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Does Shingles Cause Pain In Hip And Abdomen Along With Numbness In Hands?
Question: I am relatively healthy/fit but am suffering from 2 bout of shingles in 3mo time. 1st in July blisters @ R groin/hip area. Treated w/5 days Famcyclivir. Felt mostly better w/some fatique. 2nd bout early Sept. Rash in same area not as bad. Gone in 4 days but continue to get worse symptoms. PHN in R hip, then nerve pain in torso worse at esp. @ night. Followed days later w/ occasional nausea/vomiting. Pain in abd. L side of sternum & navel. Pain worse @ night & lying down. then began waking abruptly w/gasp & feet/hands numb several times/night. Breathing is better when up moving. Can shingles cause these symptoms? Can they cause diapragmatic paralysis? If so, is it reversible? Will symptoms subside as virus subsides? What can i do to expedite healing? Mostly miserable now.
Brief Answer:
Diaphragmatic affectation by Zoster
Detailed Answer:
Good evening. I believe I recently answered another question of yours having to do with your shingles. Let me add a bit more information and tell you that Shingles rarely will affect the diaphragm due to "hiding out" in cervical nerve roots C3-C5 then, being released into the PHRENIC NERVE which specifically supplies 1/2 of the entire diaphragm. Generally, most patients with hemidiaphragmatic affectation are unaware of paralysis of 1 diaphragm due to the presence of accessory respiratory. However, if you were to recline back or lie down then, the presence of a paralysis of half of the diaphragm does become apparent due to inability of the accessory muscles to operate as effectively in that position as well as the fact that the rate and depth of breathing usually decrease when lying down which again reduces total lung volume and efficiency of respiration. This then, can lead to a change or drop in oxygenation of the body (and brain) and this can result in your being awoken at night with a feeling of shortness of breath and other uncomfortable sensations.
As the viral infection begins to resolve so too should the respiratory systems, however, there is no guarantee that some residual damage may not linger due to the viral activity since inflammation will have necessarily occurred and there's no telling if the phrenic nerve could've suffered some damage after the infection has subsided without doing studies or seeing how the patient does afterward from a clinical perspective.
Symptoms could take several weeks to start feeling back to normal while lying on your back. If they do not an EMG of the diaphragm itself as well as PULMONARY FUNCTION STUDIES could be done to assess overall level of electrical as well as lung function and this can then, be tracked over time to gauge improvement either by way of "tincture of time" (i.e. just waiting it out a bit to see how it heals) or by way of medications and other interventions.
Things you can do to improve and expedite healing would include pulmonary exercises that Respiratory Therapy will offer to you and help recondition the paralyzed diaphragm as quickly as possible.
Your doctors will likely prescribe medications both specifically for the viral infection and the inflammatory reaction and swelling which can be just as debilitating as the paralysis. Consider lying no more than at a 30 degree angle with head elevated so you can facilitate expansion of the chest cavity while asleep. It may also be worthwhile using a positive pressure oxygenation system to help "blow the lungs open." There are also ways to electrically stimulate the affected diaphragm across the skin (transcutaneous) using devices that are similar to TENS units so check with the respiratory therapists and see what they can offer and then, have your doctor write for it.
Of course, controlling any pain with appropriate measures and/or medications is very important and should be aggressively followed up on as pain can lead to anxiety which can alter respiratory rates which could lead to more pain and the cycle becomes vicious.
To that end activities such as meditation, biofeedback, acupuncture, visual imagery, music therapy, deep breathing and other relaxation techniques including hippotherapy (equine or horse therapy) may all act to enhance breathing and respiratory function given the paralyzed or at least possibly weakened HEMI-diaphragm and could be employed.
I would also recommend that you have a full metabolic workup if it's a been while just to be absolutely sure that you don't have any correctable problems such as diabetes, anemia, low functioning thyroid function, good Vit. B12/folate, and Normal Vitamin D levels (60-80), and good adrenal gland function. You want to be extra good about getting good restful sleep and address any problems with insomnia, nightmares, narcolepsy, and sleep apnea.
