Posts by Nicholas Myers

ironhawk53 said:Could someone please explain what "DZ 64" actually means?

Thanks in advance...

Ma'am,

I am not certain of the exact definition of that code, but it appears to be a technicality. It isn't something a clinician needs to worry about when interpreting your results.

It looks like an internal lab notation used by the technicians. If you are truly curious about the specifics, you can always ask the laboratory directly.

To reiterate, this has zero impact on the clinical interpretation of your report.

Paul Baker16 said:I have a question. My platelet count is 148, but the normal range is 150–400. I’m wondering why they are low. Everything else is within range—my blood work looks great, even my triglycerides are at 0.53; it's just the platelets. Now I'm reading stuff online and I'm terrified. Is a low count linked to infections like HIV or leukemia? I've been training like crazy for the last three and a half months—two workouts a day, three times a week, then three days once a day, and so on for three months with one rest day. I had nosebleeds twice spontaneously, but that was two months ago. I don't know if this matters or if low platelets are tied to dangerous diseases. Thanks.

Sir,

The platelet count is only very slightly outside the norm. To get a better picture, we would need to know your age, any medications you are taking, the reason for the test (see the first post in this thread for instructions), and your previous baseline platelet levels.

Generally speaking, a mild decrease or a count sitting right at the bottom of the normal range is often discovered incidentally in perfectly healthy adults. In the absence of other abnormalities, we simply view this as a variation of normal.

Your values are barely off; they are essentially at the lower limit. In fact, many clinicians would likely view this result as normal and wouldn't give it a second thought. Unless you are experiencing issues like easy bruising, bleeding from the skin or mucous membranes (such as frequent nosebleeds or bruising from minor bumps), and all other markers are fine, there is no cause for concern. For peace of mind, you could re-run the test in about a month just to track the trend—to see if the number is stable, rising, or falling.

Typically, intense physical exertion tends to push platelet counts up, rather than down.

Rebecca Mitchell24 said:Does anyone know if I need to be strictly fasting for a peripheral blood smear, or is a cup of coffee okay?

To whom it may concern,

No special prep is required for a peripheral blood smear, and you don't need to fast. If you're managing any ongoing health issues or taking specific medications, it’s probably wise to run that by the lab staff first.

Maria Nguyen93 said:Does anyone have any insight on these biopsy results? I know this isn't exactly the right forum for it, but since nobody seems to be posting anything about fibroadenomas lately... sorry, I just really need some perspective on this. It's important to me.

LD levels are currently sitting at a single point.
Cytology results: the smear shows a few scattered epithelial cells, some showing signs of atypia, along with a bit of peripheral blood.
Please consider running the search again.

This feels a bit incomplete to me. 😢

To whom it may concern,

It’s hard to offer any real insight based on such sparse data.

I’d agree with your assessment—the report feels incomplete. It likely stems from the fact that the sample material was pretty thin, offering only a handful of individual epithelial cells. Since those specific cells are exactly what we need to scrutinize for morphology, the data just isn't there. That’s why the recommendation suggests a follow-up biopsy might be necessary, depending on the clinical context and what the ultrasound shows.

swiftbear86 Asks:
You couldn't have possibly written that recipe without insurance coverage; let's be real, that's just not how it works.

So, I was at my GP's office today. Since I’m a doctor myself—just working in a different capacity—we ended up chatting for a bit. While we were talking, he got a call from a patient that highlighted a real headache. He couldn't e-prescribe her medication because his system kept throwing an error saying "Supplemental Insurance Coverage Expired." A red circle popped up on the screen, signaling the prescription failed to sync with the database. In the end, he had to print out a physical script and tell the patient to swing by the clinic to pick up the paperwork so she could take it to the pharmacy.

I'm not entirely sure what went down here, but I was told these kinds of glitches happen occasionally. Usually, you can just wait until the next day and send the prescription through without any issues. 😕

swiftbear86 said:I think the specific medication being used here is a critical factor.
If you want to, just say the word.

