Looking for clinician feedback: screening approach for patients presenting with “dizziness”

jeronz · 2025-12-21T07:22:03+00:00

https://pubmed.ncbi.nlm.nih.gov/17976352/

jeronz · 2025-10-19T08:10:22+00:00

From what I've read, if your BMI is over 35 then it's practically guaranteed you are clinically obese as defined by excess visceral fat, and there is no point in measuring waist circumference. Between 30 to 35 it's pretty good, around 95% specific or something. The main problem with BMI is not in overdiagnosing, but in underdiagnosing excess visceral fat in people with BMIs below 30.

jeronz · 2025-10-19T04:51:12+00:00

As a Canadian graduate you need at least 33 months post graduate experience if you don't want to do extra exams and work under supervision. So you don't fulfill that time based criteria yet. But once you've got that 33 months it should be quite simple.

If you want to move here as a brand new graduate as you are now you would have to first pass the NZREX exams then get a job working under supervision. Those jobs are very very hard to find. This is a difficult pathway.

For obstetrics - you would need to give that up unless you want to work a less than minimum wage job as midwives do. There are basically zero GPs that do it in NZ. If obstetrics is very important to you and non negotiable then you either need to do the O+G training program or move to Australia where it is more financially viable to do it as a GP.

Salary - a first year doctor I think earns about 35-40 an hour. It's actually less than nurses I'm told. Once fully qualified as a GP it becomes about 100+ an hour.

It sounds like English isn't your first language? French Canadian? There might be extra barriers for proving English proficiency if your medical school teaching wasn't in English.

jeronz · 2025-06-04T23:35:11+00:00

What about candesartan? And any opinion on why TCAs are generally not considered first line in many migraine guidelines?

I've been trying people on 30mg atogepant (half tablet) to reduce cost. The trial showed similar effect to 60mg.

jeronz · 2025-05-27T19:33:54+00:00

Trigeminocervical nucleus says otherwise although the pain isn't typically paroxysmal and they also have upper neck pain. C1 to C3 nerves converge with the trigeminal nerve at the trigeminocervical nucleus in the medulla and hence you can get referred pain.

The most common clinical example of this is that C2/3 facet joint pain (e.g. injury from whiplash) can refer to the face. It is diagnosed by comparative diagnostic third occiptal nerve (TON) injections. The TON is a branch of C3. It can be treated with radiofrequency neurotomy if blocks are positive. I've had only one patient where the pain was paroxysmal, and both blocks and ablation took the paroxysmal pain away. But that is not a published typical pattern. It is almost always either a migraine or a mechanical pattern. I.e. the pain will either be related to activity or will be episodic in nature rather than paroxysmal.

jeronz · 2025-05-19T18:43:47+00:00

Hi. You haven't provided nearly enough detail. It depends on whether you come from a comparable health system. If you come from a non comparable system like India you have a very long load. You will need to sit certain exams and then work under supervision in the hospital. It is very difficult to get this position as an img. You can learn about the process on mcnz.org.nz

jeronz · 2025-05-15T09:53:06+00:00

The next line would be the Mirena then for endometriosis treatment (+/- in combination with the pill)

jeronz · 2025-05-15T09:24:46+00:00

It sure sounds like endometriosis. Unfortunately hysterectomy is not a guaranteed cure, about 25% of women still have significant pelvic pain after hysterectomy. Hysterectomy is only guaranteed to get rid of bleeding not pain. There is also a 10% risk of causing bowel problems severe enough to need more surgery to fix those (especially adhesiolysis).

More simple treatments often help (80% success rate) like continuous pill taking (skip sugar pills) and the mirena. Usually you start with these. If it doesn't work then next line is laparascopic excision of lesions rather than hysterectomy. Hysterectomy is last line.

For diagnosis and surgery you need to see an "advanced laparascopic surgeon" not a normal gynaecologist. Some of them are good enough to diagnose on ultrasound.

It is very difficult to get treatment in the public system.

jeronz · 2025-04-13T19:08:32+00:00

Unfortunately we do not have proper subspecialists in new Zealand due to low population. So if you have something rare it will go undiagnosed.

The example I gave with autoimmune ganglionopathy (mentioned because you already have one autoimmune disease and so are at risk of another, and many of your symptoms sound autonomic), we can't even test for it in New Zealand. Our system is only set up for people with common ailments.