You do not want to be smoking, around people or places filled with smoke, or do any type of illicit substances or excessively ingest alcohol as all these things can lead to respiratory depression. You should also see your doctor right away if you contract a respiratory illness of any sort right away and not let it progress from a sinusitis to a bronchitis, to finally a pneumonia because then, you will have everything MAGNIFIED because of the diaphragmatic weakness.
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING to the answer?
Also, if you have no further questions or comments to place could you also do me the favor of CLOSING THE QUERY which will alert the network to process, archive, and credit this question appropriately for future reference.
In the future I'm happy to answer questions personally and you would allow me this privilege by going to the following website and writing your questions:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
This query required 44 minutes of physician specific review, research, and final draft documentation for envoy.
Diaphragmatic affectation by Zoster
Detailed Answer:
Good evening. I believe I recently answered another question of yours having to do with your shingles. Let me add a bit more information and tell you that Shingles rarely will affect the diaphragm due to "hiding out" in cervical nerve roots C3-C5 then, being released into the PHRENIC NERVE which specifically supplies 1/2 of the entire diaphragm. Generally, most patients with hemidiaphragmatic affectation are unaware of paralysis of 1 diaphragm due to the presence of accessory respiratory. However, if you were to recline back or lie down then, the presence of a paralysis of half of the diaphragm does become apparent due to inability of the accessory muscles to operate as effectively in that position as well as the fact that the rate and depth of breathing usually decrease when lying down which again reduces total lung volume and efficiency of respiration. This then, can lead to a change or drop in oxygenation of the body (and brain) and this can result in your being awoken at night with a feeling of shortness of breath and other uncomfortable sensations.
As the viral infection begins to resolve so too should the respiratory systems, however, there is no guarantee that some residual damage may not linger due to the viral activity since inflammation will have necessarily occurred and there's no telling if the phrenic nerve could've suffered some damage after the infection has subsided without doing studies or seeing how the patient does afterward from a clinical perspective.
Symptoms could take several weeks to start feeling back to normal while lying on your back. If they do not an EMG of the diaphragm itself as well as PULMONARY FUNCTION STUDIES could be done to assess overall level of electrical as well as lung function and this can then, be tracked over time to gauge improvement either by way of "tincture of time" (i.e. just waiting it out a bit to see how it heals) or by way of medications and other interventions.
Things you can do to improve and expedite healing would include pulmonary exercises that Respiratory Therapy will offer to you and help recondition the paralyzed diaphragm as quickly as possible.
Your doctors will likely prescribe medications both specifically for the viral infection and the inflammatory reaction and swelling which can be just as debilitating as the paralysis. Consider lying no more than at a 30 degree angle with head elevated so you can facilitate expansion of the chest cavity while asleep. It may also be worthwhile using a positive pressure oxygenation system to help "blow the lungs open." There are also ways to electrically stimulate the affected diaphragm across the skin (transcutaneous) using devices that are similar to TENS units so check with the respiratory therapists and see what they can offer and then, have your doctor write for it.
Of course, controlling any pain with appropriate measures and/or medications is very important and should be aggressively followed up on as pain can lead to anxiety which can alter respiratory rates which could lead to more pain and the cycle becomes vicious.
To that end activities such as meditation, biofeedback, acupuncture, visual imagery, music therapy, deep breathing and other relaxation techniques including hippotherapy (equine or horse therapy) may all act to enhance breathing and respiratory function given the paralyzed or at least possibly weakened HEMI-diaphragm and could be employed.
I would also recommend that you have a full metabolic workup if it's a been while just to be absolutely sure that you don't have any correctable problems such as diabetes, anemia, low functioning thyroid function, good Vit. B12/folate, and Normal Vitamin D levels (60-80), and good adrenal gland function. You want to be extra good about getting good restful sleep and address any problems with insomnia, nightmares, narcolepsy, and sleep apnea.
You do not want to be smoking, around people or places filled with smoke, or do any type of illicit substances or excessively ingest alcohol as all these things can lead to respiratory depression. You should also see your doctor right away if you contract a respiratory illness of any sort right away and not let it progress from a sinusitis to a bronchitis, to finally a pneumonia because then, you will have everything MAGNIFIED because of the diaphragmatic weakness.
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING to the answer?
Also, if you have no further questions or comments to place could you also do me the favor of CLOSING THE QUERY which will alert the network to process, archive, and credit this question appropriately for future reference.