Back when I was working in primary care, a Medicare official gave us a verbal directive. Apparently, an attending physician isn't obligated to prescribe any medication recommended by a specialist who doesn't hold a contract with Medicare.

When it comes to expensive prescriptions, their advice was blunt: don't even bother unless a specialist covered by Medicare signs off on it. The kicker? They mentioned how often a hospital specialist will flat-out reject a recommendation made by a private doctor. And when that happens... well, let's just say I'd rather not recount what follows.

restlessbadger2 said:He didn't include a recommendation for the viruses. Now I'm stuck—who can actually write that for me?

Well, there’s your snag. Given how tight things are with the budget right now, they've started tightening the leash on referrals and diagnostic tests.

That's why you'll likely need a specific written recommendation for neurotropic virus serology. In terms of who carries the most weight for that kind of request, you're looking at a neurologist or an infectious disease specialist first, though an immunologist or a physiatrist might also work.

restlessbadger2 said:1. I've been prescribed Lyric because of an unspecified mononeuropathy diagnosis. Even with supplemental insurance, I can't get it covered—I have to pay the full price out of pocket, which comes to about $77. Why is that?

Dear restlessbadger2,

The answer to this is straightforward, yet it remains difficult for patients, GPs, and specialists to swallow, often sparking heated debates. I'll keep my response brief. For anyone looking to vent their frustration, please remember we have a dedicated thread: A View of the American Healthcare System - discussing the (mal)functionality of the US medical system. You can continue the conversation there.

Essentially, due to budget constraints and the high cost of the medication, Medicare has dictated that only patients with refractory epilepsy qualify for the prescription to be fully covered.

For any other indications or illnesses, primary care physicians are permitted to prescribe this drug exclusively on a standard private prescription, meaning patients must shoulder the entire cost themselves.

And it isn't just Lyric; this applies to a wide range of medications.

As for why this policy exists, why specialists disagree with it, or why some family doctors ignore these rules entirely, I invite everyone interested to discuss those nuances in the thread I linked.

2. Where can I get blood testing done for neurotropic viruses? Does it require a referral, or can I go without one?

With a referral to the CDC's Virology Department at the Dr. Fran Mihaljević Infectious Disease Clinic.

However, since the costs for these tests (as they cover multiple types of viruses) are quite steep, you will need a valid medical indication and a recommendation from a specialist—and not just any specialist.

Susan Martin4 said:I have a question. I’m being treated for Hashimoto's by an endocrinologist at Mayo Clinic. Usually, the process was pretty straightforward: I'd book a specific day, show up, see the doctor, and she'd write down exactly which blood tests I needed. They'd draw the blood right there, the results would arrive at my house, and they'd include the date for my next follow-up on the report.

How is this going to work with these new models? My primary care physician gave me an A2 referral for an exam and an A3 for blood work.
I see in the document it says
When providing a consultative opinion based on a referral for a consultative exam (A1) or
a follow-up consultative exam (A2), the hospital/outpatient specialist is NOT
ALLOWED TO:
 issue internal referrals for further testing and follow-up exams
 order or issue recommendations for follow-up exams
 issue opinions regarding fitness for work

Does this mean my endocrinologist won't be able to schedule my next check-up anymore? Like, they won't be allowed to just write "next appointment on this date" on my lab results?
And does it also mean the endocrinologist can't decide on the spot if I need any additional blood work beyond what my GP already prescribed?

It seems like my primary care doctor isn't exactly an expert when it comes to thyroid issues; she wasn't even sure which hormone levels I needed tested. I really hope this doesn't mess everything up at the clinic and make things less smooth than they used to be.

Also, if the endocrinologist recommends a follow-up in a month or two—which is highly likely since I'm pregnant and need more frequent monitoring—will I actually be able to get an appointment? Because it looks like people are already booking as far out as November.
For centralized scheduling, you have to submit the referral, and from what I know, those are only valid for 30 days? But what if the appointment is scheduled for later? Now I'm seeing somewhere that a referral is valid for a year—is that actually true?

