alert, but it hasn't done anything. We are currently working on transferring her to a hospice care facility.She looks like someone on a heavy dose of oxycodone, but she hasn't had any in days. All she does is stare at us and occasionally eat a piece of candy when prompted. I asked the hospitalist what could cause this so suddenly, but he said there's nothing they can do, as it is not encephalopathy. He referred me to hospice and would give no other information.All of that long background is to say this: this doesn't look like how her encephalopathy manifested before (crying, pain, etc). Is it possible for it show up differently? The only new medication introduced last week was an SSRI, but since she only started it Friday, it seems weird that it would have an immediate effect like that, since I would think that it takes some time for it to get to the liver and metabolize (or not metabolize) and cause a rise in her toxin levels. I have also always been told that it takes weeks for SSRIs to be effective, but I don't know how that changes in cirrhosis patients. If this is not encephalopathy, but what is causing this sudden change?I want to make sure she is receiving proper care, as I'm not able to clean much from her doctors and she is not lucid. Thank you for any guidance on this situation!Here are the papers I read regarding this, in case that is important:2015, Issues in the endstage liver disease patient for which palliative care could be helpful2017, Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicityNote:I don't know her current numbers, as they messed up her labs this morning and apparently don't redo them when that happens.. ### Response: I imagine this is one of the toughest times you and your family have ever had to go through. Please don't neglect yourselves whilst looking after your mother and seek appropriate support, particularly psychological, as necessary.I am a psychiatrist, so I will try to answer your query regarding the SSRI. I'm afraid my internal medicine knowledge isn't up to date enough to help with much else here.All SSRIs are hepatically metabolised. They can therefore accumulate over long periods of time, so they must be used cautiously in liver impairment, and SSRIs with long half lives should be avoided. Of the SSRI family, citalopram / escitalopram have the least known effect on hepatic enzymes and are typically the SSRI of choice. Some specialists may prefer paroxetine, due to it having the shortest half life. Whichever is chosen, the general rule is to start low and go slow. I trust your mother's doctors have stuck with this rule. In which case, I suspect there has not been enough time for the new SSRI to accumulate to sufficient levels to be responsible for her acute deterioration, particularly if her deterioration began after just one or two doses.However, even if the SSRI isn't doing any harm, we need to ask ourselves, is it doing her any good? In the state that you have described her to be in, especially since the deterioration, I would struggle to justify continuing the SSRI. At this stage, I would argue the potential harm outweighs the potential benefits. And who knows, I might be wrong about the SSRI not being responsible; if it gets discontinued and your mother starts perking up, then all the better.Sorry to hear about this awful situation, do take care..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: You seem to have knowledge about how SSRIs work, wondering if you'd take a look at my post, possibly had SSRI-related damage happen to me. https://www.reddit.com/r/antidepressants/comments/raqwkk/my_life_has_been_upended_and_i_dont_know_what_to/. ### Response: I'm sorry to hear you and your family are going through this. I agree with her physicians that unfortunately it does sound as though your mother is approaching the end of her life and palliative/hospice type care is appropriate.Given your description, I suspect that her current condition is likely caused by hepatic encephalopathy, where toxins like ammonia build up in the body as they are unable to be processed by the failing liver. The treatment for this is usually medications that promote frequent bowel movements, like lactulose or other laxatives, as the bowel is the only other route by which these toxins can be removed.Hospice care should be focused on your mother's values and what's important to her. If you feel that it would be important to your mother to be more awake and with it during this time, it would be reasonable to ask her physicians whether medications to treat encephalopathy could be restarted. However, the counter argument is that by being more awake, your mother may also be less comfortable, the avoidance of which is another goal of end of life care. It could be that this is why her physicians have felt that holding these medications to promote her being less aware is best for her at this time. This is a conversation you should have with her palliative care doctors and together figure out what is the best way to care for her. Again, I'm very sorry and hope this helps..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 9 weeks ago i got pain on my right side under my rib cage. shortly after that nausea, bloating, and indigestion started. then my bowl movements were unpredictable and of all different types (loose... dark... normal... soft... constipation...) then dry heaving started.i have had a hell of a time getting treatment because im not critical enough during this covid19 crap. through multiple urgent care visits i finally got one to take urine and blood samples. they also got me an ultrasound and a telemed appt with a gastroenterologist.the urine was normal, but i was slightly dehydrated. not surprising given i was so nauseous drinking water was difficult. blood test was also normal except for a slightly low RBC count/low iron. the ultrasound showed no evidence of gallbladder problem, but did reveal some potential (likely benign) tumors in my liver. those apparently are completely incidental, and not urgent to diagnose immediately, but i do need to get a CT scan on them once covid restrictions lighten up.this past weekend vomiting returned for a few hours. i also developed a mild fever, and then chills with low body temp. i was also salivating uncontrollably. i had to chew gum to get the salvation to stop. it was weird af.i can only eat small portions of easy to digest food. like grapes and cream of wheat. complex foods or larger portions usually throw me into severe nausea/belching/etc. I've lost around 6lbs this far.i'm waiting for a h. pylori stool sample test to come back in the next 48hrs. at this point im praying its positive so i can get an answer and some relief.is this normal? 9 weeks feels really long. every time i think im improving it hits me and gets bad again. do i sound like im describing an ulcer? and if so does it seem like the bacterial type? can it really take this long to heal? i called the gastroenterologist and im trying to get a follow up appt soon. i realize this is the internet and is not a substitute for true medical care. im just having lots of anxiety and would love some opinions. 9 weeks of constant nausea starts to fuck with your head.note - I've been on anti nausea and proton pump inhibitors for 4 weeks. i take no other meds including nsaids. there's also no history of cancer/ulcers im my family. im also a middle aged male (early 40s). i have no major health issues, injuries, or surgeries. im an avid fitness freak. seasonal allergies, mild rosacea, and depression are my only real health problems to date.any thoughts appreciated. im in hell. getting help during covid is slow. im miserable and have a hard time living daily life.. ### Response: Most people with changes in their stools between constipation and diarrhea have irritable bowel syndrome. There are related conditions like sphincter of Oddi dysfunction or biliary dyskinesia that also cause RUQ pain and can sometimes affect stool consistency.H. pylori would be unusual with your symptoms, but it can present in many different ways. It doesn't typically cause diarrhea or other stool changes (unless it bleeds, but that's usually pretty obvious). Furthermore, if you get a stool test for H. pylori, and it's positive, that doesn't mean it causes your symptoms. Many people are asymptomatic. It really takes an endoscopy that shows significant gastritis or an ulcer to make a clear association between your symptoms and the effect of the bacteria.Your liver findings are probably not related. We see incidental liver lesions on ultrasounds all the time. But sounds like your doctors aren't too worried. I agree a CT down the road is a good idea. These are usually benign things, like hemangiomas, but worth getting a more clear diagnosis for these just in case.Other things to consider with nausea / belching with higher calorie foods is gastroparesis, which is where your stomach doesn't empty properly.I know it will be hard to get much workup now, but that's really the only way to narrow this stuff down. The tests we typically do are things like endoscopy (probably of most importance in your case), gall bladder scans, and gastric emptying scans..