Internal Medicine Blog
- 28 January 2014
- Internal Medicine Blog
By: Catherine Liebman, D.O.
Since joining the Rittenhouse Women’s Wellness Center in July, Dr. Catherine Liebman is often asked to explain “What is Osteopathic Manipulation?” and who may benefit from it. Osteopathic Manipulative Medicine (OMM) is a medical specialty that is specific to Doctors of Osteopathy (DOs). While all DOs get some training in OMM in medical school, others choose it as their specialty. For an OMM specialist the main focus is the musculoskeletal system. OMM is the application of manipulation to the body to address problems in the joints, muscles, nerves, connective tissues, and organs. Dr. Liebman incorporates OMM into conventional musculoskeletal medicine including orthopedic examinations, interpretation of x-rays and MRIs, managing physical therapy, injections, medications, and medical acupuncture, to create a unique and integrated approach to patient care.
OMM is based on the principle that the structure and function of the body depend on one another. During a visit Dr. Liebman assesses the patient for joints that are out of alignment, muscles imbalances, and connective tissues that are restricted. The dysfunctions that are identified are corrected with Osteopathic techniques. Many Osteopathic techniques are well known in other areas of musculoskeletal medicine, including myofascial release, soft tissue techniques, strain-counterstrain, muscle energy, and craniosacral therapy. The goal is to treat a patient with the most current clinical medical practices and to identify and correct the cause of pain, not just mask the symptoms.
As an example, a patient with low back pain may be evaluated for any organ or neurologic cause, receive a prescription for a medication and/or x-ray, and receive an OMM treatment to improve the symptoms immediately – all in one visit. It is truly integrated and holistic healthcare. Initial visits typically take one hour for evaluation and treatment and follow-up visits take 30 minutes. Depending on the situation, patients may need to return for more treatment. The treatment and management of the patient is tailored to her unique situation, and may include other modalities as well. However, the goal is to give patients the tools to feel and perform their best on their own and prevent further injuries.
Conditions commonly treated with OMM include:
- Chronic pain
- Acute pain
- Sports injuries
- Neck pain
- Low back pain
- Joint injuries
- 06 January 2014
- Internal Medicine Blog
Ask the Doctor: January 6th, 2014
Answered by: Dr. Linda Bullock
Question: How important is it, if you have a family history of heart disease, but are not exhibiting symptoms yourself, to have blood tests for C-reactive protein and lipoprotein A? I believe these might be better assess your risk of arterial plaque.
Answer: The U.S. Preventive Services Task Force deems these tests lacking enough evidence to use them for clinical decision making. Traditional tests (total cholesterol, HDL, triglycerides) still guide treatment.
C-reactive protein is produced by the liver and is a general marker for increased inflammation in the body. It may be associated with an increased risk for heart disease but it is not specific. Lipoprotein(a) is a circulating lipoprotein and it has been associated with an increased risk of coronary artery disease, but the added value of this test beyond measuring a lipid panel is not known at this time.
Measuring these and other tests such as the homocysteine level and the ankle brachial index may be used to guide treatment decisions in the future. Reducing risk factors is imperative, especially if you have a family history. If you smoke, please stop. If you have diabetes or hypertension, these should be treated. If you are overweight, try to reach your optimal weight. Diet and exercise are the cornerstones for risk reduction and if your cholesterol is elevated after you have maximized your healthy behaviors, you may need a cholesterol medication.
Questin: December 1, 2013
Answered By: Dr. Linda Bullock
Question: "I've been told to get my calcium from food only, and the allergist wants me to limit my dairy. There are many "calcium fortified" food items like cereals and almond milk, but is seems to me getting calcium from these products are no different then taking a pill. Should these be avoided as well?"
Answer: Taking calcium pills may be counterproductive so current recommendations suggest food sources of calcium. while dairy products are very high in calcium, there are other foods high in calcium. dark green leafy vegetables such as broccoli, kale and collard greens, oysters, salmon, sardines, molasses, tofu, parsley, dried figs and almonds, to name a few. When it comes to fortified foods, there are several stipulations to consider (according to fitday.com). 1) calcium absorption is better at higher acidity levels in the stomach 2) products with calcium carbonate are absorbed equally as well as dairy. 3) precipitation can cause the nutrients to settle on the bottom of the container, shaking the container can improve this. 4) plant estrogen is soy can increase calcium absorption. Hope this helps.
Calcium Levels in Milk vs. Almond, Rice and Soy Milk / Nutrition / Healthy Eating
Question About Menopause: Answered by: Dr. Linda Bullock
- 02 January 2014
- Internal Medicine Blog
What is cervical cancer?
