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What Causes Blood In Urine And Pain In Back And Pelvic Area?
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MMy urologist said i need to see a gynecologist for the mass, but my gynocologist said no that wasn't part of here expertise and said i need to see the urologist to get the biopsy. Can you help me know in what direction i need to go and could you tell me how a biopsy is done and how long it takes to get results? I know you haven't examined me and don't have a lot of information but what are the chances this could be cancer?
It hurts to walk, it hurts to stand for short periods of time, it hurts if i sit to long so i mostly have been laying on my side all the time. The past day or so it has been getting to the point of wearing pants hurts, liike jeans and leggings, so i wear pj bottoms. I am nausious all the time no matter if i am eating or not, and sometimes i do vomit.
Need to see a Urologist. Cancer not likely.
Detailed Answer:
Hello
Thanks for writing to us with your health concern.
I can understand your concern.
The symptoms you have, and the urologist's diagnosis all make it clear that you have an obstruction in the urinary tract.
This is leading to pain and difficulty in evacuation of urine.
Could you clarify a few points for me ?
On what basis was this 7 mm. mass diagnosed ?
Could you upload the reports that showed this ?
A gynecologist is not supposed to deal with a bladder mass in any manner.
IT is really within the domain of the urologist .
Also , who has suggested a biopsy ?
A 7 mm mass sometimes cannot be biopsied accurately.
However it can be tried.
A biopsy is done by applying local anesthetic on the skin of your abdomen, making the bladder full and then obtaining tissue from the suspected mass via a long needle.
It generally takes upto 2 weeks to obtain biopsy results.
At your age, I do not think bladder cancer is a very likely possibility.
You need to consult your Urologist ASAP for the next step of treatment.
If possible, do get back to me with the details of the workup done so far.
All the best
PLease feel free to discuss further.
Looking forward to hearing from you.
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60590.jpg)
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Interpreted by: XXXXXXX XXXXXXX BELTRAN
12/19/14 11:44
CT ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST, CT UROGRAM PROTOCOL.
INDICATION:Signs/Symptoms: gross hematuria and inability to urinate
TECHNIQUE: Noncontrast MDCT helical abdomen pelvis obtained. Then
following intravenous administration of 150 cc Optiray 350, utilizing
75 cc split bolus technique , multidetector CT imaging is performed
during simultaneous enhancement of corticomedullary kidney and
excretion of contrast into collecting system. Axial 2 mm images are
submitted. In addition, sagittal and coronal reformatted images are
constructed, along with 3-D volume rendering, performed in the
radiology PACS lab.
COMPARISON:
None
FINDINGS:
GU:
Examination demonstrating no evidence for urolithiasis hydronephrosis
or hydroureter. The excretory urogram demonstrates no filling defects
to suggest intrinsic mass within urinary tract. Bilateral ureters
demonstrate normal course and caliber. Kidneys demonstrate normal
symmetric size with uniform enhancement on the nephrogram phase.
Urinary bladder demonstrates a locule of air within nondependent
lumen. There is no significant wall thickening of the urinary
bladder. Known letter and defects within lumen of bladder identified.
The perivesical fat is unremarkable.
Adrenal glands demonstrating no nodules.
OTHER:
Enhanced liver spleen pancreas and gallbladder unremarkable.
There postsurgical changes within the stomach compatible with gastric
bypass procedure. The small bowel and colon are nondistended. There
is an enteroenteric anastomosis the left lower quadrant unremarkable.
Within pelvis uterus is grossly unremarkable. There is a 7.5 mm
calcification within right adnexal soft tissues which has a toothlike
configuration. There is surrounding low attenuation measuring up to
2.7 mm by 1.4 cm . This finding may possibly represent small right
adnexal mass such as dermoid or normal ovary containing nonspecific
calcification. There is no significant compression of the adjacent
ureter.
No fluid collections ascites or adenopathy within the abdomen or
pelvis identified.
Lung bases are clear.