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: thanks for this reply. i should have been clearer. i have had "looser stool" than normal at times. but not diarrhea. i don't believe I've had diarrhea even once so far. not sure if that natters or not. my most recent one (sry this is so gross) was small and seemed to be covered in a whitish substance. maybe mucus from excess production in stomach?also thx for the heads up that a positive pylori test doesn't mean that's the cause. frustrating, but good to know nonetheless.. ### Response: Loose stools would lean towards IBS as well. But its a pretty nonspecific symptom and doesnt narrow things down a ton. :-(.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: There are some parasites that can cause liver cysts and start giving you all sorts if weird symptoms. Did you travel anywhere before symptoms began where you walked barefoot on soil/sand or drank water from a source you dont usually drink from?. ### Response: People sure do love parasites around here. Unlikely the explanation for OP.From your comment below:Entamoeba - This causes colitis, which is bloody diarrhea, not alternating stools and RUQ pain like OP describes.Liver flukes - Almost always asymptomatic. But, easy to check for with a stool O&P like you suggest.Cystic echinococcus - OP had a liver ultrasound. CE would show a bunch of cysts, and should be apparent to the radiologist..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: From what I've learned from House MD, it's definitely either sarcoidosis or lupus.Also, you get an upvote for your username.. ### Response: TuberculosarcoidolupusCANCER..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I was reading this tweet thread from Dr. Monica Gandhi about molnupiravirhttps://twitter.com/MonicaGandhi9/status/1415093950000422912Molnupiravir was not developed for SARS-CoV-2- originally thought of as a broad-spectrum antiviral because it is a "nucleoside analogs". We use those a lot in HIV but they basically inhibit the virus from replicating because this compound interrupts the process of copyingwhich led me to this article in Business Insiderhttps://www.bloomberg.com/news/features/2021-03-25/merck-mrk-molnupiravir-pill-could-change-the-fight-against-covidThe first antiviral approved in the U.S. was idoxuridine, a herpes treatment regulators green-lit in 1963, generations after the discovery of antibiotics. Its among a widely used class of drugs called nucleoside analoguessynthetic versions of nucleosides, critical building blocks of DNA and its counterpart, RNA, the messenger molecule that delivers instructions to a cells protein-making factories. Nucleoside analogues prevent viruses from replicating, or from replicating effectively, inside cells.When they do invest, they have much more incentive to focus on chronic diseases than acute ones, which entail inherently shorter treatmentand revenuewindows. If you look at what drugs have been developed against viruses, you have HIV, you have hep C, you have herpes. Those are all chronic infections. That means longer-term therapy,And so here I am, my High School Biology in mind, wondering how if day to day my cells are dividing and so need to replicate DNA, how providing a drug that inhibits replication is safe, especially for chronic diseases where the drug is taken on a daily basis for well, the long term.For the care and feeding of the automod:I am a 60 year old male, non-smoking, and this question has recurred off and on for a few years now, mostly in by frontal lobe I believe, though friends insist that that is located in my rectum. ### Response: Antivirals like acyclovir and similar nucleoside analogues act only on the cellular machinery within viruses, but not the cellular machinery in human cells. You are right that both viruses and human cells replicate DNA, but they do it in a different way. Some antivirals work on viral DNA polymerase, some work on viral reverse transcriptase, and some probably do something else that I don't know about..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I 34(F) have been seeing a dermatologist over the course of several years, unfortunately Im in a healthcare system that is hit and miss with varying levels of doctors. Its also a healthcare system with a different first language to mine.I have been diagnosed with rosacea and seborrheic dermatitis. My skin goes from angry inflamed redness to dry and flakey.Initially I was advised to use steroids on the redness inflamed areas and to moisturise 2-3 times a day. To be honest, this doesnt work. Im using steroids weekly. I saw a good dermatologist who prescribed elidel cream which is ok, though it has not really worked well enough to prevent flare ups.Since then I was prescribed skinoren (which burns), told to wear sunscreen with multiple application daily and to start tacrolimus ointment. Avoid stress (Im a mum of 2 very small children and a critical care practitioner, so easier said than done).One dermatologist told me to stop steroids on my face as I had ?lines as a result of long term use. So should I completely stop?I cannot start tetralysal as Im breastfeeding.Are my options limited without oral medication? Will the results be worth me weaning?Im feeling pretty miserable as a woman when I can no longer wear make up without significant flare up and people asking what happened to your face?Advice is conflicting, often superficial and although I understand its chronic, will I ever have good enough skin to feel my normal self again? I only developed this in the past 6-8 years.Obligatory: BMI 20, non smoker, enjoy a glass of wine regularly. No other medical conditions or medication.. ### Response: Topical corticosteroids are inappropriate for long-term use. Pimecrolimus is much safer for long-term use and tacrolimus is more potent than pimecrolimus. Many who use azelaic acid use too much quantity and get irritation. Much smaller quantities are appropriate. Adding additional agents such as topical ivermectin and metronidazole may additionally help for rosacea, as could imidazole antifungal agents and similar for seborrheic dermatitis..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 33F, recently diagnosed with PCOS / insulin resistance, high TST, low cortisol.Im at a pretty critical point in getting my hormones fixed and after my appointment today I was notified that if I want to continue seeing the doctor that I see, there is a $100 fee per month to continue under her care. I see her three times a year but they want $1200 to ensure a spot to see her. They were very clear this was not insurance related and would be my responsibility...seems shady?? Hoping some medical professionals can explain it to me if its legitimate since, as it stands, it sounds very questionable. I want to understand.. ### Response: A physician can charge out of pocket whatever they want, not shady. Billing insurance is totally separate. This is a concierge model of healthcare that typically gives a patient more reliable access to their doctor (and is typically more expensive than other doctors). I suggest you find a different doctor that fits you situation better..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: 26F 56 120 lb No medications Non smoker No known medical issues Migraine symptoms approximately 1x/week for the last 4 weeksSo I did an MRA on Friday afternoon and the technicians gave me the results in a CD without any explanation. I didnt have a chance to speak with my neurologist. My boyfriend, who is a senior neuroscience biomedical engineering PhD student and has seen many brain scans before, immediately pointed out a strange deformity in my MRA. On the saggital view in the top middle of the brain close to the motor area there is a bump. His first thought was subdural meningioma. It was dark in the MRA image so he thinks it may not be a tumor because it isnt highly vascularized. Could it be a chat? Could it be a meningjoma covered by a subdural hematoma?Background - about 4 weeks ago I started having migraine symptoms basically for the first time. Nausea, dizziness, feeling out of breath while exercising even though I am a relatively fit person...and I had 3 episodes of mild throbbing pain on the side of my head. So I went to see a neurologist who recommended a MRA/MRI.He tried to book it before Id be set to go out of the country on holiday for 3 weeks - all the way from US to a beach in Thailand with possibly limited access to medical care. We only booked the MRA because the most urgent goal was to make sure it was not an aneurysm.I had yet another episode today - lots of nausea and feeling sort of dizzy and hard to balance at times. And I have my flight tomorrow early morning ... 30+ hours!The main question here is - how likely would it be for my situation to be dangerous enough that I should not get on a 30+ hour multi-flight trip? Any counter-indications towards flying that I may want to be aware of given my symptoms and this MRA result? The problem is that I cant speak to my neurologist until Monday morning - by then Id already be in Thailand (or sick / critically unwell due to the flight?).Any help would be greatly appreciated!! Im ok with flying as long as I can be reasonably sure that I am not putting myself at risk by doing so.. ### Response: Unfortunately, Without the images or report, it would be impossible for anyone to give advice here. Can you call your doctor or the doctor on call before you leave?