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Ask Family Physician Your Own Question
Family Physician
Family Physician, Doctor
Category: Medical
Satisfied Customers: 2592
Experience:  Emergency Medicine and Family Practice for over 26 years
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SH, i have another question for you. I am not sure if it is

Customer Question

Hi Dr. SH,
i have another question for you. I am not sure if it is related to the possible enzyme (urea cycle or other) deficiency that I may have, but my skin is squishy in a lot of places. The worst is my leg which look like the uploaded file (2 pictures on one page saved in Word) In addition, my knuckle joints and hip joints are killing me. FYI I already go to pain management. I have been on embeda 2x daily for months (the strength of my embeda is 50 mg morphine/2 naltrexone as well oxycodone/acetaminophen 10/325. The joint pain is breaking through this treatment.
Thanks for any help.
Submitted: 10 months ago.
Category: Medical
Expert:  khagihara replied 10 months ago.

Dr. SH doesn't seem to be working now. May I take your question?

Customer: replied 10 months ago.
Expert:  khagihara replied 10 months ago.

How tall are you? How much do you weigh? Any weight change? Can you attach the photos of your knuckle joints? Does anything make it better or worse? When did it start? Is it consistent? Is it getting worse? Any other symptoms? Are you aware of anything which might have triggered it? What tests did you have so far? What is your diagnosis? Any medical problems? Any surgeries? Any medications including over-the-counter pills and herbs? Any family medical history?

Customer: replied 9 months ago.
I put everything in a file (word document). I hope it is not too jumbled.
Customer: replied 9 months ago.
Here is the evening pictures of my hands when they have started hurting and I cannot close my hands into a tight fist. The file says left hand in the title but it includes both hands.
Expert:  khagihara replied 9 months ago.

Similar symptoms in your family history? Did your doctor ask you to restrict protein intake?

Customer: replied 9 months ago.
I don't know anything about my biological father's side of the family. My daughter's values are slightly elevated at 67. I asked my mother to get tested... She's an interesting lady... She got tested and her values were slightly high. However she refuses to believe that she can carry anything and that it must be the unknown part of the family. My mother's parents passed away in their fifties. The doctor , my neurologist, said that if the test is positive I will need to restrict my protein. He did not tell me to go ahead and do this. Do you recommend I do? We laughed over the fact that as a diabetic I watch my carbohydrates. With this condition, my cholesterol is elevated so I'm watching my fats. Early this year, I tried going to a multi-dimensional naturalist. She used as traditional as well as conventional medications. It didn't work out but she did test me for a ton of different allergies. Turns out I'm allergic to milk, eggs, and I have one allele for celiacs disease. So she asked me to watch or eliminate wheat. At this point, my husband recommends that I just eat tree bark and rocks. Haha. I was a vegetarian for 10 years. And I still don't really like meat. So if I should need to go on a low protein diet that will be okay with me.
Customer: replied 9 months ago.
is the edema related to the possible protein issue?
Expert:  khagihara replied 9 months ago.

If you have low protein (albumin) in the blood, you have edema because water in the blood goes into the tissue because of osmotic pressure.

Customer: replied 9 months ago.
Sorry. I don't understand. I have not been eating low protein yet
Is that why I have edema? Or will it be worse when I do?
Expert:  khagihara replied 9 months ago.

There are many causes to produce edema as following.

1. Increased capillary hydraulic pressure

1) Increased plasma volume due to renal sodium retention

Heart failure, including cor pulmonale

Primary renal sodium retention

• Renal disease, including the nephrotic syndrome

• Drugs*: Nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, fludrocortisone, thiazolidinediones (glitazones), insulins, estrogens, progestins, androgens, testosterone, aromatase inhibitors, tamoxifen; and by multiple mechanisms: vasodilators (hydralazine, minoxidil, diazoxide) and calcium channel blockers (particularly dihydropyridines, ie, amlodipine, nifedipine); also see "Arteriolar vasodilation" below

• Refeeding edema

• Early hepatic cirrhosis

Pregnancy and premenstrual edema

Idiopathic edema, when diuretic induced

Sodium or fluid overload: Parenteral antibiotics or other drugs with large amounts of sodium, sodium bicarbonate, or excessive or overly rapid fluid replacement

2) Venous obstruction or insufficiency

Cirrhosis or hepatic venous obstruction

Acute pulmonary edema

Local venous obstruction

• Venous thrombosis

• Venous stenosis

Chronic venous insufficiency - post-thrombotic syndrome

3) Arteriolar vasodilation

Drugs*: Frequent - vasodilators (hydralazine, minoxidil, diazoxide), dihydropyridine calcium channel blockers; less frequent - alpha1 blockers, sympatholytics (ie, methyldopa), nondihydropyridine calcium channel blockers[1]

Idiopathic edema (?)

2. Hypoalbuminemia

1) Protein loss

Nephrotic syndrome

Protein-losing enteropathy

2) Reduced albumin synthesis

Liver disease


3. Increased capillary permeability

Idiopathic edema (?)



Inflammation or sepsis

Allergic reactions, including certain forms of angioedema

Adult respiratory distress syndrome

Diabetes mellitus

Interleukin-2 therapy

Malignant ascites

4. Lymphatic obstruction or increased interstitial oncotic pressure

Lymph node dissection

Nodal enlargement due to malignancy


Malignant ascites

5. Other drugs* (uncertain mechanism)

Anticonvulsant: Gabapentin, pregabalin

Antineoplastic: Docetaxel, cisplatin

Antiparkinson: Pramipexole, ropinirole