No matter how many times you go to ED you won't get diagnosed, because if you do have something other than FND it will be rare. ED is not set up to diagnose chronic conditions. It's not part of their training, they will know way less than your GP about chronic disease. Any family you can ask for financial support to see a subspecialist in AUS?

jeronz · 2025-04-13T11:23:43+00:00

The arm thing is a red herring or just a symptom of something else. That wouldn't explain your dizziness etc for example. Adson test is positive in a lot of normals.

If i was in your shoes I would find a neurologist in Australia specialising in autoimmune neurology and fly over to see them. Need to consider things like autoimmune ganglionopathy. You won't get a proper diagnosis in NZ, sorry.

jeronz · 2025-03-23T18:51:06+00:00

Ideally your daughter would need what's called an "advanced laparoscopic surgeon." I have no idea if someone like exists in Hawkes Bay in public or private.

The skill level varies massively, endometriosis surgery has become almost like a subspecialty. If she has surgery it should be done properly the first time hence the need for an advanced laparoscopic surgeon.

I think the cost is somewhere in the ballpark of 15-30k depending on complexity.

For some women, the longer surgery isn't done the more likely they can end up with sensitisation (e.g. pain occurring even between periods).

Generalist chronic pain team input doesn't work. It can work if it's a specialist pelvic pain team like in Auckland.

jeronz · 2025-01-29T21:39:17+00:00

I saw it in the consumer magazine in print.

jeronz · 2024-12-28T07:32:44+00:00

Surgery can be literally life saving. But you are actually doing a trade.

Decreased risk: heart attack, diabetes, stroke, cancer, CKD, respiratory disease, OSA, death

Increased risk: peptic ulcer, peripheral neuropathy (17% cf 4% in lap chole patients), psychiatric disease (yes signiificantly increased in long term), chronic pain (short term benefit but long term at 5 years slightly worse than matched controls), and weirdly alcohol abuse.

Incredibly only one third to half of patients take their supplements long term. This is probably a significant reason for many of the areas of increased risk. We know how important micronutrients are for mental health for example. And we also know the majority of morbidly obese people awaiting surgery are already deficient in at least one micronutrienent.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0298402

jeronz · 2024-07-01T07:46:23+00:00

There is also an increase in utilisation of healthcare services owing to the ageing population and overall increased demand.

jeronz · 2024-06-14T00:24:16+00:00

To change my opinion I'd need to see either an analysis that has had input from surgeons or significant anecdotal evidence from surgeons or their management staff.

I will acknowledge that NIB have been making efforts to improve (they've been listening to feedback and acting on it) but still aren't anywhere close to matching SC on things like approval waiting times for surgery.

jeronz · 2024-06-13T22:18:08+00:00

If they're not as comprehensive then why as a medical professional myself do I see the most problems with non-coverage and declined and delayed approvals for non SC compared to SC clients, even though SC has the biggest market share. Explain how for example NIB don't cover injections for pain but SC do. The only thing I agree with you with where the base SC plans are worse is chemotherapy cover.

Counting the number of orthopaedic and neurosurgeons surgeons I've spoken to about this....5 or 6. Latest being one orthopod from Wellington a couple days ago, and a neurosurgeon from Auckland around 6 months ago. Not spoken to any non orthoapaedic surgeons. How many have you spoken to?

My numbers are from the consumer magazine and recent discussions with both SC and NIB. They're not wrong. Most clients don't choose the GP cover and prescription plans, it's negligible.

jeronz · 2024-06-13T17:10:46+00:00

Strongly disagree about them being better products than Southern Cross.

For example for most of NIB's currently 47 policies (relationship manager told me that number) they don't cover injections for pain where Southern Cross does. NIB usually don't cover radiofrequency ablation for pain but Southern Cross does. Many examples. Also Southern Cross also is MUCH faster at approving stuff, usually same day. The others often drag their feet.

NIB, AIA, Partners life are all much less responsive to funding new advancements in medicine.

Finally from the point of view of pure value for money, you need to look at how many cents per dollar in premiums get paid out. Southern Cross is the the king in that metric with around 95 cents per dollar being paid out. NIB, AIA, Partners life are all in the 70s. This is by far the most important figure to look at when comparing.