IMPRESSION:
1. Urinary bladder intraluminal air locule may be related to recent
bladder instrumentation or cystitis. Suggest further clinical
correlation. No evidence for urolithiasis, urinary tract mass or
obstructive uropathy.
2. Right lateral pelvic soft tissue calcification possible uterine
adnexal / ovarian calcification as described above.
Transcribed by: Interface, Powerscribe
Electronically signed by: Interface, Powerscribe 12/19/14 11:44
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Mass is outside the bladder ! Please upload cystoscopy report.
Detailed Answer:
Hello
I am glad you got back with the reports.
There is actually NO bladder mass !
The mass is OUTSIDE the bladder, inside the pelvis, mostly ovarian mass.
I really fail to understand how did your Urologist manage to see it during cystoscopy, because a cystoscopy only visualizes the interior of the urinary bladder, and the imaging report clearly states that there is no mass within the bladder.
Can you upload the cystoscopy report too.
The mass is outside the bladder, but it must be impinging on the bladder / ureters leading to your symptoms.
As such, the mass can be biopsied by an interventional radiologist / experienced gynecologist ( preferably Oncological Gynecologist ) .
Take care.
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/62110.jpg)
![default](/r/images/default.png)
I do have an appointment on Monday with an Oncological Gynecologist who has been in contact with my urologist and kind of said what you did about possibly not getting a biopsie because of the location. He said the oncologist will exam me and determine if it can be done and if it can't he will most likely treat it as cancer and shrink it and then go in and remove it, i was also told to think about if i want to have my eggs frozen because chemo and radiation can kill the eggs i guess?
Have detailed some steps for you.
Detailed Answer:
Hi again.
Since the mass is outside the bladder, it does not technically fall within the domain of the Urologist, but it is causing obstruction, so it is impinging on the bladder/ ureters.
You need to actually avail the cystoscopy report and know what is going on here.
Before shrinking it, you need to know what it is.
You cannot straightaway go for chemo and radiation without even knowing if it is malignant.
If it DOES come to that pass, chemo and radiation can impact your ovaries negatively, and yes, oocyte freezing is then the best option for you.
I think you should wait until you get to the Gynae - Oncologist, also retrieve the cystoscopy report, and try and get an ultrasound of the pelvis.
Before proceeding with chemo and radiation, it makes sense to have a diagnostic laparoscopy done , if the biopsy is not possible.
SO the next steps logically -
1. Consult the Gyne - Oncologist, and have an ultrasound scan.
2. When you do that, try and have the cystoscopy report in hand as well as the imaging one ( that you already uploaded here ) so that you can run these reports through him / her and know what is her / his opinion.
3. Get a biopsy of the mass if possible.
4. Get a diagnostic laparoscopy and biopsy ( via laparoscopy ) before proceeding to major treatment modalities such as chemo / radiation.
It is possible that the mass might be even accessible to surgical removal , even that can be assessed laparoscopically.
Hope what I said helps you.
Take care.
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60591.jpg)
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Take care.
Detailed Answer:
Thank you for the appreciation.
I can empathize with the pain and discomfort you must be having, also the anxiety over the uncertainty.
However, I still have a gut feeling that this is NOT cancer, it cannot be, at this age.
Please get the workup done, and feel free to revert anytime.
Wish you so much of luck with it.
Take care.
You can write in directly anytime using the following link -
http://doctor.healthcaremagic.com/doctors/dr-aarti-abraham/64623
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60591.jpg)
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You say it can't be cancer at my age, but how do explain my cousin who is only 19 days older then me, getting diagnosed with satge 4a cervical cancer and it killed her in a 11 days after being diagnosed?
Is cervical cancer more common the bladder cancer or what ever this may be if it is cancer. Would it be bladder cancer or would it be pelvis cancer because of the locatin?
I go see the oncologist tomorrow, so after that visit i will contact you and tell you what i was told, is that okay?
Bladder cancer differs from cervical cancer ; please clarify the cystoscopy
Detailed Answer:
Hello again.