“Cervical cancer” is a disease which causes the cells of the cervix to grow in an out of control way. The abnormal cells develop the ability to spread and invade other organs. When this occurs, cervical cancer can spread and ultimately lead to death. This can even occur in young, healthy woman.
What are the risk factors?
Most cervical cancer is caused by a sexually transmitted virus. This virus is called HPV. The virus is spread by skin to skin contact, which means that condoms may not protect you. Some strains of the virus cause genital warts, however most strains cause no symptoms at all. Most of the time, your immune system clears the virus. However, some woman remain infected, this constant infection with HPV can lead to cervical cancer. Having the virus does not mean you will develop cancer, although it does mean that you should be vigilant!
Other factors which can increase your risk of cervical cancer are:
*long-term oral contraception
*multiple sexual partners
What can I do?
Make sure to schedule your annual gynecological exam! The American College of Obstetricians and Gynecologists recommends annual pap smears for all women starting from 21 years of age.
The best way to detect cervical cancer is by having your pap smear. There are different recommendations for when to have your pap smear (from every 6 months-every 3 years), which depend on your previous results. However, even if you do not get your pap smear once a year you should schedule an annual exam to regularly reassess your risk factors, as well as to get an internal and breast exam and std testing when necessary. If you are under the age of 26, your doctor may also recommend the HPV vaccine series. The HPV vaccine is used to prevent infection with HPV types 6, 11, 16 and 18 and is covered by most insurances (please contact your carrier for additional coverage information)
Lastly, please make sure to follow through with any additional appointments that your physician recommends. Scheduling a colposcopy with a gynecologist may not sound like fun, but timely follow-up can make the difference between a small treatment procedure and extensive cancer therapy. In summary – don’t delay! If you have not had your pap smear for several years or if you have any further questions about cervical cancer, schedule an appointment with one of our physicians right away and take control of your health!
- 29 November 2013
- Internal Medicine Blog
Insomnia is the most common sleep complaint in the U.S. population, affecting as many of 10% of adults at one time or another. Insomnia is defined as trouble falling or staying asleep, or feeling that one's sleep is nonrestorative. Chronic insomnia can result in a number of problems--daytime fatigue, anxiety, feeling cranky or irritated, forgetfulness, or making mistakes, to name a few--and because of this, it can affect the relationships and work of those who experience it.
Insomnia has many causes, and determining what is causing one's sleep problems is often the first step toward finding a solution. For example, certain medical conditions that cause pain or breathing difficulty can keep one awake. Having to get up to go to the bathroom frequently can interfere with sleep. Some medications may have side effects that make sleep difficult. And stress or anxiety--due to work issues, the death of a loved one, etc.--can make a good night's sleep a chronically unattainable goal.
So how do we handle the inability to sleep well through the night? For starters, if you do have an uncontrolled physical symptom or medical issue causing your insomnia, talk to your doctor about it! The next step is to promote a restful sleep environment. This is referred to as "Sleep Hygiene". First, make sure you have a set bedtime and wakeup time, and stick to them. Do not nap or doze during the day. Make sure your bedroom is dark and quiet, and kept at a comfortable temperature. Use an eye mask or earplugs, or a white noise machine, if needed. Exercise daily, but not right before bedtime. Do not have any alcohol, caffeine, or nicotine in the late afternoon or evening. And be sure to resolve any stressful issues from your day long before bedtime.
If you are still unable to sleep, then further steps may be taken. One option is to retrain your body to sleep through the night using the following method. If you cannot fall asleep after 15-20 minutes, get out of bed and do something relaxing, like reading. Do not engage in any activities that are goal-oriented or will make you more alert. When you start to feel tired, then return to your bed. If you are unable to fall asleep after another 15-20 minutes, repeat this cycle until you are able to fall asleep. Remember that even if you do not get a full night's sleep at first, you should stick to your regular wakeup time. This may take a couple of weeks to result in a full night's sleep, but eventually your body will adjust to the sleep cycle you are enforcing.
For those who do not respond to any of the above measures, other options--like cognitive or relaxation therapy--may be helpful. A formal sleep study, or even referral to a sleep medicine doctor, may be indicated. And as with any health concern, if your insomnia persists, you should follow up with your doctor to get to the bottom of it.
- 29 October 2013
- Internal Medicine Blog
By: Jillan Rowbotham, D.O.
It's an experience almost everyone has had: you wake up to find one eye seemingly glued shut. You carefully pry your lashes from the crust that has them stuck to your cheek revealing an eye that is red and watery – the dreaded pink eye.