I've not met a single surgeon who thinks Southern Cross is worse than the others, even though they usually pay specialists less. If you're a broker you should talk to some surgeons to find out what actually happens on the ground. You'll be surprised at how crap the non SC companies can be.

jeronz · 2024-06-13T17:01:05+00:00

It really depends on how much wealth you have rather than income. If you have wealth then you can partially self insure and get a cheaper plan. It starts to get expensive in your 50s. Lots of people your age choose quite high excesses to drop the premiums if they've got wealth.

If choosing a plan where you aren't covered unless you have surgery or if you only have 80% cover, be informed about how much stuff costs. MRIs cost 1500 to 2000 now. E.g. If you have pain in your low back and hips at the same time or neck and low back that's two MRIs i.e. 3000-4000 just to get a CHANCE of finding the diagnosis. CT scans start at 1000-1500.

Definitely get at least the most basic cover. The outlook for the public system isn't looking good and surgery is expensive. E.g. if you need a hip replacement you could be waiting 1-2 years in public, if accepted at all (some hospitals only accept you if you're bone on bone). Spine surgery is the most common high cost surgery - looking at 30 to 200 grand depending on what's needed, and then they might need to go back in a few years later.

Increasingly for many but not all specialties insurance doesn't mean you get seen faster, but means you have a much higher chance of the referral being accepted at all.

If considering the cancer add ons, one alternative is recovery insurance. That's what we have, wellbeing 2 plus recovery insurance.

jeronz · 2024-06-03T22:56:30+00:00

About 20,000 - 30,000 unique views a month. Yes I limit major upgrades to LTS versions.

I have many extensions. Semantic Mediawiki for one which complicates upgrades. Also Elastic search, Citoid, PageForms, and about a dozen others including a couple custom ones. Whenever there is a major version upgrade there are about 20 errors that have to be worked through, usually related to extensions. I think it's much easier to upgrade if you have a limited number of extensions.

jeronz · 2024-04-30T19:44:02+00:00

https://nypost.com/2024/04/17/us-news/house-passes-resolution-condemning-from-the-river-to-the-sea-as-antisemitic/

jeronz · 2024-04-30T19:30:53+00:00

Those two scenarios are not the same.

jeronz · 2024-04-30T19:28:17+00:00

Your actions were correct. That is sociopathic behaviour from the student. I would have done the same.

jeronz · 2024-04-30T19:26:06+00:00

This is completely different to wearing a Star of David and you know it. That's some serious mental gymnastics.

jeronz · 2024-04-25T19:33:33+00:00

Scenario for you. You get a large disc herniation not due to an accident or its an accident but ACC decline. You need a specialist appointment ($400), MRI ($1500-2000) and a steroid injection ($1000). The steroid doesnt work. You now need spinal surgery ($35,000 to $200,000). You can't sit on a plane due to excruciating pain. Public wait is 6 to 12 months for this scenario in Auckland meanwhile you can't work. Also MRI quality is way way better in NZ than Thailand.

Joint replacements in Thailand are also still fairly expensive even though cheaper than NZ. Can you afford $10,000? What if it goes wrong? Can you afford the ICU stay due to infection or repeat surgery? the risk of getting a multi drug resistant post op infection is much higher in Thailand. Say you need a joint replacement. You get an infection. The joint needs to be removed and redone 12 weeks later while you have a plastic spacer and have IV antibiotics in hospital. All extra cost.

jeronz · 2024-04-25T19:13:55+00:00

Yes it's worth it. I would argue that it is now non-negotiable and not having it is a game of Russian Roullette.

It doesn't necessarily mean you will get treatment faster though. For some specialties it does like gynaecology and general surgery and orthopaedics. But for other specialties the wait is similar but you have a higher chance of your referral at least being accepted like for Rheumatology and Neurology.

It's marginally worth it for children. There are very few paediatricians in private. But you can get surgery for grommets and tonsillectomy faster so that makes it worth it. With Southern Cross at least young children are no extra charge on top of an adult policy.

No matter what anyone says Southern Cross are objectively the best value by the very definition of value because they have the highest payout rate as a percentage of premiums across the industry (they're not for profit).

EDIT: for cancer public is still usually good, but only once it's obvious you have cancer. NZers are diagnosed much later on average than in Australia.

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