We are continuously talking bladder cancer here, and frankly the diagnosis is debatable still, which makes all this speculative.
However I can understand your anxiety and need to look at all possibilities, and it is not your fault really, because the tests are confusing to say the least.
One point which strikes me pertinently is this - if the urologist says that he could see the mass during cystoscopy ( somehow everything revolves around this statement of his ) - they he should have taken the biopsy there and then.
Because in cases of a mass inside the bladder, a biopsy is most commonly taken by cystoscopy, because you are seeing the mass right in front of you ( according to him he did see it ! ).
This needs to be discussed with him, it is actually the urologist who can clarify matters here.
Regarding your question about your cousin, here is my logic.
Bladder cancer is more common in men, 1 case in women compared to 15 in men.
Furthermore, 9 out of 10 cases are seen in patients over the age of 50, so you can see why I strongly think this is NOT bladder cancer.
Regarding your cousin, again, this does have a peak around the age of 30, and it is depending on various other factors - infection with HPV ( human papilloma virus ) hastens the progression, so it is possible that a female close to 30 might have an advanced cervical cancer, particularly if she ignored symptoms for long.
Also, I think the mass is outside the bladder, this is more likely to be a mass in the pelvis, outside the bladder ( again the urologist's claim during cystoscopy is what is setting me off course in my thoughts - that is a huge blank that needs to be filled, the clarification of the cystoscopy report ! ).
Also, I am NOT using the word cancer anywhere, I still feel the mass is benign , or at worst, a borderline tumour ( not requiring chemo or radiation ).
I hope I am proved right !
ALso, please do revert after the oncologist's consultation.
Take care.
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60591.jpg)
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I will let you know after the appt with the oncologist today!
Let me know how it goes .
Detailed Answer:
Exactly !
You have got the gist of it.
THe dilemma lies with the Urologist, and he really needs to offer an explanation.
If he saw the mass, why not biopsy it ?
That is the key issue .
Am sure there is some error in communication there.
Please let me know how it goes.
I too wish to make sense of this, as much as you do.
Take care.
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60591.jpg)
![default](/r/images/default.png)
He is actually at a loss for what it is going on, he named so many things that it could be, he did say my uterus was a little big but not that much i believe he said it was 8, i dont know anything else because he was telling me that while doing everything else in the exam. He said something about me having a retro introverted pelvis, what is that? Because he seemed surprised especially since he said i thought it would be the opposite, he did that by sticking his finger up my butt, and first for me lol, i got a good laugh which i needed.
I hope this clears some things up for you and maybe makes more sense and maybe closes the gaps in some of your questions?
Get a pelvic ultrasound, review the bloodwork and cystoscopy report.
Detailed Answer:
Hi again.
I have always had my own idea of what this is .
As I told you earlier, if you read the answer to the first follow up question, I said that the mass is OUTSIDE the bladder, inside the uterus , and most probably an ovarian mass ( just scroll upwards ) .
As it turns out, I was right it seems, since the oncologist too finds an ovarian tumour.
However again, removing the ovary and fallopian tube is a very drastic thing to do.
Most ovarian masses are benign and can be managed medically, surgery being indicated only if medical / conservative treatment fails.
I would really like to look at the blood work, also I still very much want to know the cystoscopy report.
I am sure you are entitled to ask for it, particularly since it caused and continues to cause so much of confusion.
The mass should ideally again be biopsied, imaged ( a pelvic ultrasound scan is a must ) and if need be, assessed / treated by a laparoscopy.
I think you mean a retro verted uterus, normally the uterus faces forwards towards the bladder, but a retro verted uterus faces backwards.
It is a normal anatomical variant, and not an issue at all.
Well , the plot thickens !! ( please do not mind the attempt at humour, I could detect a similar disposition in your personality ! ).
There are still some gaps, and seriously, the main thing is what the Urologist saw !
The next steps are pretty clear to me - review the Cystoscopy report AND the bloodwork, get a pelvic ultrasound scan done which will clarify the ( ? ) ovarian mass, and go in for a biopsy or laparoscopy.