Pink eye is the common name for conjunctivitis, inflammation of the thin membrane that covers the eyeball and inner surfaces of the eyelids. Acute conjunctivitis can be caused by an infection, allergies, or an unknown irritant. Infectious pink eye can be viral or bacterial and both are quite contagious.
Though many people think pink eye is always caused by a bacteria and needs an antibiotic eyedrop, the most common cause of infectious conjunctivitis in adults is the adenovirus, the same virus that can cause the common cold. Sometimes viral pink eye comes as part of a general cold syndrome with swollen lymph nodes (glands), fever, sore throat, and a runny nose. The eye can have a burning, sandy, or gritty feeling, is often crusted shut in the morning, and will have a watery or mucus discharge throughout the day. The other eye usually becomes infected in the next day or two. Just like a cold, viral pink eye symptoms often get worse for the first three to five days then gradually improve over one to two weeks. There is no cure for viral conjunctivitis and antibiotic eye drops will not reduce the duration or intensity of symptoms. Over the counter antihistamine eye drops or artificial tears can help with the eye discomfort. A warm or cool wet washcloth (whichever feels better) can also be soothing.
Bacterial conjunctivitis can involve one or both eyes. Whereas the discharge with viral conjunctivitis is watery with perhaps some mucus, bacterial conjunctivitis causes a thick white, yellow, or green discharge. The affected eye will continuously ooze throughout the day, with more pus-like discharge accumulating just a few minutes after the eye is wiped. An antibiotic drop or ointment can improve symptoms and reduce the likelihood of spreading the infection to others.
Both viral and bacterial conjunctivitis are spread by contact, usually with objects which have come into contact with the infected person's eye secretions. For an example, an infected person touches her eye then touches her phone or a door handle. Some organisms can live for many hours on a surface so it is easy to see how it can spread. Infected individuals should consider themselves contagious as long as they have eye discharge and should not share tissues, towels, cosmetics, or bed linens. They need to discard any cosmetics that may have become contaminated. They should avoid touching the infected eye and wash their hands frequently to help reduce spread to others. Antibiotic eye drops can reduce the spread of bacterial conjunctivitis but do nothing to reduce the spread of viral conjunctivitis. Viral conjunctivitis is like a cold and the decision to return to work or go to a social gathering should be similar to how one would behave with the common cold.
Contact lens wearers need to wear glasses until their eye is no longer red. Their lens case should be discarded and the contact lenses disinfected overnight or replaced if disposable.
If you are not sure if you have viral or bacterial pink eye or you think you need an antibiotic please make an appointment to be seen in the office. Calling first thing in the morning (as soon as you unstick your eye, of course) can help us be sure to see you that day.
A red eye that is associated with moderate to severe pain, loss of vision, or intense sensitivity to light (cannot keep the eye open for more than a few seconds) indicates a more serious condition that could potentially lead to blindness if left untreated. Contact lens wearers are at higher risk of more serious infections, particularly with extended-wear lenses. Evaluation should be sought immediately at an Opthalmologic ER such as Wills Eye or Scheie Eye Institute.
- 27 September 2013
- Internal Medicine Blog
By: Catherine Liebman, D.O.
With the change in seasons come changes in the rest of our lives, including how our bodies feel. While some of us may feel fatigued or run down in this busy time, others may develop new aches and pains or exacerbations of old injuries. Pain can arise for a variety of reasons: whether it’s a new job requiring you to sit all day long, or a new hobby or sport that’s placing different demands on your body. The good news is that there are a lot of options that can help. Medications, exercise, yoga, meditation and acupuncture can all help to relieve pain and get you moving again.
Acupuncture is one of the best researched modalities in Complementary and Alternative Medicine. In 2012 a large review of studies on acupuncture for pain was published in the Annals of Internal Medicine. This review looked at nearly 18,000 patients with chronic pain syndromes such as back pain, neck pain, headaches, and shoulder pain. The results showed that acupuncture was superior to both sham (fake) acupuncture, and traditional treatment alone.
The even better news is that the side effects are minimal. The most common side effects are small amounts of bleeding after the needles are removed, and temporary itching at the location of the needles. While many people cringe at the thought of voluntarily being poked with needles, the reality is that most patients enjoy the treatments. The placement of the needles is relatively painless and it leaves people feeling calm, relaxed, and pain-free.
So how does acupuncture work to relieve pain? There are several answers to that question. Firstly, acupuncture treats the underlying conditions that predispose people to having pain in the first place. By accessing points of the affected meridian, the flow of qi, or energy, is optimized. Secondly, needles may be placed in tight or painful muscles to reduce spasm and muscle tension. Oftentimes, gentle electric stimulation or heat is used to increase the pain-relieving effects. Electroacupuncture, or acupuncture with electric stimulation, has been shown to increase the body’s production of natural pain-relieving chemicals. The overall effect is proper balance in the flow of energy, decreased tension in the muscles, and decreased pain.
