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