Take care, and keep in touch.
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60591.jpg)
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Results
29-Dec-2014 12:49
Basic Metabolic Panel -Next Draw
Glucose, Serum 67 mg/dL (Low)
Range: 74 - 99 mg/dL
Sodium, Serum 142 mmol/L (Normal)
Range: 136 - 145 mmol/L
Potassium, Serum 4.3 mmol/L (Normal)
Range: 3.5 - 5.3 mmol/L
Chloride, Serum 108 mmol/L (High)
Range: 98 - 107 mmol/L
Bicarbonate, Serum 24 mmol/L (Normal)
Range: 21 - 32 mmol/L
Anion Gap, Serum 14 mmol/L (Normal)
Range: 10 - 20 mmol/L
Blood Urea Nitrogen, Serum 9 mg/dL (Normal)
Range: 6 - 23 mg/dL
Creatinine, Serum 0.63 mg/dL (Normal)
Range: 0.51 - 0.95 mg/dL
Comments: ---
THIS TEST IS PERFORMED USING AN
IDMS-TRACEABLE ENZYMATIC CREATININE
METHOD. CALCULATIONS OF ESTIMATED GFR
SHOULD BE PERFORMED USING EQUATIONS FOR
IDMS-TRACEABLE CREATININE METHODS.
Calcium, Serum 8.6 mg/dL (Normal)
Range: 8.5 - 10.1 mg/dL
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
Cancer Antigen, GI Ca 19-9
Cancer Antigen, GI Ca 19-9 < 1.20 U/mL (Normal)
Range: 0.00 - 30.90 U/mL
Comments: CA 19-9 testing is performed by chemiluminescent
immunoassay using the Siemens Advia Centaur. Values
obtained with different analytic methods cannot be
used interchangeably.
.
Serum CA 19-9 measurement is indicated for the serial
measurement of CA 19-9 to aid in the management of
patients diagnosed with cancers of the exocrine pancreas.
This assay is not intended for screening or diagnosis of
cancer in the general population. The results must not
be used as the sole means for clinical diagnosis or
patient management decisions.
.
Patients known to be genotypically negative for the XXXXXXX
blood group antigens will be unable to produce CA 19-9
antigen, even in malignant tissue. Phenotyping for the
presence of the XXXXXXX antigen may be insufficient to
detect true XXXXXXX antigen negative individuals.
.
The performance characteristics of this
test have been determined by UH Laboratory.
This test has not been cleared or approved
by the FDA; however, the FDA has determined
that such clearance is not necessary. The
test is designated by the manutacturer as
"for research use only." The results must
not be used as the sole means for clinical
diagnosis or patient management decisions.
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
Cancer Antigen, 125
Cancer Antigen, 125 8.3 U/mL (Normal)
Range: 0.0 - 30.2 U/mL
Comments: CA 125 testing is performed by chemiluminescent
immunoassay using the Siemens Advia Centaur. Values
obtained with different analytic methods cannot be
used interchangeably.
.
Serum CA 125 measurement is intended for use as an aid
in monitoring patients previously treated for ovarian
cancer. This assay is not intended for screening or
diagnosis of cancer in the general population. The
results must not be used as the sole means for clinical
diagnosis or patient management decisions.
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
Carcinoembryonic Antigen
Carcinoembryonic Antigen 0.5 ug/L (Normal)
Range: ug/L
Comments: REF VALUES
NONSMOKERS 0-2.5
SMOKERS 0-5.0
CEA testing is performed by chemiluminescent immunoassay
using the Siemens Advia Centaur. Values obtained with
different analytic methods cannot be used interchangeably.
.
Serum CEA measurement is intended for use as an aid in
the management of patients previously treated for cancer.
This assay is not intended for screening or diagnosis of
cancer in the general population. The results must not
be used as the sole means for clinical diagnosis or
patient management decisions.
