General Medical issues thread

[love_the_life]

I think there's a misunderstanding somewhere. My GP advised that I need to go to Emergency to do the CTPA.

So me asking can I do CTPA without paying is not evil.

Perhaps I misunderstood but I thought you said that you couldn't get a CTPA at the hospital and that presenting to emergency was the only option for a non-charged one. I thought your GP's advice was that if your symptoms became worse (shortness of breath or such) to go to emergency, but it was not actually to have the routine CTPA.

 

[JohnK]

Perhaps I misunderstood but I thought you said that you couldn't get a CTPA at the hospital and that presenting to emergency was the only option for a non-charged one. I thought your GP did advise that if your symptoms became worse (shortness of breath or such) to go to emergency, but it was not actually to have the routine CTPA.

GP said he cannot refer me to hospital to do CTPA because I already have positive d-dimer reading. Apparently if he requested a CTPA they would Triage me and wouldn't accept me with positive d-dimer.

Last week he asked me how I felt when discussing blood results. He advised to present to Emergency if symptoms got worse. He also mentioned that we may need to do CTPA and I said I'm concerned about claustrophobia and need sedation. I don't have Valium anymore as GP's won't prescribe.

With this week's result I want to wait another week and redo d-dimer. GP advised that alternate option was Xarelto 10mg and then check d-dimer in 2 weeks.

This is my understanding. It's confusing. Fingers crossed.

 

[Pushka]

GP said he cannot refer me to hospital to do CTPA because I already have positive d-dimer reading. Apparently if he requested a CTPA they would Triage me and wouldn't accept me with positive d-dimer.

Why wouldn't the hospital accept you because of the positive d-dimer? Triage is just a way of sorting priorities.

 

[JohnK]

Why wouldn't the hospital accept you because of the positive d-dimer? Triage is just a way of sorting priorities.

I don't know, this is what GP told me.

 

[Princess Fiona]

I don't know, this is what GP told me.

I rarely if ever dip into this thread. But based on what you have reported the GP said I would strongly advise getting a second opinion.

There are so many holes in this diagnostic pathway I don’t even know where to begin.
But I’ll try.
VTE (blood clot in deep veins / lung) is a potentially life threatening condition.
Anyone who has had a postive D dimer as a rule out test for it has not had it ruled out and requires further testing.
There is no pathway that leads to a few weeks of anticoagulant meds and repeat the D dimer test.

No public hospital Emergency or Radiology would rule someone ineligible for a CT scan due to a positive D Dimer, in fact it’s the exact opposite to what you are interpreting the GP told you.

 

[andye]

I imagine what @JohnK has been told is that an outpatient (public or private) radiology provider would not do it because they have a protocol that says if you have a potentially life-threatening condition you should be being seen and assessed urgently I.e in ED (accepting that urgent is not instantly). Most people accept that.

[I'm not sure that that's necessarily true. Many times I've found that something described as 'policy' is just entrenched habit based on what usually happens]

One of the things that I think @JohnK is struggling with here is that PE is not the most likely diagnosis. It is the most important however.

To put it into non-medical terms: would you get on a plane with a 10% crash-rate (even if the safe one had a rubbish lounge and might be delayed for a few hours)?, or how many times have you ever seen a horse win from 10-1?

 

[Quickstatus]

@JohnK

If you can't find a bulkbilling CT provider , then you need to attend Emergency

They will assess you like any patient with letter from GP. They will then likely do the CT. This could be also the way to get it done under sedation - as you are in a hospital. I don't know how long you need to stay for but it won't be a walk in, do test and walk out which I think is what you want. They may even admit you into hospital depending on the totality of the circumstances

Taking Xarelto for a few weeks is really NOT an option without a diagnosis for so many reasons. One, it is not without significant risk, Two, it implies you have a blood clotting disorder which in of itself requires further investigation. Three, what happens if you get a repeat of symptoms or if the symptoms don't do away- do you then keep taking Xarelto or do you periodically take xarelto whenever you have symptoms. A raised D-dimer is not a diagnosis of pulmonary embolus.

This needs to be sorted out properly, you can't make this problem go away with some pills.

 

[JohnK]

One of the things that I think @JohnK is struggling with here is that PE is not the most likely diagnosis. It is the most important however.

I'm struggling to understand whats going on. No shortness of breath, no sharp pains, no dizziness. I have had a nagging cough, occasionally my collarbone on left side hurts when I cough. This is not under the chest. This on top, possibly muscles or even bone, severe inflammation in collarbone on either side for long, long time that comes and goes. Chronic inflammation that is all over the body and not limited to one area.

Doctor has interpreted this as possible pulmonary embolism and has ordered d-dimer.

The first thing he said to me was how do you feel. I feel fine. No signs of heart attack, no sharp pains (most of my pains are dull), no signs of blood clot, no new signs of fatigue. He said if cough gets worse to present to emergency. He said we may need to do a CT Scan at some point. No urgency at all. D-dimer is 0.70!

This week went to visit for follow up of blood and urine results and we did further blood and urine. Discussed CTPA and I mentioned sedation. D-dimer is 0.57 and I have no symptoms of blood clot or heart attack. Cough came back for a day or two and is now gone.

I might be one of those people with no symptoms. My take on CTPA is just to rule out blood clot in lung.

What if d-dimer was 0.55 or even 0.54? Still concerns about blood clot?

What if CTPA negative and still high d-dimer?

What if CTPA positive? Do they do procedure to try and break down blood clot or just prescribe Xarelto 20mg?

We're back to the time outpatients wanted me to do liver biopsy to rule out cirrhosis of liver even though every single marker suggests no issues with liver. No, I'm not doing liver biopsy.

