Internal Medicine Blog
- 24 March 2015
- Internal Medicine Blog
Spring is on its way! Along with budding trees and flowers comes pollen — a common trigger for allergies. Limiting the frequency and duration of your exposure to pollen can prevent or decrease symptoms and reduce your need for medications. For those who suffer from spring allergies here are a few tips to make the season more enjoyable.
- Limit outdoor activities when pollen counts are the highest, between 5am and 10am.
- Pay attention to pollen reports, available with the daily weather report and online, and stay indoors when counts are high. Dry, windy days are more likely to have large amounts of pollen in the air than damp, rainy days when most pollen is washed to the ground.
- Keep windows and doors closed to keep pollen from drifting into your house. Likewise, keep your car windows rolled up and sunroof closed when you drive and adjust your ventilation system to re-circulate inter-compartment air instead of drawing air from outside.
- Pollen can accumulate on your clothes and hair while you are outdoors. Remove your shoes at the door and change out of clothes you’ve worn outside. Shower to rinse pollen from your skin and hair. Your pet’s fur presents a similar problem. Though it is certainly not practical to bathe your dog every night, try to keep pets off of the furniture and out of your bed so that you will limit your exposure.
- Wash bedding often and always machine dry. Pollen may collect on laundry if it is hung outside.
- Rinse out your nasal passages once you are inside for the day or before you go to bed. If you can’t get the hang of a neti pot, pick up a reusable nasal irrigation kit available at most pharmacies.
- 02 March 2015
- Internal Medicine Blog
As spring comes along, some of us are starting to think about our summer vacation plans. If you are one of those people who is considering traveling to an area that requires updating your vaccines or getting vaccines that are not required growing up in the United States, it is never too early to get started with your Travel Visit.
There are a few things to keep in mind before traveling:
· Schedule your travel appointment as soon as possible. We recommend 4-6 weeks in advance.
· Have a list of your medical problems, medications, allergies and your doctors name and phone numbers.
· If you have artificial devices in your body.
· Insurance companies may or may not pay for the travel visit, vaccines and medications.
· Some vaccines require more than one shot.
· We do not carry the Yellow Fever Vaccine. You are able to do a travel visit with one of our doctors and then they will give you a Rx to get the vaccine injected at a local pharmacy.
· Check with your insurance company if you require more medication for extended vacations.
How to prepare for your travel visit:
· Have your travel itinerary with you at the time of your visit.
· Have a copy of your previous vaccines.
Scheduling a travel visit will help to ensure that you make the best out of your trip!
- 02 January 2015
- Internal Medicine Blog
2015 has made an arrival and now is the time to consider making some resolutions. These goals will help you focus on a healthier you in the new year.
1. Be informed about what you are consuming
If you are not in the habit of reading food labels I highly recommend it. Many people underestimate calorie, fat, and sodium content and overestimate portion size. Even with reading individual labels it can be hard to keep track of your total consumption throughout the day. Keeping a food diary can make this easier and there are many websites and apps that make it less time consuming and more informative. Livestrong.com and Sparkpeople.com are two popular sites that also have phone apps.
2. Start moving
You don’t have to join a gym or start running marathons to be healthy. Take a class, do an exercise video at home, or walk on your lunch break. As a general goal you should aim for at least 30 minutes of physical activity every day but this can be broken up into three 10-minute sessions if you don’t have 30 minutes in a row available. Weight training is an important part fitness and weight loss plans. Meeting with a personal trainer can help you learn what weights and exercises will best help you meet your goals.
3. Eliminate tobacco
If you don’t smoke, don’t start. “Social smoking” still counts as smoking; consider making this the last year you light up when having a drink. Even those occasional cigarettes add up over time. If you are not ready to quit right now at least pause to consider it – is there a goal time, even if it is far in the future, you would like to be quit by (ie your wedding or a child’s graduation)? What would change in your life if you were no longer smoking? Just thinking about quitting can bring you closer to being ready. If you are ready to quit and would like some help please come in and see us. Even if you aren’t able to stay quit you are still better off than if you didn’t try.