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
Complete Blood Count -Next Draw
White Blood Cell Count 6.2 X10E9/L (Normal)
Range: 4.4 - 11.3 X10E9/L
Red Blood Cell Count 4.53 X10E12/L (Normal)
Range: 4.00 - 5.20 X10E12/L
Hemoglobin 10.5 g/dL (Low)
Range: 12.0 - 16.0 g/dL
Hematocrit 36.1 % (Normal)
Range: 36.0 - 46.0 %
MCV 80 fL (Normal)
Range: 80 - 100 fL
MCHC 29.1 g/dL (Low)
Range: 32.0 - 36.0 g/dL
Platelet Count 267 X10E9/L (Normal)
Range: 150 - 450 X10E9/L
RDW-CV 18.0 % (High)
Range: 11.5 - 14.5 %
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
HCG, Beta Quantitative -Next Draw
HCG, Beta Quantitative < 2 IU/L (Normal)
Range: IU/L
Comments: REF VALUES
NONPREGNANT FEMALE <5
MALES <5
TEST PERFORMED BY CHEMILUMINESCENT IMMUNOASSAY
AND DETECTS FREE BETA SUBUNIT AND INTACT BETA HCG.
THIS TEST IS NOT INDICATED FOR USE AS A TUMOR
MARKER.
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
Lactate Dehydrogenase, Serum -Next Draw
Lactate Dehydrogenase 167 U/L (Normal)
Range: 84 - 246 U/L
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
PT + INR, Plasma - Next Draw
Prothrombin Time, Plasma 11.6 sec (Normal)
Range: 9.3 - 12.5 sec
International Normalized Ratio, Plasma 1.1 (Normal)
Range: 0.9 - 1.1
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
12:49
Glomerular Filtration Rate
Glomerular Filtration, Rate >60 (Normal)
Comments: Reference Range: >60 mL/min/1.73m2
IF PATIENT IS XXXXXXX XXXXXXX MULTIPLY RESULT
BY 1.210.
CALCULATIONS OF ESTIMATED GFR ARE PERFORMED
USING THE MDRD STUDY EQUATION FOR THE
IDMS-TRACEABLE CREATININE METHODS.
CLIN CHEM 2007;53:766-72
Performing Lab UH (Normal)
Comments: University Hospitals Case Medical Center, 11100 Euclid Ave., XXXXXXX OH 44106
Ultrasounds
Examination: Renal ultrasound
Clinical History:FLANK PAIN,UTI
Comparison:None
Findings:
Limited evaluation due to overlying bowel gas. Suboptimal
visualization of the kidneys.
The right kidney measures 9.2 cm in in length. Normal cortical
echogenicity. Mildly lobulated contours. Echogenicity in the renal
sinus may be secondary to increased vascular markings. No definite
shadowing stones seen. No evidence of hydronephrosis.
The left kidney measures 7.8 cm in length. Normal cortical
echogenicity. Mildly lobulated contours. in the renal sinus may be
secondary to increased vascular markings. No definite shadowing stones
seen. No evidence of hydronephrosis.
The urinary bladder is partially fluid distended, otherwise
unremarkable.
IMPRESSION:
1. Limited study.
2. No obvious shadowing renal stone or hydronephrosis bilaterally.
3. Linear echogenicities in bilateral renal sinus may be secondary to
vascular markings.
Dictated: 12/05/14 1508
EXAMINATION: Pelvic Ultrasound
HISTORY: left lower quadrant pain
COMPARISON: None
FINDINGS:
The uterus measures 8.5 cm x 3.6 cm x 4.6 cm. The endometrial stripe
measures 9 mm in thickness.
The right ovary measures 2.7 cm x 1.8 cm x 1.6 cm. There is
nonspecific 7 mm echogenic focus in the right ovary. The left ovary
measures 1.8 cm x 1.2 cm x 1.5 cm. Arterial and venous flow is
demonstrated to the right ovary. Vascular flow is demonstrated to the
left ovary. There is artifact on the Doppler waveform in the left
ovary, however likely overlap of arterial and venous waveform.
No significant free fluid in the pelvis.