Acupuncture is becoming more and more widely accepted as an effective modality for relieving pain. In fact, the United States military is a big supporter. Military medics are trained in acupuncture so they can quickly reduce an injured soldier’s pain on the battlefield until they can be transported to a medical center. But you don’t have to be a wounded veteran to benefit from acupuncture. At the Rittenhouse Women’s Wellness Center we provide acupuncture services to our patients at both locations.
- 29 July 2013
- Internal Medicine Blog
- 27 June 2013
- Internal Medicine Blog
By: Jillan Rowbotham, D.O.
With summer now in full swing sunburns are, unfortunately, an all too common occurrence. More than 30 percent of adults and 70 percent of children and adolescents report at least one sunburn during the course of a year. The best approach for sunburn is prevention through sun avoidance or diligent use and reapplication of a sunscreen. Sometimes, despite our best efforts, we end up lobster red after a sunny day.
Sunburn is a self-limiting condition that usually resolves in a few days. There is nothing you can do to reverse the skin damage or speed up the healing time but there are some things you can do, and things you shouldn’t do, to reduce pain and further damage.
Do get out of the sun as soon as possible if you think you are starting to get burned.
Don’t just apply sunscreen over burned areas in an attempt to stay outside longer.
Don’t think that a “base tan” is healthy and that it will protect you from getting sunburned. Tanned skin provides an SPF of less than four. Any change in skin color is a sign of damage and increases your risk of premature skin aging and skin cancer.
Don’t underestimate the relief you can get from an over the counter anti-inflammatory medication such as aspirin, ibuprofen (Advil, Motrin) or naproxen (Aleve). These medications are especially helpful if you take them as soon as you notice pain, don’t wait until the pain gets really bad.
Do be aware that NSAIDs such as ibuprofen or naproxen will make your skin more sensitive to the sun while you are taking them so take appropriate precautions to avoid getting burned again.
Do use cool water to soothe sunburned skin. A cool bath, shower, or compress (a towel soaked in cool water) can give you some relief. If your shower water pressure is high it is best to opt for a bath or cool compress to avoid pressure on your burn.
Do drink plenty of water. Sun exposure and heat can cause fluid loss through your skin.
Do feel free to use aloe on intact sunburned skin. Keep commercially-prepared aloe lotion or gel in the refrigerator to make it extra soothing. You can also apply aloe gel directly from the plant. I keep an aloe plant on hand for such occasions and have found that it makes a great houseplant and is surprisingly easy to keep alive.
Don’t use petroleum jelly, butter, egg whites, or other home remedies on your sunburn.
Don’t be tempted to pop a blister if one develops. Popping a blister will increase you risk of infection. If a blister does rupture on its own then apply a bit of antibacterial ointment and keep it clean and covered with a bandage. Don’t remove the top layer of skin, it helps protect the tender underlying skin and will eventually come off on its own. If left alone blisters will generally heal without scarring in 7-10 days.
Do treat peeling skin gently. Keep the peeling area moisturized and don’t try to speed up the peeling with harsh exfoliants or scrubbing with a loofah.
Do come into the office if your sunburn is severe, blistering, and covers a large part of your body; if you have developed a skin infection from scratching sunburned skin, or you have a severe sunburn that does not begin to improve within a few days.
If you have a severe sunburn and also have fever, headache, confusion, nausea, vomiting, blurry vision, or fainting you may also have heat exhaustion or heat stroke. If you have any of these problems, you should go to the emergency department immediately.
- 29 May 2013
- Internal Medicine Blog
Summer has arrived and for many of us that means getting out and about on vacations and weekend getaways! RWWC wants to remind all of our patients looking to traverse the globe that we are here to provide you with the preventative care and information that you need to ensure a trip focused on destination and not illness!
This summer (and all year-round) you can make an appointment with us to review your itinerary and medical history, provide necessary vaccinations and prescriptions as well as get advice on staying healthy throughout your trip. We have also recently subscribed to a data source to make sure our patients also get the most up-to-date news on not only health risks but also any domestic problems in the country of their destinations. What better way to care for our patients than to try and ensure their health AND safety?