In the future I'm happy to answer questions personally and you would allow me this privilege by going to the following website and writing your questions:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
This query required 44 minutes of physician specific review, research, and final draft documentation for envoy.
Above answer was peer-reviewed by :
Dr. Shanthi.E
My refresh question is for neurologist Dr. XXXXXXX Saghafi, who has been most helpful. I would also like to send my recent bloodwork results which appear to be normal.
Question: today I began experiencing the following symptoms: sharp pain in thoracic spine w/ tingle& burn radiating to L ribcage, stomach upsets w/nausea, no vomiting, nerve pain at original blister site R hip/groin, dizziness, low grade headache, congestion & cough, breathing difficulty supine, facial flushing, occasional chills, but no fever & general feeling of nervous system out of whack, but NO BLISTERS at present. I now know from 1st two bouts of shingles these are symptoms I had prior to blisters presenting. Are these typical symptoms? I am deeply fearful there is something much more serious underlying all this.
I have taken some of your advice. I’ve been resting, eating well but not much, taking large doses of sublingual Bvit. Complex, L-lysine 1000 mg/day, deep breathing & spirometer breathing, acupuncture 1x/wk. I just began the Valtrex 500mg today, as symptoms began getting worse.
I live in rural NM w/out many healthcare options and really don’t know what to do next. Any recommendations are greatly appreciated. Thank you so much, you have been very comforting & helpful thus-far.
Still miserable in NM
Question: today I began experiencing the following symptoms: sharp pain in thoracic spine w/ tingle& burn radiating to L ribcage, stomach upsets w/nausea, no vomiting, nerve pain at original blister site R hip/groin, dizziness, low grade headache, congestion & cough, breathing difficulty supine, facial flushing, occasional chills, but no fever & general feeling of nervous system out of whack, but NO BLISTERS at present. I now know from 1st two bouts of shingles these are symptoms I had prior to blisters presenting. Are these typical symptoms? I am deeply fearful there is something much more serious underlying all this.
I have taken some of your advice. I’ve been resting, eating well but not much, taking large doses of sublingual Bvit. Complex, L-lysine 1000 mg/day, deep breathing & spirometer breathing, acupuncture 1x/wk. I just began the Valtrex 500mg today, as symptoms began getting worse.
I live in rural NM w/out many healthcare options and really don’t know what to do next. Any recommendations are greatly appreciated. Thank you so much, you have been very comforting & helpful thus-far.
Still miserable in NM
Brief Answer:
You need to hit this thing hard and fast
Detailed Answer:
Hi there...."still miserable in NM...." I'm sorry you're miserable....I went to NM once for a telemedicine conference (of all things!)... XXXXXXX I didn't do any sightseeing while there cause I was busy every day of the conference....but I was enamored just being there. All the things one hears and reads about the SW United States and then, I was suddenly there....it was a bit chilly at night....I thought it would be hotter.....well, I was coming from XXXXXXX OH so who knew exactly what a desert was like? Well, I did spend one year living and working as a doctor in a border town (Mexicali, MX).
So what you're experiencing may be one of 2 things. Either it's a recrudescence of the shingles infection which would really suck if that were the case....but it wouldn't XXXXXXX me since you have not been on suppression therapy....or it is the painful AFTER effects of a herpes infection called POST-HERPETIC NEURALGIA.
My recommendation would be to be aggressive with the suppression therapy using Valtrex and maybe even in conjunction with a modestly high steroid such as prednisone to really batten down the hatches on these symptoms otherwise things may escalate again. Stay VERY WELL HYDRATED since Valtrex can cause kidney stones. I would stay on suppression therapy for a minimum of 8-12 weeks just to really whack this thing out of your system.
I doubt any of the other stuff you're taking (Bvit, Bcomplex, or L-lysine) will have any effect on the course of the shingles....but I see no down side to taking them except for whatever money you're paying out of pocket.
It is not unusual to get these types of symptoms in the wake of a recent acute infection. As your doctor but I would recommend a greater number of times per day for suppression of the Valtrex. When it comes to suppressing these infections...you can never be TOO HEAVY HANDED.....this virus is nasty and it will force its will upon you if you don't strike first.