IMPRESSION:
No evidence of uterine fibroids.
No evidence of ovarian cyst. Nonspecific small 7 mm echogenic focus in
the right ovary.
Interpretation of the examination assumes negative pregnancy test.
Please clinically correlate.
Dictated: 11/27/14 1636
Another CT scan
Abdomen/Pelvis CT
Patient Name: HOLZHAUER XXXXXXX R
Unit No: F0000
EXAM# TYPE/EXAM CPT(s)
0000 CT/CT ABD/PEL FOR RENAL STONE * 74176
Study: CT of abdomen and pelvis without contrast dated 11/30/2014.
Indication left-sided pelvic pain with history of gastric bypass
surgery.
Comparison: None.
Technique: Axial CT of the abdomen and pelvis was performed without
intravenous or oral contrast.
Findings: Visualized lungs are clear. No pleural effusion is evident.
The heart is not enlarged. No pericardial effusion is evident. The
aorta is without aneurysmal dilation evident.
The noncontrast appearance of the liver, spleen, adrenal glands, and
pancreas is grossly unremarkable. The gallbladder is present. No
radiopaque urinary tract calculus is evident. No free fluid, free air,
or lymphadenopathy is evident in the abdomen or pelvis.
There are surgical changes compatible with gastric bypass surgery. The
bowel is without evidence for obstruction. The appendix is not
definitively identified on this exam but there is no inflammation in
its expected anatomic location. There is some colonic diverticuli
without CT findings evidence of acute diverticulitis. The bladder is
suboptimally distended for full assessment. The uterus is present.
Degenerative changes noted of the spine, SI joints, and 6. There is a
small fat filled umbilical hernia. Oval subcutaneous gas in the right
gluteal soft tissues may relate to an injection site.
Impression:
1. Diverticulosis coli without CT findings evidence to suggest acute
diverticulitis.
2. No radiopaque urinary tract calculus is evident.
3. Other findings as discussed above.
Dictated: 11/30/14 1718
Very important to get the Urologist 's findings.
Detailed Answer:
Thank you for uploading the tonne of information.
Essentially , in a word - ALL NORMAL !
If you had no symptoms, I would say you are a very healthy person.
Now, I again have reviewed the first imaging report ( that had you thinking of the 7mm mass ) .
That mentions that the ' mass ' is likely to be an ovarian mass or a normal ovary with echogenic focus within ( calcification which is a normal finding with age ).
I now strongly think that it is a normal ovary that you have, and actually no mass there too.
However, your urinary symptoms are quite significant and MUST have a reason.
Have you got a complete urine microscopy and routine test and a urine culture done ?
Has infection been ruled out ?
Also, now it is IMPERATIVE to get hold of the cystoscopy report and ask the Urologist what mass on earth did he see ?
Because frankly, now there is no mass according to me at best, and an ovarian mass ( highly likely to be non malignant ) at worst !
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60591.jpg)
![default](/r/images/default.png)
Better repeat the test with a straight XXXXXXX sample.
Detailed Answer:
Hi again.
If you had a florid yeast infection, yes, that could have contaminated the sample.
A straight XXXXXXX sample would have been conclusive.
If the symptoms have persisted inspite of antibiotics, it is not likely to be an infection , or , the other end of the spectrum - an incompletely treated , severe infection.
Why not repeat the urine testing with a straight XXXXXXX sample ?
Again, the cystoscopy report is out of reach yet ?
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60591.jpg)
![default](/r/images/default.png)
I peed blood this morning so i have to call them and givee them this information so hopefully i can talk to them and they can just give me a verbal reading of the results so that i can forward to you.
Yes, we can do nothing but wait till the confusion is sorted out.
Detailed Answer:
Okay I thought you said a straight XXXXXXX sample was not done.
It is much better if they email the information to you.
Verbal communication has already caused you so much distress and confusion.
I too, will wait then with you.
Take care.
![doctor](https://image.askadoctor24x7.com/files/images/profile/doctor/icon/60590.jpg)
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