Since many insurance companies do not cover travel medicine, the cost of the visit is $75 plus the cost of any vaccinations that you may require. Many vaccines (Hepatitis A and B as well as the Tetanus vaccine) are covered by most insurances, but some are not and some insurance plans have limited coverage. We recommend you schedule your appointment six weeks before your departure so that you have ample time to get all of your vaccines as well as allowing you time to call your insurance after the appointment if you have any questions about coverage for vaccines that your physician recommends.
When calling us to make an appointment, please make sure to tell the receptionist your itinerary so that the doctor can prepare for your appointment. Certain vaccinations, including those against rabies, Japanese encephalitis and Yellow Fever are only available at specialized travel clinics. We'll help you determine whether you need any of these vaccines and direct you to the appropriate clinic. Travelers to equatorial Africa and parts of South America will require proof of vaccination against yellow fever, so be sure to follow through with any referrals your doctor recommends.
We hope that you are planning some wonderful adventures this year, but please make sure you come and see us first!
- 28 May 2013
- Internal Medicine Blog
By: Maria Mazzotti, D.O.
After lung cancer, breast cancer is the second deadliest cancer in all women, and periodical screenings are the best way to control it. Several medical studies have shown that being screened for breast cancer effectively lowers the mortality rate for women affected by this disease.
While different medical groups offer a wide range of recommendations, it is generally accepted that women between the ages of 50 and 70 should be screened. Screening should continue if the patient is in good health, until the patient’s life expectancy is less than 5 to 7 years. While it is agreed that routine screening mammography can be stopped at age 75, the age at which to start screening varies anywhere between 40 and 50. At that time, the decision should be shared between the patient and the medical professional, and should take into consideration all potential benefits and complications. This includes the individual’s level of breast cancer risk, established by medical history and by use of a risk prediction model. The most commonly used one is the Breast Cancer Risk Assessment Tool (Gail model), available online at www.cancer.gov/brisktool/ .
Studies show that breast cancer in women between 40 and 49 is usually more aggressive than breast cancer diagnosed in someone 50 or older. Therefore, if it is agreed by the patient and their doctor that breast screening be started at age 40, it should be performed yearly until age 49. Starting at age 50, the screening can take place every 1 or 2 years, depending on the risk of disease.
While there are obvious benefits to being screened, there are also two uncommon, but significant drawbacks:
- False positive results - when a mammogram suggests that a woman may have cancer and she does not. This may lead to more unnecessary testing and increased anxiety. This is more likely to happen in women under 50 years of age.
- Radiation exposure - because the mainstay of testing is mammography, this procedure exposes patients to radiation. However, studies show that the number of lives saved by catching then onset of cancer early greatly outweighs the small risks that come from radiation exposure.
There are several specific symptoms to keep in mind when being vigilant about breast cancer:
- Breast pain or tenderness - while breast pain and tenderness are commonly associated with hormonal and dietary changes, as well as with stress, breast pain that is continuous and does not change with your cycle is a little more concerning.
- Nipple discharge - if you are having a discharge from one or both of your nipples, you should see your doctor. It is common that healthy women can squeeze out a small amount of yellow, green or brown fluid from their nipple. Clear or bloody discharge is more worrisome and should be followed up with a visit to your doctor.
- Inverted nipples - while it is normal for women to have inverted nipples when breasts develop or after breast feeding, if the change occurs without having breastfed, you should also see your doctor. This may be the first sign of breast cancer.
- Breast skin changes - changes in breast skin can be signs of a rare but very serious form of breast cancer called inflammatory breast cancer.
Worrisome symptoms include:
Skin that feels warm or hot
Color changes—skin looks pink, red or purple.
Dimples or pits on the skin (like the rind of an orange)
A flat nipple
A nipple that turns red
A crust or blister on the nipple.
A nipple that points in (if it pointed out before)
Painful, swollen breast
There are a few lifestyle factors that can be introduced or modified to reduce your risk of breast cancer:
Increased physical activity - exercise seems to protect against the disease in both premenopausal and postmenopausal breast cancer. Weight gain and obesity are mostly associated with an increased risk of postmenopausal breast cancer.
Alcohol consumption - as few as 3 drinks per week of any type of alcohol increases your risk of breast cancer.
Smoking - both passive and active tobacco exposure has been associated with an increased risk of breast cancer, especially among premenopausal women.
Diet - there appears to be evidence that a diet high in fruits and vegetables is associated with a lower risk of breast cancer. Conversely, eating more than five servings of red meat per week may cause an increased risk of hormone-positive premenopausal breast cancer. Diets low in calcium and Vitamin D have been associated with higher risks of breast cancer in premenopausal women.
Rittenhouse Internal Medicine™ has received the highest recognition (Level 3) from the National Center for Quality Assurance (NCQA). What this means for our patients – learn more