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Definitely call the Dr on call now.. ### Response: Your symptoms would not match anything you described may or may not be on your MRA images. That being said besides vascular anomalies nothing else can be commented on in an MRA. So seeing dark or light things outside of the vessels does not mean anything, that's what the MRI is for..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: My mom was diagnosed with Diverticulitis/Ischemic colitis on Saturday. I picked up an Rx for her and it said take every 6 hours.Yesterday, I called urgent care to see if taking it every 8 hours was a possibility, as my mother has moderate dementia and it's difficult to get her up in the middle of the night. They said no...has to be 6 hours, but I don't have to wake her up in the middle of the night.This makes no sense to me; if it's not allowed to switch to 8 hours, then it means it's critical to take it every 6...which means I have to wake her.I already have sleep issues, and waking her at 3am every night is going to be a whole ordeal and struggle. Sure, I'd love for her to sleep through the night, but I don't see how they can say I don't have to wake her. It doesn't make sense.I just want to do the right thing. Can someone give me guidance? Thanks!!Edit: I actually called the pharmacy first, before reaching out to the urgent care: they said they could not provide guidance.. ### Response: It is rarely necessary to dose flagyl more than every 8-12 hours, this is sufficient for the large majority of indications as it maintains adequate blood levels. I don't typically give it more frequently than this and work in an ICU with very sick patients. Every 8 hours is a reasonable compromise. There is another medicine called augmentin that is used for diverticulitis and is twice a day.The general push recently has been to not use antibiotics for diverticulitis, though with your mother's age it is still appropriate to prescribe these. But in any event wouldn't get overly concerned about the flagyl dosing interval provided she is getting it more often than every 8 to 12 hours.Remember I do not know your mother's specific situation, so this is not meant to supplant the information from your providers, just that without any other details a less frequent dose of flagyl is adequate..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thanks so much for this. I called her doctor and we'll see them on Friday. Thanks to your prompting, I asked if they would like to make any changes. They haven't yet...maybe because she already started...? Thanks again!!!This was an urgent care so she probably was not seen by an actual physician.. ### Response: I think interrupting the night sleep of an elderly infected woman seems a bit of an odd choice even in the hospital.Give her one dose right when she wakes up, and one dose right when goes to sleep. Then space the others as evenly during the day as possible. (So for example, she goes to sleep at around 21:00 and awakes at 7:00 her doses should be at: 7:00-11:30-16:30-21:00).On the other hand, the active metabolite of metronidazole (flagyl) has a half-life of 9-19 hours. So taking it more than thrice daily is also odd..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Thank you much. It's 250mg. I called her GI doc to update them and to see if they want to do any changes, and they scheduled to see her on Friday She was seen in an urgent care so probably these were not prescribed by a physician. ### Response: Fair enough, in my country every antibiotic has to be run through an MD (we don't really have DOs), so I assumed the same..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: [16M] So 2 days ago i felt pain on my right eyelid, the pain is like bruise, I don't really care about it. The next day the pain wasn't gone, so I checked "Inside" of my eyelid and it's more red than the left side, now i am worried about this. My current hospital only accepts critical/emergency cases so I can't go there for now. What should I do about it? Is it bleeding inside?Edit : Nearby pharmacist says it's an infection/allergy and gave me eyedrop "DexOph", could this help me?. ### Response: Ophthalmologist here. The picture isnt great, but it looks pretty normal to me. I wouldnt just use Dexoph without seeing an ophthalmologist. Dexoph is dexamethasone which is a steroid. Unregulated use of steroid eye drops can lead to both premature cataracts and glaucoma.You should go see an ophthalmologist.Edit: can you upload a higher pixel picture of the affected eye along with a picture of the normal eye for comparison?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Female, 50, 5 5, 215 pounds, never smoked, seizures, chronic stomach issues like abdominal migraine and ileuses, breast cancer.I have lifelong chronic digestive issues, stemming from a major exploratory surgery when I was 5 years old. About 20 years ago, I started having major issues requiring hospitalization with NG tubes and all kinds of other fun stuff because of the adhesions from the 1974 surgery hardening and choking my intestines.Starting in 2006, after many other things failed, doctors treated both the pain and the hyperactive bowels using Dilaudid. Over the past 13 years, my tolerance has increased, through absolutely nothing but closely monitored physician prescriptions and instructions. Through all of these years, I have taken some hefty narcotics for about one week every month, and not at all the other three weeks. I have thanked God a thousand times that I don't appear prone to any type of addiction (Never smoked, drink a couple of times a year, no illegal drugs whatsoever, couldn't care less about gambling, etc. My worst vice is Amazon.)Between this and absorption/metabolic condition, I get extremely little relief from the highest oral dosage that my PCP is comfortable with: 8mg every 6 hours.I'm currently in breast cancer treatment, halfway through Herceptin infusions that are supposed to continue through September. From the very beginning, Herceptin gave me diarrhea, and it has worsened to date to the point that I am in the hospital about one out of every three weeks because such severe diarrhea that I am dehydrated, critically low on magnesium, excruciating cramps because it flares my chronic condition, and you can imagine the rest.Two weeks ago I went to the emergency room with the usual symptoms, was given my now usual dose of two milligrams IV Dilaudid immediately followed by 1 mg every 3 hours for the next 8 days inpatient. Normally, they start tapering off by spreading out doses around day 4 and I am home and much more comfortable by day 8. This time, however, they noticed significant thickening of my colon on a CT scan, so on day six, when the Dilaudid had just calmed my bowels and decreased my pain, they had me do colonoscopy prep, which not surprising brought excruciating pain back with 18 hours of non-stop diarrhea.SO... hospitalist has access to 13 years of hospital records outlining the progression of all of this, has recent records showing mastectomy, Herceptin, labs consistent with six months of diarrhea... yet still harangued me the entire visit, accusing me of being there basically faking it for the Dilaudid. I could never keep him focused enough on my actual issues to get any help from him or get any questions answered because he was so convinced that there was no illness, only addiction. He claimed he read my records. I couldn't get him to call any of my other doctors. I couldn't get him to look at the December prescription bottle the nurses took from my purse and locked up that was still half full. The day of the colonoscopy, for the first time in my life, I told them I was a 9 on a scale of 1 to 10 in pain ... I'm very conservative with those numbers. Asked if I could have just one dose of 2mg of Dilaudid to get me back on track and was denied. Then he started the discharge process that day... with renewed diarrhea every couple of hours and 9 on the pain scale AND no tapering of Dilaudid. Being on Medicare (disability on the first try, approved in 2017 in less than 90 days due to the severity of illness), I threatened to report him because I didn't believe I was ready for discharge, and he told me with hostility that I could stay one more day but then I was out.I was discharged with the same level of diarrhea I went in with, more pain that I went in with, and spent three lovely days in bed crying my way through Dilaudid withdrawal. All caused by a doctor who lectured me for 4 days on the opioid epidemic. I can't imagine how many people would have become addicted in my situation instead of just gutting out the withdrawal.How do I get this to stop? Isn't there any overarching agency or physician type or anything I can do to have it documented once and for all that there has never been an addiction problem and that there is a room full of files documenting the illness and the reason for the medication?I'm seriously considering stopping life-saving breast cancer medication because on top of all of the pain and diarrhea, I can't face another week like the week he put me through. This wasn't my first experience with a doctor so obsessed with this notion, but it was by far the worst.What the hell are people with decades of documentation, debilitating chronic illness, and zero evidence of any addiction at any time supposed to do?. ### Response: I read it somewhere in this but you need to 1) go to a pain clinic and 2) have a medication contract that may even cover pain crisisDilaudid isn't a great chronic opiod and ideally you should be switched to methadone or buprenorphine, but again, that's something that should be discussed at the pain clinic.Also, I would reexplore with a GI your hyperactive bowels and see if you can find an alternative to opioids for it's management..