When do you question your consultant?

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beepbeeprichie
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Hi all,

I've been suffering from a problem with my knees for the last 12 months (basically the condition is called Patellofemoral pain syndrome and there is uncertainty in the scientific community about the pathology.

Anyway, I've been to see a consultant who gave me an MRI which came back negative (unfortunately it seems that the condition rarely shows on an MRI - the MRI scan was really to rule out other etiologies).

I've been reading the medical literature fairly closely and it seems that there is a specific imaging technique (technetium scintigraphy) which can reliably diagnose the condition. It seems that my consultant isn't aware of this (although the position has received support in the literature it isn't the 'mainstream view'.

Should I go back to my consultant (with the appropriate literature) and ask him about it. Or would this be a bad idea? I'm really uncertain about what to do (the condition is not agony but it has disrupted my life quite a bit).

Thanks!
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Dopamine Dreams
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I've challenged my Neurologist on my migraines before and I challenge my Psychiatrist on my mental health every time I see him. I believe heavily in patient autonomy, with my migraines I knew I was right (cause being analgesic induced migraines) as opposed to being instructed to take Tramadol, Paracetamol, Naproxen and Sumatriptan to combat migraines.

Re: my psychiatrist I knew for a fact that increasing my dosage of Agomelatine/Valdoxan (25mg to 50mg) was causing me increased lucid dreaming by increasing dopamine levels in the frontal cortex. The answer was to drop my Agomelatine/Valdoxan back down to 25mg. Instead he was keen on px'ing me an anti-psychotic (quetiapine) to pretty much knock me out every night).

Furthermore I suffered a slipped disc last November, and just 3 days ago was lugging a wardrobe upstairs and my back gave way. I insisted on oral-morphine for the pain but my GP refused this and px'd me Dihydrocodeine and valium - despite me insisting that I've always been a poor metaboliser of Codeine, Tramadol and Dihydrocodeine in the past and that Oramorph was the best thing to prescribe me.

I guess not everyone is as confident as me in challenging their GP or consultant. I've always read heavily around the medical literature and educated myself. I go privately for most of my healthcare and when I'm paying £250 for a 20 minute appointment with my neurologist to shrug his shoulders I think it's incredibly important to challenge him and get the best care available.

If you're not being treated as best as you could be, NHS or otherwise, stand up for yourself, challenge your consultant and DON'T take no for an answer.

Patient Autonomy > Consultant's Thoughts
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Tiger Rag
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You have to be careful with what you read online though. Because what you've read, may not be true for every single person with that diagnosis.
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shiggydiggy
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(Original post by beepbeeprichie)
Hi all,

I've been suffering from a problem with my knees for the last 12 months (basically the condition is called Patellofemoral pain syndrome and there is uncertainty in the scientific community about the pathology.

Anyway, I've been to see a consultant who gave me an MRI which came back negative (unfortunately it seems that the condition rarely shows on an MRI - the MRI scan was really to rule out other etiologies).

I've been reading the medical literature fairly closely and it seems that there is a specific imaging technique (technetium scintigraphy) which can reliably diagnose the condition. It seems that my consultant isn't aware of this (although the position has received support in the literature it isn't the 'mainstream view'.

Should I go back to my consultant (with the appropriate literature) and ask him about it. Or would this be a bad idea? I'm really uncertain about what to do (the condition is not agony but it has disrupted my life quite a bit).

Thanks!
Would having that scan change the management of your condition? Probably not.
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hslt
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(Original post by beepbeeprichie)
Hi all,

I've been suffering from a problem with my knees for the last 12 months (basically the condition is called Patellofemoral pain syndrome and there is uncertainty in the scientific community about the pathology.

Anyway, I've been to see a consultant who gave me an MRI which came back negative (unfortunately it seems that the condition rarely shows on an MRI - the MRI scan was really to rule out other etiologies).