Thank you as well, for your supportive comments and I'm very pleased that you've been uplifted in some small way by my comments and suggestions; I'm genuinely pleased to be able and offer my medical knowledge to someone literally a couple thousand miles away and know that they think it's made a difference for them.
Therefore, if the present information has been as helpful as before I would absolutely glow at reading some written feedback and seeing a STAR RATING by yourself on the question.
If you have no further questions or comments to place could you also do me the favor of CLOSING THE QUERY which will alert the network to process, archive, and credit this question appropriately for future reference?
I'm happy to answer questions personally through the following website:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
This query required 32 minutes of physician specific review, research, and final draft documentation for envoy.
You need to hit this thing hard and fast
Detailed Answer:
Hi there...."still miserable in NM...." I'm sorry you're miserable....I went to NM once for a telemedicine conference (of all things!)... XXXXXXX I didn't do any sightseeing while there cause I was busy every day of the conference....but I was enamored just being there. All the things one hears and reads about the SW United States and then, I was suddenly there....it was a bit chilly at night....I thought it would be hotter.....well, I was coming from XXXXXXX OH so who knew exactly what a desert was like? Well, I did spend one year living and working as a doctor in a border town (Mexicali, MX).
So what you're experiencing may be one of 2 things. Either it's a recrudescence of the shingles infection which would really suck if that were the case....but it wouldn't XXXXXXX me since you have not been on suppression therapy....or it is the painful AFTER effects of a herpes infection called POST-HERPETIC NEURALGIA.
My recommendation would be to be aggressive with the suppression therapy using Valtrex and maybe even in conjunction with a modestly high steroid such as prednisone to really batten down the hatches on these symptoms otherwise things may escalate again. Stay VERY WELL HYDRATED since Valtrex can cause kidney stones. I would stay on suppression therapy for a minimum of 8-12 weeks just to really whack this thing out of your system.
I doubt any of the other stuff you're taking (Bvit, Bcomplex, or L-lysine) will have any effect on the course of the shingles....but I see no down side to taking them except for whatever money you're paying out of pocket.
It is not unusual to get these types of symptoms in the wake of a recent acute infection. As your doctor but I would recommend a greater number of times per day for suppression of the Valtrex. When it comes to suppressing these infections...you can never be TOO HEAVY HANDED.....this virus is nasty and it will force its will upon you if you don't strike first.
Thank you as well, for your supportive comments and I'm very pleased that you've been uplifted in some small way by my comments and suggestions; I'm genuinely pleased to be able and offer my medical knowledge to someone literally a couple thousand miles away and know that they think it's made a difference for them.
Therefore, if the present information has been as helpful as before I would absolutely glow at reading some written feedback and seeing a STAR RATING by yourself on the question.
If you have no further questions or comments to place could you also do me the favor of CLOSING THE QUERY which will alert the network to process, archive, and credit this question appropriately for future reference?
I'm happy to answer questions personally through the following website:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
This query required 32 minutes of physician specific review, research, and final draft documentation for envoy.
Above answer was peer-reviewed by :
Dr. Bhagyalaxmi Nalaparaju
Again, thank you for your very knowledgeable, detailed answers and kindness. I am familiar w/the Midwest as I am originally from St. XXXXXXX & husband is from XXXXXXX We go back there often and I miss the beautiful fall colors you are probably experiencing now.
I am wondering if it is typical for me to experience PHN pain in many nerves other than just the nerve path where blisters presented along w/ a general feeling of total nervous system excitement?
Also, I tend to agree w/your recommendation of bumped up suppressive therapy w/Valtrex, any suggestion on how to convince my Dr. Of that since she seems to think that 3days of 500mg is enough. BTW, yesterday was my last day of Valtrex script she gave me. I have concerns that stopping abruptly will only trigger the virus again. I am feeling somewhat better, but still not normal by any means.
I truly appreciate your suggestions and will be awaiting your input. Thank you.
A little less miserable in NM.
I am wondering if it is typical for me to experience PHN pain in many nerves other than just the nerve path where blisters presented along w/ a general feeling of total nervous system excitement?
Also, I tend to agree w/your recommendation of bumped up suppressive therapy w/Valtrex, any suggestion on how to convince my Dr. Of that since she seems to think that 3days of 500mg is enough. BTW, yesterday was my last day of Valtrex script she gave me. I have concerns that stopping abruptly will only trigger the virus again. I am feeling somewhat better, but still not normal by any means.