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Awaiting my follow up appointment after questionable minimal supravermian atrophy that was found on my brain MRI last week. Im unable to find valuable information with the phrase supravermian atrophy online. Im hoping someone can shed some light on what a finding like this could possibly be related to. Im too impatient to wait until my follow-up to learn more about it.27F, 5 8, 138 lbs, European ancestry. I work full-time as a critical care RN in a peds ICU. History of gangrenous appendicitis age 5, Guillain barre related to a suspected tick-borne pathogen age 8, asthma (controlled by corticosteroids,) anxiety (relieved with PRN benzos,) vasovagal syncope episodes during ovulation since the age 16. I spent my early childhood on military bases with known toxic contamination (Fort McClellan, Fort Bragg.) I dont do drugs, I drink maybe 1-2 times a month. PALB2 & CHEK2 gene mutations. Dad was diagnosed with stage IV Glioblastoma, age 48. Paternal uncle died of a brain tumor age 3. Paternal aunt had endometrial cancer at 27. Mom has history of substance abuse, Sjogrens, rheumatoid arthritis. Maternal grandpa received a heart transplant (acquired heart disease,) maternal grandma and aunt had ductal cell carcinoma (after menopause.) I was out of work for over a month due to an intermittent fever ranging 99-103. No pathogens detected in my pancultures. Blood work was normal: CBC, BMP, TSH, HIV, Syphilis, B12, Vit-D, thiamine, folate. In the past year Ive had the following symptoms: fatigue (I could sleep 16 hours a day if I was able,) dizziness, occasional double vision, compulsive sighing/feeling out of breath, itchy/burning armpits, twitching throughout my body, headaches (~3/week,) cold hands and feet, high blood pressure, stress and urge incontinence (especially around ovulation,) severe abdominal pain right before a bowel movement, sometimes I pass out from the pain. Ive noticed changes in my speech: fluency, long pauses between words, losing track of sentences. I cant hear people or retain information unless Im staring directly at them, and I have worsening sound sensitivity. My memory has suffered. I will quickly lose new information and have difficulty recalling information on the spot. I find bruises on myself because Im clunky and clumsy.I want to feel young, healthy, and happy. Please help.. ### Response: Can you post the full MRI report? I too have trouble understanding what that term means; the vermis is a part of the cerebellum, but the space above it (supravermian) in my experience refers to a space containing CSF, not brain tissue..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Hi so I (23f) have had a sudden onset of joint pain mostly in my hands and arms. It may have been more gradual than I noticed, but this week has been very brutal! Its like my finger joints are just VERY achey and my elbows are also in pain fairly frequently (mostly when my elbows are bent).I work on a computer all day, but am not a typist. I am usually working on excel spreadsheets doing data analysis which I guess I never thought of as typing as its more of a critical thinking thing as my main task. That being said my hands are on a keyboard for the majority of the day.Now my FIL had surgery for carpal tunnel syndrome last year, and it feels like exactly what he described and I am panicking a bit bc I didnt really think that I was a candidate for having this issue so early on in my life! Is it possible that I have carpal tunnel syndrome? What else could it be?Im just scared of the financial ramifications an issue like this may have (Im broke as shit!! But I do have insurance!), but I obviously want to take care of it ASAP instead of letting it get worse. What should my course of action be/how long should I wait before getting it checked out in person?Thanks in advance for your time!ETA: not sure if this is relevant to this issue, but I am in relatively good health. I am overweight but have lost around 50 pounds since the beginning of the year and am well on my way to a healthy weight. I eat mostly cleanly and walk a lot. I used to be an avid weightlifter but have not gotten back into it after a knee injury in 2018 (big part of how I became overweight... lack of movement & depression from losing my job & other stresses due to my injury). I also was a 4 sport athlete in high school: softball, swimming, track & field (discus & shot put), and volleyball. I dont know if any of this is helpful but if it could be a contributing factor I thought I would mention it.. ### Response: Yes, it's possible for you to have carpal tunnel- it just really depends on your level of activity with hands.You aren't locked into surgery. I'd start with getting an ergonomic setup for yourself and taking frequent breaks from typing. I would also look into getting a wrist brace to sleep with at night, and begin using that for a week or two and seeing if you improve. Chances are if you take early action you won't need surgery for quite some time- if ever..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Wow, that is great news! Will that help with the elbow pain as well? Also do I still need to see a specialist or set something up with my primary care physician?. ### Response: It can help with the elbow as well, yes.If you end up seeing a doctor they will tell you what I just did. I'd say hold off and start with what was mentioned unless it progresses significantly or it starts actively impacting your ability to function..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Hey, for the past year or so I've been smoking socially (about twice a month). I know that death/critical care rates are much higher for smokers, but I haven't smoked in about a month and don't plan to start again so where does that put me? I'm an otherwise healthy, moderately fit 18 year old. I know info isn't available for covid19, so if you know this regarding respiratory infections in general let me know, anything is helpful. ### Response: Puts you somewhere between the smokers and the non-smokers, closer to the non-smoker side of things. Good on you for planning not to smoke again. That's about the best thing you can do..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Age: 30sSex: MaleHeight : 5Ft 8inWeight: 180Race: LatinoDuration of complaint: 5 months+Location: Texas, US. Abdominal pain, blood in stool.Medical Issue: Had recurring blood in stool that increased in intensity and frequency. Saw doctor and prescribed Cipro after which frequency of bowel movements and amount of blood increased. Given prednisone which seemed to increase amount of blood in stool. Had CT scan of abdomen which revealed hepatic mass lesions. Primary care doctor advised and arranged for admission to emergency room for an MRI of the abdomen. ER doctor however reviewed scans from CT and believed they were cysts and wouldn't proceed with MRI. ER doctor emphasized need for colonoscopy first which I have scheduled for 31st, but he worries that is too far away. For reference it took me 6 weeks to get the CT scan. I didn't get a referral/authorization for an MRI from my primary care doctor. ER doctor told me to return on Monday and that I may possibly be scheduled for colonoscopy through their hospital. How critical is all this? I'm worried as I now have to wait the weekend at minimum, but likely will have additional weeks of waiting for paperwork/insurance authorization/scheduling before I can get these procedures.. ### Response: You didnt mention any blood test results (e.g. liver function test).Also, did the imaging study not reveal anything in your GI tract?Either way, yes you should undergo a colonoscopy as soon as possible. The results of the colonoscopy will inform further management decisions.If you feel like fainting, or experience any symptoms that you consider to be drastic, go to the ER.Best wishes..