I've been reading the medical literature fairly closely and it seems that there is a specific imaging technique (technetium scintigraphy) which can reliably diagnose the condition. It seems that my consultant isn't aware of this (although the position has received support in the literature it isn't the 'mainstream view'.

Should I go back to my consultant (with the appropriate literature) and ask him about it. Or would this be a bad idea? I'm really uncertain about what to do (the condition is not agony but it has disrupted my life quite a bit).

Thanks!
You have the diagnosis, what would confirming it with a different test (possibly not available on the NHS) do to change how they manage you?

Ultimately, the consultant will not do a further test if they don't think that it will change anything they do and he is confident in his diagnosis.
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hslt
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(Original post by Dopamine Dreams)
Furthermore I suffered a slipped disc last November, and just 3 days ago was lugging a wardrobe upstairs and my back gave way. I insisted on oral-morphine for the pain but my GP refused this and px'd me Dihydrocodeine and valium - despite me insisting that I've always been a poor metaboliser of Codeine, Tramadol and Dihydrocodeine in the past and that Oramorph was the best thing to prescribe me.
i'm fairly glad that your GP didn't just handout oramorph straight away to be honest, it being a controlled drug and all that - a lot of people are poor metabolisers of codeine, but I hadn't heard of this for tramadol..? (but I do sympathise with the psych and migraine stuff)

If you're not being treated as best as you could be, NHS or otherwise, stand up for yourself, challenge your consultant and DON'T take no for an answer.

Patient Autonomy > Consultant's Thoughts
Ultimately I think it's important to stand up for your self, and don't accept an answer you don't understand, but in this case I can't possibly see how a different scan would alter anything, and I'm not sure that this scan would be available.

My advice, as it's worrying you, OP, so see your consultant to talk to them about it and take your evidence with you, but don't be surprised if they say no, because it's either not available, or wouldn't change anything no matter the result. It's your right to have a proper discussion with your doctor, and receive the best available treatment, but it's not your right to demand whatever treatment/investigation you want unfortunately.
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shiggydiggy
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(Original post by Dopamine Dreams)
Patient Autonomy > Consultant's Thoughts
Nah.

Patients have the autonomy to select from the options proposed by the consultant.
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Dopamine Dreams
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(Original post by hslt)
i'm fairly glad that your GP didn't just handout oramorph straight away to be honest, it being a controlled drug and all that
I understand in some circumstances why oramorph may not be prescribed, however:

Codeine is a controlled drug
Dihydrocodeine is a controlled drug
Tramadol is a controlled drug
Diazepam is a controlled drug
Lorazepam is a controlled drug

All of which I take regularly, with Tramadol and Lorazepam being dispensed on repeat prescription each month in fairly large quantities.

I was prescribed oramorph by the same doctors surgery over a period of 6 months last year to help with my slipped disc, and 2 further periods of 2 months whilst recovering from kidney stone removal surgery.

I'm still in absolute agony and taking way above the amount of Dihydrocodeine and Diazepam that they prescribed for me as well as taking quite large doses of Quetiapine and Zopiclone to essentially knock me out until I can call back and request oramorph for the 3rd time on Monday.

There was absolutely no reason against prescribing oramorph in my situation, they know I don't respond well to Dihydrocodeine, am tolerant to Diazepam, and have safely been using Oramorph for large periods of time in the past.
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hslt
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(Original post by Dopamine Dreams)
I understand in some circumstances why oramorph may not be prescribed, however:

Codeine is a controlled drug
Dihydrocodeine is a controlled drug
Tramadol is a controlled drug
Diazepam is a controlled drug
Lorazepam is a controlled drug

All of which I take regularly, with Tramadol and Lorazepam being dispensed on repeat prescription each month in fairly large quantities.

I was prescribed oramorph by the same doctors surgery over a period of 6 months last year to help with my slipped disc, and 2 further periods of 2 months whilst recovering from kidney stone removal surgery.