Unfortunately, that workflow is becoming a thing of the past. You contact your primary care physician just to get a referral, while the specialist handles the thyroid management exclusively.

Essentially, for the diagnosis you're managing, issuing a standard specialist referral isn't typically justified. It isn't considered appropriate for an endocrinologist to write internal referrals for patients who already have an established diagnosis.

Checking thyroid hormone levels—which is pretty straightforward—can be done via a standard insurance referral before your scheduled specialist visit, and the endocrinologist can then review those results to decide if your medication needs adjusting.

Furthermore, the primary care doctor is supposed to determine the schedule for future check-ups. An endocrinologist shouldn't explicitly dictate the exact date of the next appointment, though they can suggest *when* a hormone check is necessary. You shouldn't be handed a printed appointment slip for your next visit.

However, I see that some colleagues at the hospital still recommend specific dates, and I hear rumors of patients receiving appointment slips for three or six months out based on certain types of insurance referrals, even though that isn't permitted.

In my view, the primary care physician acted correctly.

If additional tests are needed, such as a thyroid ultrasound, the endocrinologist can certainly provide a recommendation for them.

But for the comprehensive management of Hashimoto's, especially for patients already under a specialist's care, I don't see the justification for bypassing the GP. Primary care doctors need to remain involved in the process.

If their only role is signing paperwork, it begs the question: what purpose do they actually serve?

And if you feel uneasy about your primary doctor being involved in the management of this condition, then you'll simply have to find a new one—someone you actually trust.

Specialized referrals are being closely monitored, so primary care physicians will be writing them less and less frequently. This means they'll have to take a more active role in the diagnostic and treatment decisions for their patients. From what I can see, that was the entire point of this reform.

Jason Vaughn482 said:Which specific tests are being included? I’ve gathered that specialists won't be allowed to issue internal referrals anymore—which has always been standard practice—nor will they be able to order follow-ups. Instead, everything will be decided by primary care physicians. It makes zero sense; it's as if we're suddenly pretending that family doctors possess an encyclopedic mastery of every niche medical specialty when, in reality, they often lack that specific depth...
I am living through a perfect, albeit frustrating, illustration of this madness right now. For months, I've been breaking out in these skin lesions on my arms and legs; they flare up, itch incessantly, and leave me feeling miserable, yet they eventually subside. Regardless, I have a fundamental right to know what is happening to my own body. My doctor refuses to give me a referral, dismissively telling me, "Oh, don't even bother applying anything, it'll pass on its own." When I explicitly ask for a dermatologist referral, he insists it isn't necessary. Now, I'm sitting here waiting for Monday, wondering: what happens if he still refuses? If this becomes the universal standard, we are all well and truly doomed. This is just one trivial, everyday example, but it serves as a grim harbinger of how much control we are losing.

Specialists will still be able to issue internal referrals if the primary care physician sends the patient over with a referral marked C or D (and naturally, B).

They won't be allowed to issue internal referrals if the PCP sends a patient with an "A" designation on the referral.

If a patient arrives with an "A" designation, then yes—the specialist cannot issue an internal referral, cannot recommend a follow-up, cannot schedule the return visit, and cannot mandate any specific treatments or diagnostic tests. The primary care doctor actually has the right to deny or withhold anything the specialist suggests. However, that doctor then carries the liability if something goes wrong with the patient. Consequently, every PCP will think twice before following a specialist's advice or recommendation.

Now I'm just waiting for Monday. If they don't give it to me... what then? If that's how it goes, we're all doomed.

Even before this, your PCP wasn't strictly obligated to give you a referral. You couldn't force them to send you to, say, a dermatologist if they didn't see the need. Nothing has fundamentally changed regarding that authority.

If you can't find common ground with your PCP—if you're living in fear that they might actually try to treat something (like strep throat or a skin lesion) and you feel they lack the skills to do anything beyond handing out a script (which is often wrong anyway)—then there is only one solution: find a new doctor.