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Sorry in advance for the formatting. My mother is the patient. She is a 62 year old female, 52, ~140 lbs, a caucasian, and she has several issues with chronic pain/osteoporosis/degenerative disc disease/some nerve issues/arthritis that her doctor has prescribed a 12.5 mcg fentanyl patch for that she changes every two or three days. She was on a higher dose when she started using the patches but she did not like the side effects, so her doctor cut the fentanyl dose in half to 12.5 mcg. She is taking lexapro, wellbutrin, a blood pressure medication (I think bystolic), montekulast, and possibly a diuretic (unsure if shes still taking that) daily. As needed, she is prescribed voltaren gel and voltaren pills, Valium, and norco (hydrocodone 10/325). She has some additional health issues that arent relevant to my concerns (high bp, asthma, primary lymphedema, some allergies. Dementia runs in her family, but the people who have had it have all been very sharp until their early 80s.Since she has been on the fentanyl patch for a few months now, my fatherwho is a physician himselfand I (who live with her) have noticed some very concerning things. We all see the same physician, so he knows all of us and our character. I would like to tell the doctor about these concerns using a letter, but Im not sure if Im being too wordy or if I should contact him another way. Please give me your constructive criticism as to how I can effectively communicate with him so these concerns get addressed. Heres what I have written:Dr. Doctor,I am writing out of concern for my mother, [major_bummers mom] (DOB XX/XX/XXXX). I am aware that I have no power regarding my mothers care and no right to her personal health information. However, as a daughter, I have some concerns regarding my mothers current usage of the fentanyl patches you prescribe her. I wanted to reach out to you about them personally because I dont think she has the mental ability to realize how much of a toll these patches have taken on her. I realize not all of these concerns I have about her cognitive ability/memory/ability to preform daily functions could be attributed to her use of the fentanyl patches, but the timing leads me to think it is the cause.My father and I noticed that about two weeks after my mother began using the fentanyl patches, her overall productivity became much less than normal. She is now spending her days sleeping as much as she can (10 hrs per night with a 3-4 hr nap) and gets a significantly less amount of work done compared to before she started using the patches. She says she thinks her pain is under better control with the patch, but her avoidance of physical activity and her daily complaints of increasing or new pains tell me it is not working as well as originally hoped.My mother has seemed to slowly lose her critical thinking skills, her ability to remember things, and speak/think at her normal speed. She was the type of person to remember where everything in the house is, even years after it was put somewhere, but now she has started to lose things such as everyday items, important documents/records, and even her own controlled medications. (She normally hides them so she has to think about where they are before taking a narcotic, but recently she forgot where she put all of her scheduled medications and had my dad and I flipping the house upside down looking for them for about 6 hours. She also separated one fentanyl patch from the others and has been saying she has been unable to find it for days, making me wonder if she actually put two on.) Along with my concerns about her memory is that in the past month and a half or so, she has started remembering things that have never happened/things shes made up in her head and has been unintentionally giving my father and I completely false information, which has caused a lot of frustration within the family. She will become unnecessarily upset with us as she genuinely doesnt realize some of her memories are extremely inaccurate or have never been real. Usually, this results in an argument with her until she either gives up or understands our explanations as to how and why what she remembered couldnt have happened. She often asks the same basic question (such as are you going to work today?) several times per day because she doesnt remember the answer from the first three times shes asked. Her accounts of something that weve both seen are usually inaccurate.On bad days, her speech is sometimes very slowalmost incomprehensibleand my dad and I have to either work on completing her sentences for her or ask her to form a complete thought/statement before speaking. I dont feel like the person Im talking to is my mother and is instead someone that is either mentally handicapped, drunk and drowsy, or demented. She often seems mentally absent or half asleep when I am trying to have a normal conversation with her, even with no distractions.Lastly, my biggest concern is that her ability to react to things has slowed down substantially since she began having a strong opiate in her system on a constant basis. When I have the opportunity, I ask/offer to drive her places because she is a danger to herself and others behind the wheel. She has made a habit of going below the speed limit and stopping at places she has the right-of-way to be a safer driver, in her words. This is a woman that used to love to drive fast cars on racetracks. She has started to slam on the brakes when she approaches a stopping point because she does not slow down in time to stop properly/safely. It seems that her situational awareness has taken a nosedive since she started using the patches. If she were to cause an accident, which she has almost done on many occasions since starting the fentanyl patch, a police officer would absolutely see she is driving while incapacitated/under the influence of a drug.It pains me to see my mother like this and hope you understand my concerns. I am grateful for your time reading this letter and hope you will keep my observations in mind when proceeding with my mothers care. My family and I very much appreciate all that you have done for us. If you need further detail or have any questions, please dont hesitate to give me a call.Sincerely,Major_bummerEdit: added some additional health information and fixed grammar. ### Response: Make it shorter and send it. The goal of pain management (in patients without terminal illness) isnt to completely eliminate pain or get people on government disability. Its to get their pain to a level that is tolerable enough for them to main functionality (keep being employed, for example). Sounds like your mom is on too many narcotics. Based on the problems you told me (all musculoskeletal), she probably needs to be tapered off narcotics completely..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Would a bulleted list be more appropriate for a busy doctor?She has been on narcotics for years as her spine is not in good shape at all (we almost went overseas for better spine surgery technology but couldnt afford it) so I doubt shell get off of the narcotics entirely anytime soon. Shes one of the few patients with enough pain that she qualifies for disability and deserves a relatively strong opiate, but not as strong as fentanyl. I still feel like she was doing better mentally taking more hydrocodone daily instead of using a constantly releasing fentanyl patch. Granted I wasnt in the room when he initially prescribed the fentanyl patches, but it seems like a huge leap to go from 3 hydrocodone per day to fentanyl without trying something like an extended release opiate that isnt as strong as fentanyl + comes with less risks. I know shes tried things like gabapentin and lyrica before but her body didnt like them too much and she reacted to them strongly.. ### Response: There is no evidence that opioids work any better than over the counter meds for chronic, non-cancer-related musculoskeletal pain, so your assertion that she deserves a strong opioid is specious at best. Fentanyl is no better or worse than long-acting opioids, it is the dose that is most important. Regardless, her current situation is not acceptable (being zonked all day long) and I would argue that you have an obligation to notify their prescriber..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Age 16Female110lbs, maybe lessRussiaHello doctors,Our relative was hit by a car. We don't know many details at this time except that she is out of critical condition, but still unconscious.The reason for posting is because it's Russia and for most part, doctors don't really care for their patients, especially if it's a public hospital.Can someone please tell me what are some of the must be done tests, scans, blood work after an accident.Thank you. ### Response: It's impossible to know without knowing how exactly they were injured. I would assume that if she is unconscious, they would do some kind of imaging of her brain to make sure there isn't any bleeding in there..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: For example, this morning we had a 63 yo patient that had been sinus tach since her admission a day or two ago. She was alert but not fully oriented during morning rounds. This morning, over the course of an hour, she slowly went from 115 to the 40s. She ended up bradying down and a code was called. There was a short run of vtach right before we started coding her. She ended up regaining spontaneous circulation and was moved from step down to ICU.As far as her history, I barely saw her chart. I know she was suffering from c diff and chest pain. There was critical care protocol for fentanyl and propofol but other than that I have no idea.Is this something related to electrolytes? Cardiac issues? Need more information? Her ekg strips were normal sinus tach prior to the event. Ive also seen this in other patients that were DNR where they just Bradyd to asystole. Any insight is appreciated.. ### Response: Definitely need more info. Bradying down essentially just means someone is dying. So for that patient in the ICU I'm gonna assume she has lots of possible reasons to die. Electrolytes absolutely, acid/base yes, hypoxia, hypotension, MI, PE etc etc. The list is literally endless. Brady codes are the most frequent ones I have seen usually..