I'm still in absolute agony and taking way above the amount of Dihydrocodeine and Diazepam that they prescribed for me as well as taking quite large doses of Quetiapine and Zopiclone to essentially knock me out until I can call back and request oramorph for the 3rd time on Monday.

There was absolutely no reason against prescribing oramorph in my situation, they know I don't respond well to Dihydrocodeine, am tolerant to Diazepam, and have safely been using Oramorph for large periods of time in the past.
Only morphine is kept in a locked up cupboard in hospitals though, its a higher class of control drugs ('schedule 2 controlled drug)... and codeine is available OTC is boots, well not even OTC it's on the shelves. Gotta go to the 4th class to get to benzodiazepines, and then the lowest class for opoids and some opiate preparations. Just because two things are 'controlled drugs' doesn't mean they have anywhere near the same levels of control.

Your back story (no pun intended) does make it seem more plausible that they would give you oromorph and i would understand why they might, but I'm still not surprised that they didn't want to just start you on it without seeing if it was responsive to other things. If you OD or sold the morphine then they would have no legs to stand on legally, where as doing it this way (i,e, escalating up the WHO pain ladder) is the protocol that is defensible if you end up needing oromorph.

I wasn't attacking you but I was genuinely interested in what you said about tramadol. Was hoping you would answer that question...

EDIT - I do understand your point of view, so please don't just have a go at me for sticking by my personal point of view. Sounds like a complex situation which would be difficult for anyone to manage.
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Dopamine Dreams
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(Original post by hslt)
Only morphine is kept in a locked up cupboard in hospitals though, its a higher class of control drugs ('schedule 2 controlled drug)... and codeine is available OTC is boots, well not even OTC it's on the shelves. Gotta go to the 4th class to get to benzodiazepines, and then the lowest class for opoids and some opiate preparations. Just because two things are 'controlled drugs' doesn't mean they have anywhere near the same levels of control.
I don't wanna be a complete **** and it's nothing personal, I respect your reply but:

Morphine is a Class A drug - not 'schedule 2'
Codeine Phosphate is a Class B drug, or Class A if prepared for injection
Dihydrocodeine is a Class B drug, or Class A if prepared for injection
Tramadol is a Class B drug, or Class A if prepared for injection
Diazepam is a Class C drug, not '4th class'
Lorazepam is a Class C drug, not '4th class'

Codeine Phosphate is not available OTC. Only 8mg/500mg Co-codamol is

To put Tramadol and Diazepam, which are both addictive substances, on repeat prescription for a patient without review is very irresponsible. More irresponsible than prescribing Oramorph by the 100ml bottle with regular patient reviews.

Tramadol poses the risk of death by Serotonin Syndrome, whereas Oramorph does not.
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hslt
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(Original post by Dopamine Dreams)
I don't wanna be a complete **** and it's nothing personal, I respect your reply but:

Morphine is a Class A drug - not 'schedule 2'
Codeine Phosphate is a Class B drug, or Class A if prepared for injection
Dihydrocodeine is a Class B drug, or Class A if prepared for injection
Tramadol is a Class B drug, or Class A if prepared for injection
Diazepam is a Class C drug, not '4th class'
Lorazepam is a Class C drug, not '4th class'
Different terminology for different contexts, I'm afraid in a medical context I'm right. Sozza boss. But just read this NHS page on what a controlled drug is - http://www.nhs.uk/chq/Pages/1391.aspx?CategoryID=73.

The Misuse of Drugs regulations include five schedules that classify all controlled medicines and drugs. Schedule 1 has the highest level of control, but drugs in this group are virtually never used in medicines. Schedule 5 has a much lower level of control.
Or the patient information here:
http://www.patient.co.uk/doctor/controlled-drugs


END OF DEBATE ON THAT MATTER


Codeine Phosphate is not available OTC. Only 8mg/500mg Co-codamol is
Yeah, 8mg codeine phosphate - therefore codeine is available OTC, in low dose, but still available. I believe tramadol is in some countries too, America in some states.