So back to high d-dimer. I don't know what to do. It's all very confusing. It's all very stressful. And no @Quickstatus my expectation going to Emergency was not just walking in and walking out.

 

[Pushka]

I'm struggling to understand whats going on. No shortness of breath, no sharp pains, no dizziness. I have had a nagging cough, occasionally my collarbone on left side hurts when I cough. This is not under the chest. This on top, possibly muscles or even bone, severe inflammation in collarbone on either side for long, long time that comes and goes. Chronic inflammation that is all over the body and not limited to one area.

Doctor has interpreted this as possible pulmonary embolism and has ordered d-dimer.

The first thing he said to me was how do you feel. I feel fine. No signs of heart attack, no sharp pains (most of my pains are dull), no signs of blood clot, no new signs of fatigue. He said if cough gets worse to present to emergency. He said we may need to do a CT Scan at some point. No urgency at all. D-dimer is 0.70!

This week went to visit for follow up of blood and urine results and we did further blood and urine. Discussed CTPA and I mentioned sedation. D-dimer is 0.57 and I have no symptoms of blood clot or heart attack. Cough came back for a day or two and is now gone.

I might be one of those people with no symptoms. My take on CTPA is just to rule out blood clot in lung.

What if d-dimer was 0.55 or even 0.54? Still concerns about blood clot?

What if CTPA negative and still high d-dimer?

What if CTPA positive? Do they do procedure to try and break down blood clot or just prescribe Xarelto 20mg?

We're back to the time outpatients wanted me to do liver biopsy to rule out cirrhosis of liver even though every single marker suggests no issues with liver. No, I'm not doing liver biopsy.

So back to high d-dimer. I don't know what to do. It's all very confusing. It's all very stressful. And no @Quickstatus my expectation going to Emergency was not just walking in and walking out.

There are four medical people here telling you what you should do. There is no confusion. You are just not listening.

The d-dimer test is not diagnostic. It only tells medical people what they need to test for next if positive. This is why you need a ct scan.

 

[Quickstatus]

What if d-dimer was 0.55 or even 0.54? Still concerns about blood clot?

The number is irrelevant. The fact that it's elevated is.

What if CTPA negative and still high d-dimer?

Then you don't have a blood clot. As I said there are non blood clot reasons for a raised D-dimer

What if CTPA positive? Do they do procedure to try and break down blood clot or just prescribe Xarelto 20mg?

Xarelto or one of the anticoagulants AND referral for investigations as to why you got a pulmonary embolus

I don't know what to do

We have advised you on what to do.

My take on CTPA is just to rule out blood clot in lung.

Correct. Getting it wrong by assuming it is or it isn't a blood clot without a diagnosis is not good.

even though every single marker suggests no issues with liver

Liver cirrhosis is not detectable on a blood test. No one makes such a diagnosis that way.

 

[andye]

@JohnK

You don't need to worry about the d-dimer if there is no PE

Although there are treatments to break up a pulmonary embolus, they are usually only used if the clot is massive or the patient is shocked. So yes, most likely outcome if PE is the proper dose of xarelto

I realise you are a thoughtful man who likes to see the logic of situations. However, doctors train for years to make decisions like this. I disagree with how your doctor is managing this but I think he/she is having their better judgement swayed by your reluctance to do the appropriate tests

 

[JohnK]

There are four medical people here telling you what you should do. There is no confusion. You are just not listening.

The d-dimer test is not diagnostic. This is why you need a ct scan. Now.

Advice not ignored, thanks @Pushka.

Will try to get CTPA done. I don't know where yet. Prefer sedation and I no longer have Valium.

 

[Quickstatus]

This is one of the reasons why Drs should explain to their patients WHY are doing a test and the potential outcomes.

 

[JohnK]

This is one of the reasons why Drs should explain to their patients WHY are doing a test and the potential outcomes.

I went with my wife to Gastroenterology outpatients last week. This is the 3rd time we've seen this specialist. What a pleasant man.

I'm there for support and to try and explain things to my wife but this doctor explains everything. He explains everything, why he's changing reflux medication, plans for what next if reflux continues. He even talks slowly so wife can understand as her English is not great.

 

[Pushka]

This is one of the reasons why Drs should explain to their patients WHY are doing a test and the potential outcomes.

I guess we aren't in the examination room listening to the conversations. But on the other hand telling people possibilities, of which there could be many, can also be too much information at that time.

Did he give you a cardiogram? GP did one on me as soon as the DVT was detected.

 

[RooFlyer]

We're back to the time outpatients wanted me to do liver biopsy to rule out cirrhosis of liver even though every single marker suggests no issues with liver. No, I'm not doing liver biopsy.

I think this bit is a neat summary of this long saga. Health professionals give opinion/advice. Patient thinks they know better and don't follow doctor's advice.

Rinse, repeat.

 

[tgh]

The depth of care and patience exhibited by the md's on this thread is laudable+++…well done everyone.

While I disagree with the lifestyle (can afford to gamble but can't afford to pay), the op's attempts to understand his conditions are also laudable,(IMnsHO)

 

[Quickstatus]

the op's attempts to understand his conditions are also laudable

I actually prefer people ask Dr Google. One benefit of that is they come with some info and more importantly questions. It also gives me an idea of what they are concerned about.

In the end, Claustrophobia and cost are relevant concerns.

When I locumed in Brewarrina once, I didn't consider the cost part. The patient had a recurrent ear infection, I gave her a script for antibiotics. I realised soon after she and others in the same situation will not get the medicine. Despite all the safety nets in Australia, it remains a significant issue

 

[Quickstatus]

Just on the topic of cost/safety nets @JohnK . There is the Medicare safety net. Are you eligible?

 

[JohnK]

I don't think I'm eligible @Quickstatus.

Apparently I earn a lot but no one considers the amount owed.