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I'm trying to understand a current family situation where I believe doctors are being hasty with care.My brother in law, about 30 years old 6ft 250lbs, is currently in the hospital for acute pancreatitis due to alcoholism which stressed the one kidney he had (genetic one kidney). He's currently sedated on vent, dialysis crrt, and insulin drip. He was admitted a week ago after he called an ambulance. With only symptoms being nausea and stomach pain. Since being admitted he was bumped down to 30% oxygen with breathing therapy, 5.0 PEEP, and his vitals and blood work were all in normal ranges for an adult male. Then they lessened his sedation and he was responsive. Hand squeezing and pointing. However other blood work and vitals dipped a bit after he had breathing trouble from bile due to pancreatitis.Additional: I think initial intubation was due to shock/hyperventilation upon admission or lung infection? Doctors have said all organs are viable. Torso MRI showed a good gallbladder, liver, and lungs without liquid. Family told they should not worry about organ donation yet(family match donation to improve health). Organs are not necrotic.I'm not trying to decide if my BIL needs a DNR. That's not my choice to make. I'm just curious how doctors factor offering it or when it's needed.TLDR; So, why would a doctor recommend a DNR for such a young patient that could seemingly recover? When do you consider patients to be at a point of no return? Is it standard to ask any critical patients to sign a DNR? Do Doctors weigh stats before offering or just their judgement?If you were this patient would you ask for a DNR?. ### Response: Your BIL is critically unwell and requiring multiple organ support. He has de-facto multi-organ failure because his kidneys are needing dialysis, his blood pressure is being supported by drugs and he is being ventilated for what sounds like ARDS.The DNAR is if these things stop working, so he does not undergo futile CPR. If he recovers and leaves ICU theyll tear that DNAR up (or you can ask them to), but it wont affect the quality of his care to have one in place.Currently -depending on where you are- he isnt a transplant candidate due to the alcohol, as well as being critically ill..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Absolutely this. DNR is NOT the same thing as comfort care or withdrawing life sustaining treatments. Them asking about a DNR in this case probably means they think he is unlikely to survive or have a good outcome from CPR. But its important for everyone to consider what they would want done if they were to have a catastrophic health event, regardless of their current health.Okay but studies have shown that a DNR can result in lower quality of care, and typically do. In the BIL's case, although he is critical, he is responsive, and has only been in the hospital for a week. He has made significant recoveries like oxygen levels being reduced and other blood work levels being stabilized to healthy amounts.We are being told both organs have capacity to recover or with the kidney some function. They aren't necrotic. Couldn't he still qualify from a family member match willing to donate? Doctors have not moved towards that idea either.I guess my question is- how does a doctor stack the odds like that? Yes, on paper he has three machines doing organ functions. But is there not potential for recovery? If the oxygen intubation progresses with therapy, he could also remove feeding tube. There is also potential for getting pancreatitis managed, and kidney support with regular dialysis treatments or donation.Does a doctor weigh statistics or is it just judgement? And what helps them make that judgement? Because I feel like someone with the potential to recover, who is pretty young, would not be a candidate for a DNR.Now if there was a clearer document that outlined CPR in a worst case scenario then yes I see that. But signing a generic DNR with chances of recovery and treatment options seems very pessimistic. Especially given that BIL has a condition that can cause asphyxia and there have been cases where DNRs do result in vent being removed.. ### Response: Simple answer is at the moment none of his organs need replacing- or rather theyre broken in a way a transplant wont fix. An organ isnt like a broken gear, the whole system needs to work for the organ to work.And nobody is taking him off life support prematurely due to a DNAR. Its simply stating if his heart stopped beating that would be the end of treatment. irrespective of age, if he reaches that point he isnt surviving in his current condition.As previously mentioned, if he continues to make progress forwards then theyll tear up the DNAR anyway, but at the moment your BIL is not somebody I would expect to survive chest compressions- it would be another organ not working, without the ability to support it or replace it to ensure survival..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: When you sign a DNR it isnt just a genetic DNR. There are different sections to it. It asks if you are ok being on a vent if needed. It asks if you are ok having a feeding tube if needed.You can be ok with life support, just not CPR if it comes down to it.. ### Response: This is a difficult question to answer without knowing the full clinical picture. What is his day to day ventilation settings? Just because he is down to 30% doesn't meet his PEEP is down. How has his spontaneous breathing trials go? What does his CXR show? What do you mean the blood work is great? What are his I/Os? How is his kidney function?.


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: He's got a feeding tube because he's been sedated. But he's had bowel movements. Constant IV hydration drip but no urine in catheter.They had been doing breathing therapy with him that is when they lowered his sedation and oxygen. He seemed to be doing better with 30% and then bile in the tube then his condition worsened. He's now at 50% again. They have done several torso scans but they haven't given details on the scans diagnostics.That's most of what I have based on what I've been given. They said his kidney and pancreas are not necrotic. He did have an infection in his lungs when he was admitted but they cleared out several days ago. However since he had bile with the intubation he has liquid in the lungs again.. ### Response: There's far too many details still being missed here to state that his care is hasty. You have an individual who has one kidney on continuous dialysis while having low blood pressure. He is making no urine at all. For some reason, he was intubated for pancreatitis, so I assume it was because of ARDs. He sounds critically ill..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: To clarify, just because the organs aren't necrotic doesn't mean they are functioning. Also organ donation has nothing to do with DNR. The appropriateness of someone to donate only comes after they have died or are literally about to. In the US people self-declare at the DMV so the organ donation services already know their intent in most cases.He has multisystem organ failure, plus underlying conditions which will make his recovery harder than someone without those (alcoholism, solitary kidney) based on what you have written, so it is absolutely imperative to find out what his wishes might be regarding code status. In the absence of any clear directives from the patient in the past, the family is asked to predict what the patient would choose for themself if they were able to sit in on the discussion and weigh in--basing this off of past comments, how they engaged (or avoided) healthcare interventions on their own, etc.I suggest that his designated healthcare agent and any other family present, have a care conference with the intensivist. This is a time set aside in a nearby conference room, not at the bedside or in the hall. Include one of his nurses if possible, any specialists who can make it (often harder to arrange) and then the unit's social worker/case manager. The purpose is to outline exactly where he is on his trajectory, what the major challenges are, what the expected chances of recovery appear to be at this point, and then a discussion of next steps. Find out more about why the doctor was recommending DNR. Hear what they have to say about this based on their experience. It might be because they don't feel he will likely be resuscitated if they make attempts, therefore, to attempt shocks and compressions would be futile. If they feel it would be futile, then it would represent only harm to the patient and not comfort or cure. I cannot predict what they are thinking so you need to find out, but this has been my experience from working in ICU as an RN and Care Manager.If he cannot be weaned off of the vent shortly, he will need a trach and a PEG (feeding tube in his side). If he stabilizes enough to be discharged from ICU (off of CRRT, off of high vent settings, off of any vasopressors that are stabilizing his BP, only on X number of antibiotics, etc) then he will meet criteria to transfer to a ventilator rehabilitation hospital or LTACH (long term acute care hospital).If this happens, it is a long slog. Is it something he would want? Also, he might not survive it and could have a downturn at any time, heading back to the hospital. Knowing this, is this something the family would predict HE would want? If so, you have your answer. If not, then it is