4. Increase your water intake
Most of us don’t drink enough water. The Institute of Medicine determined that adequate daily intake for a woman is 2.2 liters, which is just a little more than the classic “eight 8-ounce glasses” or 64 ounces. You need more when you are exercising, sick, pregnant or breastfeeding, or in a warmer climate. Staying well hydrated helps your skin and other important organs and can fight off fatigue and hunger. Count up the amount of non-caffeinated fluid you are drinking in a day – how close to 64 ounces are you?
5. Get enough sleep
Most adults need seven to eight hours of sleep, six is generally not enough. Getting a good night’s rest can help you function better in every aspect of your waking life. Cutting out some screen time or having the kids help more around the house can help get you into bed earlier. Make this the year you seek help if you suffer from chronic insomnia or anxiety that prevents you from getting sleep.
6. Moderate caffeine intake
A moderate amount of caffeine is 200 to 300 milligrams (mg) or about two to four 8-ounce cups of brewed coffee a day. Don’t forget to count caffeine in tea (black, green, or iced tea), soda, and hot chocolate. Because caffeine can interfere with your sleep cycle even if you do not have problems falling asleep, I recommend finishing your last caffeinated beverage at least eight hours before you go to bed.
7. Moderate alcohol intake
If you drink alcohol, do so in moderation. Moderate intake for a woman is one drink a day. One drink is considered 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor.
8. Manage stress
Stress symptoms can affect your body, thoughts, feelings, and behavior. Stress can cause many physical symptoms including headaches, digestive issues, chest pain, memory problems, and eczema, to name a few. Stress that is left unchecked can contribute to health problems such as high blood pressure, heart disease, obesity, and diabetes. Managing your stress is an important part of any healthy lifestyle. Regular exercise, particularly yoga and tai chi, getting enough sleep, practicing relaxation techniques, and maintaining a good social support system can help reduce stress. Many people benefit from professional counseling to find stress management strategies that work for them.
9. Stay up to date with routine screening tests
Depending on your age and other risk factors this may include PAP smears, mammograms, colonoscopies, cholesterol screening, etc. Not sure if you are due for anything? An annual physical provides a good opportunity to review current screening recommendations and get up to date.
10. Be an active participant in your health
Learn what you can about any health conditions you have and stay informed about what conditions run in your family. Know what prescriptions, over-the-counter medicines, and supplements you are taking and what they are for. Keep track of the dates of your most recent screening tests and any abnormal results. We are always happy to provide a copy of your labs to you and to go over anything you may have questions on – just ask!
- 25 November 2014
- Internal Medicine Blog
I often tell patients to wait for the first cold week of the fall/winter season to stop their allergy medications. And while that works for a lot of people, I am forgetting that the holidays can also be a source of allergy flares. This is due to exposure to mold, dust mites, seasonal greenery/decorations live and artificial and foods .
During the holiday season the weather gets colder so we tend to keep the door sand windows shut more than in the other seasons, so the usual indoor allergens (pet dander, mold and dust mites may be higher). Another reason is that during this time of the year pets tend be indoors more increasing our exposure. Also we are bringing in live plants/trees that may have mold spores and mildew which thrive in the damp evergreens. The sap on the aromatic evergreen trees can also be source of skin irritation. When opting for the artificial decorations, keep in mind that these are also often stored in dusty/moldy basements which can be a problem for those reasons. The sometimes potent Potpourri aromas can also be a problem for asthma patients. Also keep in mind that those beautiful Poinsettia’s are in the rubber family and can cause problems for us who have latex allergies. When warming up by the wood burning fireplaces don’t forget that they can be sources of a lot of ash and smoke which may cause problems for you and your guests. And we often overlook the effects of stress which can also trigger asthma symptoms for some of us.