I truly appreciate your suggestions and will be awaiting your input. Thank you.
A little less miserable in NM.
Brief Answer:
A Bengals/Reds person, huh? Now, in NM?
Detailed Answer:
Thanks for writing back and asking your question. Yes, the fall colors are in season to be sure.....but with that means, "Brace boys....but here comes Ole Man Winter," HA!
It is possible to have sensations in other dermatomal distributions other than the one you are currently noticing is being attacked. It's NOT common to break out with the blisters in any more than 1 distribution at a time.
Unfortunately, I do not know of an EASY way to talk to your doctor except to come right out and express your concern and FEAR that you may have to battle with yet another band of blisters due to early stoppage of therapy. I suppose you could do something like hit the internet and find articles that discuss how this suppressive therapy works in shingles and then, print out the article to show her....but honestly, I think that might rub her the wrong way....There's no easy to do this without coming off as, "Oh, I want to do things MY way....or I am sure I know better than you because I read the internet too!" LOL.
I think I would simply say that after 2 bouts of shingles and after not being able to find the reason for the bouts that you're very afraid of stopping the medication for fear of a recrudescence which has already happened.
You could change doctors?
You could hop a bird to Cleveland? You'd be here in about 4 hrs.....we'll get you in the office and back home in time to see that beautiful desert sunset!" HAHA!
Good luck....if you figure out the magic way to tell someone that a doctor that they're WRONG...please let me know....that way I can use that pearl.....AND perhaps, consider LISTENING to you myself once in awhile......! ROFLMAO!
Doctors just have really big egos....so, that 's the nature of the beast.
If the present information has been as helpful as before I would absolutely love to read some written feedback and see a STAR RATING on the question.
In fact, there is another question I believe which remains open and has not been rated or STARRED! Could you do that one as well? These stars and blurbs really help us out a lot more than you think.
If you have no further questions or comments to place could you also do me the favor of CLOSING THE QUERY which will alert the network to process, archive, and credit this question appropriately for future reference?
I'm happy to answer questions personally through the following website:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
This query required 15 minutes of physician specific review, research, and final draft documentation for envoy.
A Bengals/Reds person, huh? Now, in NM?
Detailed Answer:
Thanks for writing back and asking your question. Yes, the fall colors are in season to be sure.....but with that means, "Brace boys....but here comes Ole Man Winter," HA!
It is possible to have sensations in other dermatomal distributions other than the one you are currently noticing is being attacked. It's NOT common to break out with the blisters in any more than 1 distribution at a time.
Unfortunately, I do not know of an EASY way to talk to your doctor except to come right out and express your concern and FEAR that you may have to battle with yet another band of blisters due to early stoppage of therapy. I suppose you could do something like hit the internet and find articles that discuss how this suppressive therapy works in shingles and then, print out the article to show her....but honestly, I think that might rub her the wrong way....There's no easy to do this without coming off as, "Oh, I want to do things MY way....or I am sure I know better than you because I read the internet too!" LOL.
I think I would simply say that after 2 bouts of shingles and after not being able to find the reason for the bouts that you're very afraid of stopping the medication for fear of a recrudescence which has already happened.
You could change doctors?
You could hop a bird to Cleveland? You'd be here in about 4 hrs.....we'll get you in the office and back home in time to see that beautiful desert sunset!" HAHA!
Good luck....if you figure out the magic way to tell someone that a doctor that they're WRONG...please let me know....that way I can use that pearl.....AND perhaps, consider LISTENING to you myself once in awhile......! ROFLMAO!
Doctors just have really big egos....so, that 's the nature of the beast.
If the present information has been as helpful as before I would absolutely love to read some written feedback and see a STAR RATING on the question.
In fact, there is another question I believe which remains open and has not been rated or STARRED! Could you do that one as well? These stars and blurbs really help us out a lot more than you think.
If you have no further questions or comments to place could you also do me the favor of CLOSING THE QUERY which will alert the network to process, archive, and credit this question appropriately for future reference?