To put Tramadol and Diazepam, which are both addictive substances, on repeat prescription for a patient without review is very irresponsible. More irresponsible than prescribing Oramorph by the 100ml bottle with regular patient reviews.

Tramadol poses the risk of death by Serotonin Syndrome, whereas Oramorph does not.
Tramadol is slightly suspect but really not that uncommon on repeat, diazepam on repeat is, since you used the word, highly irresponsible and not very common in the last decade.

Although yes tramadol poses risk of SS, this isn't the biggest risk with tramadol, nor does it outweigh the risks of oramorph - so it's kind of irrelevant as a point as far as I can see.

I assume that when you talked about being a poor metaboliser of tramadol you weren't, therefore, talking about a comparable situation to that of codein metabolism which is what I was asking about.

Fun chatting, ta ra.
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Dopamine Dreams
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(Original post by hslt)
Different terminology for different contexts, I'm afraid in a medical context I'm right. Sozza boss. But just read this NHS page on what a controlled drug is - http://www.nhs.uk/chq/Pages/1391.aspx?CategoryID=73.



Or the patient information here:
http://www.patient.co.uk/doctor/controlled-drugs


END OF DEBATE ON THAT MATTER




Yeah, 8mg codeine phosphate - therefore codeine is available OTC, in low dose, but still available. I believe tramadol is in some countries too, America in some states.



Tramadol is slightly suspect but really not that uncommon on repeat, diazepam on repeat is, since you used the word, highly irresponsible and not very common in the last decade.

Although yes tramadol poses risk of SS, this isn't the biggest risk with tramadol, nor does it outweigh the risks of oramorph - so it's kind of irrelevant as a point as far as I can see.

I assume that when you talked about being a poor metaboliser of tramadol you weren't, therefore, talking about a comparable situation to that of codein metabolism which is what I was asking about.

Fun chatting, ta ra.
You need to familiarise yourself with Schedule 2 of the Misuse of Drugs Act (1971) which is the primary source of classification of controlled drugs.

http://www.legislation.gov.uk/ukpga/1971/38/schedule/2

So yes, you stand corrected and it is end of debate on that matter.

An for a second time, Codeine is not available OTC. Only Co-Codamol is.

Going off topic now; so I'll leave OP to seek answers to their question. Though feel free to PM me if you wish to continue...
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hslt
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(Original post by Dopamine Dreams)
You need to familiarise yourself with Schedule 2 of the Misuse of Drugs Act (1971) which is the primary source of classification of controlled drugs.

http://www.legislation.gov.uk/ukpga/1971/38/schedule/2

So yes, you stand corrected and it is end of debate on that matter.

An for a second time, Codeine is not available OTC. Only Co-Codamol is.

Going off topic now; so I'll leave OP to seek answers to their question. Though feel free to PM me if you wish to continue...
Off topic indeed, so last thing on the matter, my link below shows the revised drugs lists from 2001 not 1971 like yours, where schedule 2 100% does not include any of the drugs you're talking about. I don't understand how this can't be correct, you might explain why I'm wrong though.

http://www.legislation.gov.uk/uksi/2.../contents/made
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beepbeeprichie
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(Original post by OU Student)
You have to be careful with what you read online though. Because what you've read, may not be true for every single person with that diagnosis.
I realise caution is a virtue but I am talking about serious peer reviewed papers by experts in their fields. How do I know my dr is up to scratch on his reading? Isn't blind faith a bit silly?
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Jamie
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(Original post by Dopamine Dreams)
I've challenged my Neurologist on my migraines before and I challenge my Psychiatrist on my mental health every time I see him. I believe heavily in patient autonomy, with my migraines I knew I was right (cause being analgesic induced migraines) as opposed to being instructed to take Tramadol, Paracetamol, Naproxen and Sumatriptan to combat migraines.