One other big group that causes problems this time of the year is food allergies. Often times, we do not want to disappoint friends and relatives by not trying the home made foods, but before doing so, do not forget to ask if the ingredients include something you are intolerant or allergic to. These can include milk, eggs, peanuts, tree nuts, fish, shell fish, soy and wheat. These 8 groups account for 90% of food allergies.
There are things we can do to reduce our exposure so we can still enjoy the holiday season without a trip to the doctor or ER. When handling any live trees you may want to throw on Latex free gloves so you do not come in contact with the sap from the evergreen trees. You may also want to water the trees down with your garden hose or blast them with the leaf blower before bringing them in. When handling the artificial decorations, make sure you dust them off and maybe wear a mask when doing so.
If all else fails, thankfully there are medications that can help. Antihistamines like,Benadryl, Zyrtec, Claritin and Allegra often are enough. Hydrocortisone creams can help with skin irritations also. Patients who have asthma should make sure their Albuterol inhalers are still good. Also, if you have food allergies make sure your Epipen is not expired. Sometimes, though, if you have tried a thing or two you may still need help from your doctor or need to see an allergist, so do not feel like you need to treat on your own.
- 27 October 2014
- Internal Medicine Blog
It is never a good time to get sick but unfortunately the cold and flu season is once again squarely upon us. The common cold lasts an average of seven to ten days and usually starts with a sore throat and possibly low grade fever, then progresses to nasal and sinus congestion. Finally, a cough, sometimes productive of mucus, is usually the last symptom to develop and the last to resolve. There is not yet a cure for the common cold and antibiotics not only won’t help but increase the risk of allergic reactions, side effects, and development of resistant bacteria. Plenty of rest and fluids is a mainstay of treatment but there are also many medicines available over-the-counter that can help make things a little more manageable - the key is picking the right medicines for the symptoms you are having.
Over-the-counter cold preparations are confusing with endless combinations of medicines and claims to alleviate certain symptoms. The best approach to selecting the most helpful one is to understand what active ingredients are in each pill and what they are expected to treat. This can help you tailor what you are taking to your current symptoms and limit side effects.
Dextromethorphan, also termed as “DM”, is a cough suppressant that acts directly on the cough center in the brain. It comes as a liquid cough medicine or as a pill. In some studies two teaspoons of honey were shown to be just as effective for reducing nighttime coughing.
Guaifenesin works by thinning mucus or phlegm. This can be helpful if you are having a lot of post-nasal drip (mucus down the back of your throat, clearing your throat a lot), or are coughing up mucus. It should be taken with plenty of water.
Oxymetolazone is a nasal spray also sold under the brand name Afrin. It can give you quick relief from nasal congestion but it cannot be used for more than 72 hours or 3 days in a row. If used longer than that it can actually cause worsening congestion. I like to use Afrin for those nights when you simply cannot breathe out of your nose and the misery of that keeps you from sleeping. It also can be helpful if you are congested before plane trips to help your ears equilibrate to pressure changes.
Pseudoephedrine is a very effective decongestant that is sold behind the pharmacist’s counter though you do not need a prescription for it. You will need to show identification to purchase it and are limited to the quantity you can buy at one time. It is the “D” component in Mucinex –D, Allegra – D, etc. Decongestants relieve nasal stuffiness by narrowing blood vessels and reducing swelling in the nose. This narrowing can affect other blood vessels as well, which can increase blood pressure. This medicine is not a good choice for people with heart disease or poorly controlled high blood pressure. Some people cannot take pseudoephedrine because it makes them feel jittery, spacey, or gives them palpitations. It comes in a 4-6 hour preparation or a 12-hour preparation. Until you know how it affects you I recommend the shorter lasting form.
Pharmacies tend to be sold out of it often during the height of cold season so I like to make sure I always keep some on hand.