I'm happy to answer questions personally through the following website:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
This query required 15 minutes of physician specific review, research, and final draft documentation for envoy.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Can't believe you said "Reds" fan...it's Cardinals all the way! Husband & I have a healthy rivalry going every fall but my guys usually win!
You're helpful and honest reply is appreciated. I have noticed that you have never commented, or suggested, the gabapentin for long term PHN pain mngmt. As much as I prefer natural remedies over meds, I also realistically know there is a time when meds are the preferred option. What are your thoughts on gabapentin? How does it work on nerves? I also know that my stomach/hiatal hernia do not accept many medications w/out painful upsets and have concerns there. Even just the 3days of Valtrex 500mg upset it again. Thank you so very much for your help.
Cardinals fan in NM.
You're helpful and honest reply is appreciated. I have noticed that you have never commented, or suggested, the gabapentin for long term PHN pain mngmt. As much as I prefer natural remedies over meds, I also realistically know there is a time when meds are the preferred option. What are your thoughts on gabapentin? How does it work on nerves? I also know that my stomach/hiatal hernia do not accept many medications w/out painful upsets and have concerns there. Even just the 3days of Valtrex 500mg upset it again. Thank you so very much for your help.
Cardinals fan in NM.
Brief Answer:
Cardinals? Birds? Really? Wow...who'd a thunk? LOL
Detailed Answer:
Well, you guys must really have a healthy relationship if you can live in the same household together with those 2 teams opposing one another! HAHA!
No real such problems in our household...since my wife doesn't even understand most of the professional sports anyways, let alone rooting for any particular team so she just goes with the hometowners (she's from Mexico...so her sport is either Soccer or Bullfighting!).
So, there is a reason I didn't mention gabapentin....I don't think much of it as a ROBUST post herpetic neuralgic treatment. It really doesn't work very well in my opinion though it is commonly used. What I believe works better is either a compounding cream with ingredients of gabapentin, bupivicaine or marcaine, and dexamethasone which you must get from a compounding pharmacy. Or, high dose Lyrica I believe works better than gabapentin as a stand alone.
Has your doctor considered giving you something like Cytotec along with the Valtrex to relieve stomach upset? I've had good luck with that combination in patients sensitive GI-wise to the Valtrex but who not respond to the combination with something like Prilosec, Prevacid, Omeprazole, or Nexium.
If I have helped you understand a bit more about your condition of PHN then, would you do me a huge favor and leave some written feedback as well as a STAR RATING?
In addition, if you have no further questions or comments on this thread I'd very much appreciate your CLOSING THE QUERY from your side as this will signal to the network that the case is ready for processing, archiving, and appropriate crediting.
This query required 24 min. of physician specific and directed efforts in reviewing, researching, and documenting the final draft for envoy.
Cardinals? Birds? Really? Wow...who'd a thunk? LOL
Detailed Answer:
Well, you guys must really have a healthy relationship if you can live in the same household together with those 2 teams opposing one another! HAHA!
No real such problems in our household...since my wife doesn't even understand most of the professional sports anyways, let alone rooting for any particular team so she just goes with the hometowners (she's from Mexico...so her sport is either Soccer or Bullfighting!).
So, there is a reason I didn't mention gabapentin....I don't think much of it as a ROBUST post herpetic neuralgic treatment. It really doesn't work very well in my opinion though it is commonly used. What I believe works better is either a compounding cream with ingredients of gabapentin, bupivicaine or marcaine, and dexamethasone which you must get from a compounding pharmacy. Or, high dose Lyrica I believe works better than gabapentin as a stand alone.
Has your doctor considered giving you something like Cytotec along with the Valtrex to relieve stomach upset? I've had good luck with that combination in patients sensitive GI-wise to the Valtrex but who not respond to the combination with something like Prilosec, Prevacid, Omeprazole, or Nexium.
If I have helped you understand a bit more about your condition of PHN then, would you do me a huge favor and leave some written feedback as well as a STAR RATING?
In addition, if you have no further questions or comments on this thread I'd very much appreciate your CLOSING THE QUERY from your side as this will signal to the network that the case is ready for processing, archiving, and appropriate crediting.
This query required 24 min. of physician specific and directed efforts in reviewing, researching, and documenting the final draft for envoy.
Above answer was peer-reviewed by :
Dr. Raju A.T
Answered by
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