appropriate to consult hospice to make him comfortable. Another service to consult if you have it available is Palliative Care. In many hospitals they are consulted for complex cases like this who are taking a long time to recover. They are particularly helpful to the patient to improve quality of life while recovering, as well as provide support and guidance to family.At the end of this long post, I offer you two things. One-you are in my thoughts. I know how difficult this is and you are on a crash course of learning right now. Two, please use this resource that many families in your position find extremely helpful--patients let us know so often this has helped them in cases like yours: Hard Choices for Loving People booklet. ### Response: If this was me I would want a DNR and a DNI signed. More importantly, I would want a MOLST form singed indicating exactly the care that I would want, the care that I don't want, and for how long. That is to say, give me antibiotics for one week and see how I do, if nothing's happening then stop all unnecessary treatments.What I like to see in patients is an end goal. What happens far too often, is patients will sit in an ICU for an extended period of time deconditioning and not getting better, but family does not want to do anything for fear of making the situation worse or feeling like they are murdering a family member by taking away care. Recognize that his pancreas is not well at all. His kidneys are not well at all. His liver is not well at all. Assumedly, his lungs aren't either.Let's say he is extubated. Now we have a burnt pancreas. And kidney. And liver. If you are this young and have liver dysfunction or failure, that's a life of slowly getting sicker and sicker until you can possibly but probably not get a liver transplant in the future. It's painful. If his kidneys are truly shot and he requires dialysis in the future, that's 50 years of spending 3 days a week going to get dialysis and sitting there having your blood cycled over and over for hours, just to go home and not feel well. Then you do it again. Then you do it again. That's a lot of stress for a 30-year-old. A 30-year-old that already has alcoholism. If your pancreas is constantly becoming inflamed, diabetes maybe in the future or at least insulin dependence. A 30-year-old diabetic will have a low quality of life.DNR and DNIs are to preserve a patient's dignity thinking about the long-term consequences to their health and quality of life. The idea that saving people is enough, is not enough. By stating do not resuscitate, You're saying to give a chance, but don't take it farther than he would like given all that has happened, and will happen in the future.The doctor sees this all the time. The doctor sees a family that holds on to hope that everything will be okay because their family member is " a fighter, " but neglects to see that the patient has already fought 25 rounds and has been knocked out three times. And also neglects to see that, if they come out of the fight, they essentially will have an agonizing future for the rest of their life..


Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Hello Reddit,My younger brother was 27, Male, maybe 6 foot and 375 pounds, half white/asian, no drugs, no smoking, extremely rarely drinking (like less than once a month).I don't recall what his early symptoms were but I found a virtual chat that said he may of had "uncomplicated cystitis" and had antibiotics prescribed for it. He saw a urologist and eventually had a nephrostomy tube, then had surgery later and was noted with a failed kidney. They were unable to remove it due to his weight and having hemorrhage concerns, at least that was my understanding, and that's it for a his existing medical condition, with an exception.I'm first wondering how he developed this condition to begin with. Would the failed kidney have caused the infection? I wish I had the full records so I could paint a better picture, but ultimately I can only guess that his high blood pressure was a cause, plus having a high stress job.Ever since all this, he had to urinate every like hour and this caused issues with work and sleep. I really don't understand why this kept happening and nothing was given to him for it. Would having a failed kidney cause that? This started back at the end of 2020 and the tube and surgery may have been in Q2/3? I now can't remember what happened first.From that I'm mostly wondering about the reason for frequent urination and if he would have got infected some other way outside of high blood pressure. He almost never leaves the house, and I fear he'd only get sick if a family member came home with something.Fast forward to the bulk of my reason to post. On January 13, 2023 he mentioned some nasal congestion and some body aches. He didn't seem to get better on the 14th so I asked if he wanted to see a doctor and he said not yet. This eventually came with some headaches so we tried to go to an urgent care but the wait times were 3+ hours so we figured try a Teladoc (98point6 for this call) and get an appointment later. He mentions a head ache lasting 4-5 days, dull/sharp pains in waves from front to back, also going behind his eyes. He was taking ibuprofen, and was asked about a fever and he said he wasn't sure but his head seems warmer compared to his body. They basically said to take Afrin and Excedrin and go to urgent care if things don't get better. When he went to take the afrin that night, he blew his nose and had a nose bleed, and per our father he had nose bleeds from time to time, but not that super often.Come January 19 I take him to urgent care and I do have his visit summary. Blood pressure 174/89 (why the fuck didn't anyone talk about this), temporal temperature of 98.1 (maybe the medication lowered it?), pulse 90, respiration 18, oxygen saturation 97. They gave him Toradol and sent him home. I feel like a fucking asshole that I wasn't in there with him, I had to drop him off and attend a work meeting that I should of canceled, and our mother picked him up. This is all very local, like within 15 minute drives.He doesn't seem to get better and on the 22nd he talks about some vision issues so I immediately take him to the nearest ER, which is a satellite and not attached to a large hospital. He goes to a back room almost immediately after checking in - alone, and again I feel like a fucking loser as I should of gone there with him to help explain everything - who knows exactly what he said since he was dealing with headaches. I did come back and talk to one of the nurses, but that didn't seem to change anything they expected.He had the following lab tests done, CBC With Diff, CG4 PANEL POC, Comprehensive Metabolic Panel Poc, PCR Influenza A & B and Covid 19 (POCT). Also had a CT Head W/O Contrast and EKG. Done today was just the CG4 and Comprehensive Metabolic, guess the CBC was still processing? I don't recall any notes on this, and his MyChart is closed.They didn't seem to find anything, even though he had a 171/105 blood pressure, they did ask if he had history and I didn't have a full answer, but said it wouldn't be surprising since the rest of the family has medication for it, but he didn't have a primary care doctor to prescribe it. He had trouble finding one since COVID and it really pisses me off that I didn't help him find one somehow. He also had 100.1 temperature.They gave him .9% NaCl (NS), tylenol, benadryl, toradol and reglan, and sent him home.The next day I don't remember exactly what triggered this, maybe balance, but we took him to the ER attached to the hospital and the doctor almost immediately said he wasn't going home that night, he saw something. They put him in a gown and my brother was shivering mad, and he normally likes it cold. Sometime that night I believe he got a room and had some tests, and they said he had meningitis, and shortly after was uncertain of contagious so the room was adjusted and we had to wear N95 masks and a face shield / gown. This went for maybe 2-3 days, and it bothers me so much because this was the most critical time that I could of had talking to my brother and I minimized my time like a coward and asshole. I believe our mother was there the whole time though.After that 2-3 days it was cleared for bacterial and said likely viral (they never said what he had) and the additional PPE was stopped. I remember he texted me to bring apple juice, yogurt, and fruit cups, which I did, but asked if it was okay because I thought hospitals didn't want outside food. They said it was okay as long as it conformed to a low sodium diet, which those did.During this I know he had a lumbar puncture, which is likely how they found the meningitis, and had a CT/MRI that they said was clear. Then suddenly the next day he developed delirium. He was able to answer our questions and knew who we were, but it was like he was living in a video game or something. He'd also spring up very quickly pulling wires to urinate (and frequently) which caused concerns for the monitoring and fall prevention, since he was a little wobbly and I think bumped his side one day because of the bar being down for the accessibility access for the toilet.The doctors believed the delirium was due to his lowered sodium levels, which could have been to the frequent urination and low sodium diet. He was drinking a ton