Phenylephrine is the decongestant that is sold in the pharmacy shelves and can be a good choice for people who do not like the way pseudoephedrine makes them feel. Some feel it is a less effective decongestant.
Drowsy antihistamines include Benadryl (diphenhydramine) and doxylamine which is found in NyQuil, Alka-Seltzer Night, and other night time preparations.
Many combination pills will also include acetaminophen as a pain reliever and fever reducer. Be mindful of how much you are taking. It is best not to take additional acetaminophen, or Tylenol, with these as too much can be toxic to your liver.
If you have any questions or concerns about the use of over-the-counter medications please do not hesitate to contact us. If your symptoms are lasting longer than usual, you have a persistent high fever, shortness of breath, or just don’t feel right it may be more than the common cold. Please come in and see us in the office.
- 29 September 2014
- Internal Medicine Blog
As we embark on Breast Cancer Awareness month, it is worthwhile to review the statistics, risk factors, and preventive strategies of this globally devastating disease. Breast cancer is the most frequently diagnosed malignancy worldwide. It is the most common female cancer in the U.S., and it is the second leading cause of cancer death in women in the U.S., with over 40,000 deaths annually.
Non-modifiable factors that are associated with an increased risk of breast cancer are female gender, white race, increasing age, postmenopausal status, and prolonged exposure to estrogen, such as early onset of periods or late menopause. Family history of breast or certain other cancers may also increase your risk--this should be discussed with your doctor. Other factors that may increase the risk of breast cancer include obesity in postmenopausal (but not premenopausal) women, and hormone replacement therapy. Lifestyle factors have also been implicated in the diagnosis of breast cancer. For example, there is a significant dose-dependent relationship between alcohol intake and breast cancer, even with as little as three drinks a week. Smoking also appears to increase the risk of breast cancer.
There are also some protective factors that appear to decrease breast cancer risk. Breastfeeding is one example. Physical activity appears to be another protective factor--yet another good reason to get out and exercise! Finally, there is some evidence that soy products, and other phytoestrogens like legumes, flaxseeds, and sesame seeds may be protective.
So aside from awareness of negative/positive risk factors, how can we reduce our risk of developing breast cancer? Cancers are most easily treated if they are detected early; therefore, the first line of attack against breast cancer begins at home, by developing "breast self-awareness". Each woman should be familiar with her breast/axillary (armpit) exam--including skin and texture changes, as well as lumps. Any change from your baseline should be brought to the attention of your doctor immediately. Clinical breast exams, performed by your doctor during your annual gynecological appointment, are another important factor in screening for breast cancer. And mammograms are advised by most professional organizations starting at age 40; the specific interval for these can again be discussed with your doctor, depending on your age. Finally, women with family history may be advised to consider testing for one of the known breast cancer genes. Breast cancer takes a terrible toll on the women and families whom it has affected; awareness of risks and preventive tools is the best defense we have in containing, and hopefully one day, curing, this disease.
- 26 August 2014
- Internal Medicine Blog
One of most frequent reasons that women come to see their primary care physician is to discuss abdominal pain and bloating. I don’t think a day in the office goes by that I do not hear those words. Most frequently these patients have what is known as Irritable Bowel Syndrome (IBS). Not surprisingly, it is the most commonly diagnosed gastrointestinal condition, affecting 10-15% of the population.
The true definition of IBS is: a gastrointestinal syndrome of chronic abdominal pain and altered bowel habits (without other organic cause) at least 3 days per month in the last 3 months. Commonly, the abdominal pain is intermittent and described as “crampy”. Exacerbations can occur frequently and are associated with eating and times of increased stress. The abdominal pain associated with IBS can vary in intensity and location, but is often relieved with bowel movements. Other common symptoms include: bloating, gas, nausea, diarrhea and/or constipation, and feeling full quickly. “Red flag” symptoms such as anorexia, weight loss, persistent rectal bleeding, pain awakening a patient from sleep or certain lab findings (i.e. anemia) are rarely associated with IBS and should prompt a further workup for an alternative diagnosis.