Re: my psychiatrist I knew for a fact that increasing my dosage of Agomelatine/Valdoxan (25mg to 50mg) was causing me increased lucid dreaming by increasing dopamine levels in the frontal cortex. The answer was to drop my Agomelatine/Valdoxan back down to 25mg. Instead he was keen on px'ing me an anti-psychotic (quetiapine) to pretty much knock me out every night).

Furthermore I suffered a slipped disc last November, and just 3 days ago was lugging a wardrobe upstairs and my back gave way. I insisted on oral-morphine for the pain but my GP refused this and px'd me Dihydrocodeine and valium - despite me insisting that I've always been a poor metaboliser of Codeine, Tramadol and Dihydrocodeine in the past and that Oramorph was the best thing to prescribe me.

I guess not everyone is as confident as me in challenging their GP or consultant. I've always read heavily around the medical literature and educated myself. I go privately for most of my healthcare and when I'm paying £250 for a 20 minute appointment with my neurologist to shrug his shoulders I think it's incredibly important to challenge him and get the best care available.

If you're not being treated as best as you could be, NHS or otherwise, stand up for yourself, challenge your consultant and DON'T take no for an answer.

Patient Autonomy > Consultant's Thoughts
what a fascinating person you are. its refreshing to have someone involved in their own healthcare, but take care not to overstretch yourself. sometimes one would hope they know better.

Did you know that dihydrocodeine and codeine follow different metabolism routes for instance?
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Jamie
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(Original post by beepbeeprichie)
Hi all,

I've been suffering from a problem with my knees for the last 12 months (basically the condition is called Patellofemoral pain syndrome and there is uncertainty in the scientific community about the pathology.

Anyway, I've been to see a consultant who gave me an MRI which came back negative (unfortunately it seems that the condition rarely shows on an MRI - the MRI scan was really to rule out other etiologies).

I've been reading the medical literature fairly closely and it seems that there is a specific imaging technique (technetium scintigraphy) which can reliably diagnose the condition. It seems that my consultant isn't aware of this (although the position has received support in the literature it isn't the 'mainstream view'.

Should I go back to my consultant (with the appropriate literature) and ask him about it. Or would this be a bad idea? I'm really uncertain about what to do (the condition is not agony but it has disrupted my life quite a bit).

Thanks!
ignorant question here.
What are you looking for on this fancy new scan, and what would the treatment then be changed to?
surgery?
steroids?

[I'm not challenging, i don't actually know]
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beepbeeprichie
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(Original post by Jamie)
ignorant question here.
What are you looking for on this fancy new scan, and what would the treatment then be changed to?
surgery?
steroids?

[I'm not challenging, i don't actually know]
To provide a definitive diagnosis, rather than guessing?
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Le Nombre
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(Original post by beepbeeprichie)
I realise caution is a virtue but I am talking about serious peer reviewed papers by experts in their fields. How do I know my dr is up to scratch on his reading? Isn't blind faith a bit silly?
You should definitely ask, same as you would your accountant, lawyer or any other professional but be aware that if it's new then NICE, or whatever it's called now, may not allow the consultant to use it and even if they do the NHS may not permit it in your circumstances due to cost.
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Sacapunta
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Yeh, I would bring up the idea of the scan with your consultant and get his thoughts on it.

Patient's know best about their condition in my opinion and healthcare works best when the patient guides their own care.
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My-My-My
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(Original post by Dopamine Dreams)
You need to familiarise yourself with Schedule 2 of the Misuse of Drugs Act (1971) which is the primary source of classification of controlled drugs.

http://www.legislation.gov.uk/ukpga/1971/38/schedule/2

So yes, you stand corrected and it is end of debate on that matter.

An for a second time, Codeine is not available OTC. Only Co-Codamol is.

Going off topic now; so I'll leave OP to seek answers to their question. Though feel free to PM me if you wish to continue...
Co-codamol IS codeine (with paracetamol).
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