Jason Vaughn482 said:In your opinion, how often should someone with high blood pressure actually need to see a specialist? At the end of the day, if someone has been struggling with hypertension for fifteen years, I’d imagine they ought to undergo additional testing, like an ultrasound or something similar... yet most family doctors won't even bother measuring their blood pressure. Most of them, anyway. It seems we're all left having to rely entirely on our own home monitors.

Same answer as before—find a different doctor.

Kyle Lee7 said:My psychotherapist mentioned to me last week that since their rehabilitation program doesn't actually account for psychotherapy (much like how they wouldn't include physical therapy in a standard plan), it falls under the category of a regular psychiatric consultation. Since those are limited to three visits per year, anything beyond that means we'll be paying out of pocket $33.
Normally, you'd see a therapist once a week. If you skip vacations and holidays, that works out to about 45 sessions a year. So, if I'm paying for 42 of them at $100 each, that's roughly $1400 annually just for psychotherapy. It’s still technically cheaper than seeing a private practitioner—who usually charges $300 or more per session—but it feels incredibly silly. I mean, psychotherapy is its own established category, and this specific clinic is a premier referral center that has been doing this for 60 years... and now, all of a sudden, psychotherapy effectively doesn't exist? Unless, of course, the folks over at the psychiatric hospital manage to talk their way out of covering it.

Bit by bit, we are starting to look more and more like the USA (and not in a good way...).
It's honestly not surprising when you consider the fact that 35% of the population ends up subsidizing healthcare for 100% of the users. ☕
Personally, I'm one of those people who pays for the standard coverage plus supplemental insurance, and yet I still end up going to my neurologist privately and my gynecologist privately...

I have to admit, this is news to me. I’ve heard whispers about extra fees floating around, but I haven't seen anyone state this officially.

From what I understand, there are referrals for outpatient care, and psychotherapy definitely doesn't fall under the umbrella of a simple "consultation."

Furthermore, there is no regulation stating a limit on annual visits—the mention of three follow-ups usually refers to post-hospitalization check-ins within a six-month window. There is also no rule saying, for instance, that a GP can't refer someone to a psychiatrist ten times a year.

Those kinds of numbers are just hallway talk, unofficial chatter. Officially, I haven't seen a single document mandating a cap on annual psychiatric visits or a specific number of physical therapy sessions for any given diagnosis. 🤷

Karen White4 said:Is this the same thing as an OGTT—fasting and postprandial? I don't see the difference. Apparently, I can get the OGTT done at my local clinic; I found out today.
So where am I supposed to go for this GUP?
Or is it the exact same test?
My doctor just gave me a referral for the OGTT... well, it's an electronic referral, but she also gave me a printed copy, so now I'm just confused.

Ma'am,

An OGTT is not the same as a fasting and postprandial GUP.

Unfortunately, you won't find the specific OGTT that includes insulin measurements—which is what your specialist requested—at a standard local clinic. They only perform the basic version, where they check your fasting glucose and then check it again two hours after you drink a specific amount of glucose dissolved in water.

Local clinics don't measure insulin levels in parallel with blood glucose.

The fasting and postprandial GUP works differently: first, they draw blood to check your fasting glucose, then you eat a meal (breakfast), and two hours later, they draw blood again to check your glucose levels.

That is essentially how it's handled at the clinic.

George Wilson7 said:Is it actually possible to have pulmonary tuberculosis—given how long I've been coughing—while still having a perfectly clean chest X-ray?

Ma'am,

According to medical literature, it is indeed possible. Roughly 15% of patients presenting with primary pulmonary tuberculosis show normal results on a chest X-ray.

Hannah Lopez29 said:I received my lab results today, and they show the following:

HLA phenotype A 2,3, B 7,18, Bw6-.

Hello,

Your interpretation is spot on; you don't have HLA-B27 or HLA-B35.

Based on what was tested—specifically the A and B groups, though others exist—you carry HLA-A2, HLA-A3, HLA-B7, and HLA-B18.

These specific markers aren't strongly or uniquely linked to any particular autoimmune condition. While almost any HLA type can be associated with a slightly higher risk for certain issues, the ones most definitively tied to disease (within the A and B groups, to keep it simple) aren't present in your report.