Unfortunately there are no tests specific to the diagnosis of IBS. Frequently, a physician will run blood or stool tests and maybe order additional procedures such as a colonoscopy to rule out other potential causes of symptoms. If no other source is found and no “red flag” symptoms are present, a diagnosis of Irritable Bowel Syndrome is made.
There are 4 different subtypes of IBS:
1) Diarrhea predominant
2) Constipation predominant
3) Mixed type
Treatment options vary between the different types.
As any patient who suffers from IBS knows, making the diagnosis is only half of the battle. Treatment for this ailment takes time, patience and diligence to improve symptoms. IBS is a chronic disease, which means most patients will likely have it for life. That being said, the majority of patients will be able to control their symptoms with one or more of the treatment modalities available.
Upon diagnosis, a patient should take time to keep a log of symptoms and what the circumstances were at that time (what she ate, what she did, etc). This will help to elucidate any specific pattern or specific food that may be contributing to a patient’s pain. It has long been thought that certain foods in certain individuals can be a source of IBS symptoms. If a patient has been diagnosed with Irritable Bowel Syndrome, her first step should be to eliminate foods known for high gas production such as: beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, pretzels, bagels, alcohol and caffeine. In many patients, reduction in these foods can bring around a significant improvement in abdominal pain and bloating.
If still with significant symptoms despite reduction of high gas forming foods, a patient may decide to follow a stricter approach with the low FODMAP (fermentable, oligo-, di-, and monosaccharides and polyols) diet. High FODMAP foods are poorly absorbed and are rapidly fermented in the gut causing gas and bloating. Such foods are listed below.
Oligosachharides: wheat, barley, rye, onion, leek, garlic, shallots, artichokes, beets, fennel, peas, pistachio, cashews, legumes, lentil and chick peas..
Disaccharides: lactose (milk, ice cream, yogurt)
Monosaccharides: apples, pears, mangoes, cherries, watermelon, asparagus, sugar snap peas, honey and high fructose corn syrup.
Polyols: nectarines, peaches, plums, mushrooms, cauliflower, artificially sweetened chewing gum and other sweets
Obviously this can be a very restrictive diet. If taking on a low FODMAP diet it is recommended that you do this under the guidance of a trained dietician in order to avoid over- restriction and malnutrition. Ideally a patient would be on a low FODMAP diet for 6-8 weeks at which time she would gradually re-introduce the above foods one at a time to determine which specific foods are tolerated and which are not.
Though it is thought that food allergy could possibly play a role in Irritable Bowel Syndrome, at this time there is insufficient evidence to recommend food allergy testing in patients with IBS. This is largely due to the fact that current modes of allergy testing have not been reliable in identifying affected patients.
In addition to dietary management, 20-60 minutes of moderate to vigorous exercise 5 days a week has been shown to significantly decrease symptoms of IBS. It is also important to address daily stressors through counseling and stress-reduction techniques (meditation, yoga, etc) as increased stress often leads to increased IBS symptoms.
If lifestyle interventions still fail to control symptoms, your doctor can prescribe medications specific to the patient’s symptoms. For example, anti-diarrheals in diarrhea predominant IBS, laxatives in constipation predominant IBS, antispasmodic agents, and antidepressants.
In summary, Irritable Bowel Syndrome is a very common disease affecting a large number of women. Symptoms generally consist of abdominal pain, bloating, and a change in bowel habits. In order to diagnose IBS, doctors must rule out other organic causes of gastrointestinal disease. Though it is not curable, most patients are able to control their symptoms with lifestyle changes or medications.