of Gatorade at home back home, probably around the 16th I was buying him multi-packs as I felt those helped me recover. Eventually they put him on a EEG and because of the frequent getting up and sometimes he'd just try to rip the things off, they restrained him. I wasn't there when it happened but our mom was there and it sounded a little traumatic, like saying "why are you doing this mommy, and then attempting to bite her". Not sure if that's exactly what happened but he was restrained. Either at that point or shortly after he did have a nurse assigned to be next to him 24/7 to monitor, and help him pee as he'd be responsive if he had to go and the nurses asked.During this delirium he'd talk about random stuff, sounded like he was in a game, he couldn't explain where he was, but he was still answering questions. Everyday I visited I'd ask if he knew who I was and he'd start by laughing and saying of course, and I had to be more specific with him and he'd confirm my name and that I'm his brother. During this time we had a family member with him 24/7, but would occasionally talk to him, I know I'd hold his hand and he'd squeeze back, but we'd end up sitting to the side talking to each or reading a book, etc.Finally on the 30th I was coming in to swap out with our father, who said that my brother was a bit quieter today, maybe he was finally getting some much needed sleep as it seemed like he wasn't getting any. I also noticed that he had an oxygen tube under his nose, which wasn't there before. I didn't want to wake him so I didn't do much, and this was the first day I decided to pop up my switch and play some yoshi crafted world, and I kept one ear bud out just in case.I know he had a lumbar puncture done either before I came or just as I came, and an MRI earlier (might have been the previous day, it's becoming a blur now and I hate it) and the neurologist said they see a lesion, and it looked like one of the quadrants of the brain. I honestly can't remember but it felt like a sizable portion. I also looked at the EEG from time to time as I assume they were looking for seizures and I swear I saw alerts on the machine detecting them.This was the first time that I was going to pull the all nighter, and it was normally our mother that would do that and I offered to stay but she wanted to get some rest which I understood. A bit after I was there I noticed they swapped the tube with an oxygen mask, and I regret to this day that I did not look at that monitor better, seeing if oxygen was dropping, etc. There was a nurse there but I don't know how well they were watching, I swear one of the guys before was on his phone most of the time. I remember there was a night shift change, and I don't recall how long after before the most traumatic part happens. I did ask if my brother snored normally to our parents, as I never really heard him sleep and our father said yes, and he should get a sleep study done. It reminded me of our father's sleep apnea when napping on the couch during movie night. I don't remember how long this went on for, but I think they adjusted the bed height or something, don't remember... yet another thing to add to my list of regrets.That night after playing a bit I remember my arms getting tired so I pulled the little side table near me to prop my switch up on so I could just use the remotes, and all of a sudden a bunch of nurses come rushing into the room and one of the nurses checks his neck and says no pulse, then a code blue is called. I am escorted out of the room and just panicking. I don't remember hearing the monitor beeping prior (remember 1 ear bud and I had the volume at like 1 tick), and I don't recall him snoring just before either. For all I know the sensors were faulted and he was out for awhile, I have no idea how immediate it was, or if maybe the table pulled/squeezed the oxygen tube (this all happened in like 10 seconds). I know that his monitor was beeping a lot earlier due to his blood pressure, and I don't know if they gave him medication, but I don't remember that monitor beeping at all that day. Maybe the last nurse silenced it? I don't know. I also don't know how well the nurse was watching. One of the nurses in the morning/afternoon was great and I know she was looking at his face and the monitor with great focus, and I fear the night nurses not so much. I know the nurse that night was from newborns, and just helping out.I don't understand why or how he code blued, how quick it was, or anything, but I know it took them over 20 minutes to bring him back and he was on a ventilator. They did the 24 hour thermal treatment of going cold then normal, and after that for the next few days they'd do an eye test and pain test with no responses. On February 1 they did some test with a dye to see blood movement in the brain and I saw the results that night saying there was little blood flow but not clinically brain dead. I had a spark of hope but knew I wasn't a doctor. The next day we talked to the neurologist and confirmed that he was indeed brain dead and I felt like I lost my brother for the 3rd time in that hospital. Once during delirium, then the cardiac arrest, and now. We had to decide when to pull the life support, and I watched him officially die, for what felt like the 4th time.Having to find the courage to join our father for the funeral arrangements, then the funeral which was a visitation before cremation, then picking up the urn a week later, it's been waves of trauma and it still feels like yesterday a month later. Everyday I've gone home to see my parents, and touch the urn and cry. I don't understand why he's in there and not at our house playing video games with his friends.I don't understand how he got sick to begin with, he moved in with me back in May and I tried to make things as comfortable for him as possible. This was his first winter with me and I think this house is a bit drier than the parents he lived with, but I wouldn't think that'd cause the issue. He almost never leaves, he works from home and plays games. If he caught anything it'd be from me, and I know I got sick at the end of June with COVID and he caught that from me, what a fucking loser I am. I did another trade show in September and got sick, not sure if he got it then, he didn't report time off to work (and he tries to take every time off he can).I don't understand why the teladoc didn't ask other questions, or the urgent care to find anything. Then later the first ER only commented on the high blood pressure, and it wasn't until the second ER that they knew something was up.Why did he get delirium, why did they let sodium levels drop? What was going on with the oxygen? With the monitoring he had, how did they let a cardiac arrest happen?I have so many questions and it pains me knowing that even if I get knew, it doesn't change that my baby brother is gone. We had so many plans this year, such as cooking better for ourselves, working out to lose weight, and most critically spending more time outside of his room to try new things like restaurants and take vacations. The last vacation I had with him was 2007, and he was in Hawaii with the parents in 2008 where I was rejected from going because I didn't have a job after high school.Before his delirium I remember one big ask, which was to get a hug, and that he was ready and wanting to go on adventures with me. I hadn't seen my brother much outside of a quick dinner talk from time to time, and when he moved in I was glad to be bonding with him again, and we didn't even get 1 year. We had so many plans, and the world robbed him of that.During the visitation I played the Halo song "Never Forget". He was a big Halo fan and that song always gave me the feels. I hugged his cold body for that entire song, wishing I could give him more.This is a long post and I apologize, I just needed to write, and I wonder if anyone knows what may have caused things. I fear that my lack of knowledge and experience failed to get him to the ER sooner, but it didn't seem like that even helped, they may have just done the same as they did on the first visit and turned him around.I failed to protect you brother, I am so sorry. This world is just not fair and you deserved so much more. You were the nicest person anyone would of met and you made those around you happier. I miss you so much brother, and I love you even more.I will see you again one day.. ### Response: I'm sorry for your loss.Delirium can be caused by many factors including infections, metabolic imbalances, medications, and underlying medical conditions. In your brother's case, the low sodium levels may have played a role, but it is also possible that there were other contributing factors such as an underlying infection or a reaction to medications.His low sodium could be due to frequent urination, or due to his low sodium diet, or it could be due to an underlying medical condition such as adrenal insufficiency or kidney disease.Don't know about the oxygen - but, changes in oxygen levels can occur due to changes in respiratory function, changes in blood pressure, or changes in heart function.The fact that he was on monitoring does not guarantee that a cardiac arrest could not occur. It is possible that the cardiac arrest was due to an underlying medical condition or a sudden event such as an arrhythmia. But, ultimately I don't know..