Best regards. 🙂

Robert Adams88 said:I should have noted that I was active two days before my blood draw. Does physical activity have any impact on bilirubin levels?

To whom it may concern,

I won't comment on your specific situation, but generally speaking, physical exertion—like a heavy workout—can cause a subtle bump in bilirubin levels even in healthy people. That said, it certainly wouldn't reach the levels you're seeing. Furthermore, with certain conditions like Gilbert syndrome, bilirubin levels (which are already elevated) can spike even further following physical strain.

It isn't just one thing; other factors play a role in bilirubin concentration as well.

I followed the advice given by my doctors, including Dr. Harvey.

Greetings. 🙂

feralbadger2 said:Everything is within the normal range, except for my MPV. The reference interval is 6.8–10.4, and I’m sitting at 11—so, just a bit elevated.

To whom it may concern,

MPV stands for mean platelet volume. Given the value in your results—especially if your actual platelet count is within the normal range (which I assume it is)—it shouldn't carry much clinical weight. Not in my book.

By the way, you didn't mention how much weight you've lost or over what timeframe. Also, are you still dealing with any symptoms, and have you been advised on any further follow-up or treatment?

Greetings. 🙂

swiftbear86 said:We’re currently hitting the same topic across two different threads, so I’ll leave it to the moderator to decide which one stays active for the discussion.
I really don't get why there’s this constant friction between the AMA, the specialists, the patients, and the pharmacies.

My approach is always the same: I tell patients that the specialist prescribes the specific therapy they believe is best for the diagnosis. Then, the AMA has to figure out if they can authorize an Rx under Medicare or if they have to issue a private prescription, which means the patient pays full price out of pocket.

The tension would be a lot lower if specialists warned patients upfront. Sometimes people simply can't afford the medication, and when that happens, the entire treatment plan just goes down the drain.

Well, I see what you mean ( : OKP : ), but I have no idea how to split or merge posts without making a total mess of things.

The topics are clearly linked.

I think it’s best to just leave it as is for now. We'll see how it plays out.

That said, I agree with your observation; actually, I wrote something very similar on another thread.

vividsailor7, I hear you, but I think you're missing the mark on one point. This isn't about the AMA being stubborn (though, granted, some of your examples involve both stubbornness and unprofessionalism, but that's beside the point)—it's about the fact that they'll be penalized if they don't follow orders.

Think about it this way: if you were supporting a family on your salary and someone threatened to cut your pay in half or fire you, would you still pick a fight you can't win, or would you just do what you're told?

Suppose Medicare decided that any specialist who doesn't prescribe medication strictly according to their specific guidelines would face a pay cut. How would you react then?

Hello,

I took the liberty of tweaking the title; I hope you don't mind. 🙂

It would be helpful if you could edit your post to include some spacing between paragraphs. It would make your points—which are actually worth reading—much easier to digest.

analogcanyon29 said:Let me ask one more time, if anyone knows—this is fairly urgent.

Ma'am,

If you've been vaccinated against Hepatitis B, this result is perfectly normal for a vaccinated individual, provided that only the anti-HBs is positive.

Is there anything else listed on the report? Anything else showing as positive?

Best regards.

Olivia Castillo562 said:I had sinus issues before I had a cyst removed back when I was 16. It had grown out alongside my tonsils. It was located beneath the bone at the level of the nasal bridge and was extracted through the inside of my mouth. Apparently, it was about the size of a plum; I didn't even realize it was there. Following the surgery, I dealt with headaches and pressure in the sinus on that side of my face. I went through various tests, but nothing turned up, and the situation eventually resolved itself over time.

OK, then what I mentioned previously stands.

Complete the remaining tests as scheduled, and we will see.

It’s worth noting that sometimes it takes quite a while for an autoimmune disease to manifest in a full clinical picture. Some patients can wait years before a diagnosis is actually reached.

That said, I hope that aside from the thyroid, no other autoimmune conditions are found.

Best regards. 🙂