- 01 July 2014
- Internal Medicine Blog
Breast cancer, we are taught, is an illness that all women need to be aware of, and be screened for. But how do we most effectively screen for it? This question is not as straightforward as one would think, as the recommendations for different screening modalities are always evolving, based on new assessments of available evidence. Traditionally, women were advised to do monthly self-examinations in the shower as a front-line defense against breast cancer. But in recent years, these exams have not been shown to consistently prevent breast cancer deaths (which is, after all, the goal of any screening program). Therefore, most expert groups now either recommend against self-exams entirely, or they recommend encouraging "breast awareness", which means each woman should be aware of her own body, so that she can recognize potentially alarming changes--this could include a traditional breast exam, but not necessarily.
Another mainstay of breast cancer detection has been the clinical breast exam, performed annually by a physician at the time of the gynecological examination. While the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG) recommend these exams every 1-3 years for women ages 20-39 and annually for women thereafter, the US Preventive services task force (USPSTF), an independent government-sponsored organization, notes that there is insufficient evidence for these exams, as well.
Mammography is recognized by most women as the most important tool we have for breast cancer screening, and most medical societies agree, recommending annual mammograms for all women beginning at age 40. A few influential groups, though--notably the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), and the USPSTF--feel that the evidence for mammography in women between the ages of 40 and 49 is not as strong as for women 50 and older, and they have therefore departed slightly from this recommendation. They advise instead that for these women, mammograms may be performed every 1-2 or every 2 years, and that the decision can be individualized for each woman in this age group. Annual mammography is recommended by many societies to continue throughout the later years of life, but again there is some variability--the AAFP advises screening only until age 74, the USPSTF recommends stopping at age 75, and ACOG recommends individualizing the decision to screen after age 75.
So where does all of this conflicting evidence leave doctors and patients? There is not an absolute correct answer for how to screen--but it is important that patients do what makes them feel most comfortable, that doctor assess the evidence various expert groups use in making their recommendations, and that both groups communicate their preferences and concerns about screening to one another.
- 29 April 2014
- Internal Medicine Blog
The number of Americans who are overweight and obese has reached epidemic proportions. This year the CDC estimates that 2/3rds of US adults are overweight (BMI >25) and 1/3 of the population meets the classification of obese (BMI >30). Rates have risen dramatically from 1990 through the current time period. Many factors play a role in this increase which includes an overall decrease in daily activity with increased access to and consumption of high calorie low nutrient foods, fast foods, and processed foods. Being overweight and obese is associated with many negative health consequences including (but not limited to) elevated blood pressure, high cholesterol, diabetes and pre-diabetes, metabolic syndrome, arthritis, back pain, PCOS, infertility, irregular menstrual cycles, vitamin D deficiency, depression, skin tags, colon, breast , and endometrial cancers (among others), sleep apnea, worsening asthma, and fatigue. There is good news, however! Health effects from obesity are dramatically diminished with even moderate weight losses.
While I would encourage everyone to aim for a BMI in the “normal” range, a maintained loss of 10-20% of maximum body weight produces significant health benefits and risk reduction. The National Weight Registry is a research database that has tracked successful “loosers” for over 20 years. These individuals shed at least 30 pounds and kept it off over 1 year. The most common habits of successful maintainers are eating breakfast, exercising daily (average 1 hour per day), keeping a daily food log, and weighing themselves weekly. Most of these successful individuals also lost their weight gradually at an average of 1-2 pounds per week. Making sustainable lifestyle changes is the key to success! There are many tools from food logs, support groups, individual counseling, pre-packaged meals, medications, and surgery that can help achieve goals. I would encourage anyone who could benefit from weight loss to take action! Not sure where to start? Consider making an appointment with your doctor to assess your risks and start you on a healthier path.
- 01 April 2014
- Internal Medicine Blog
By: Maria Mazzotti, D.O.
As the weather starts to give us a break, I would like to give you a few reminders to help you stay healthy and enjoy the rest of your year.
1. If you have not started your allergy medications, I would high recommend doing that immediately. Getting started early may make a big difference in controlling you allergies. That goes for Singular as well, since it take about for this particular medication to start working effectively. Also keep in mind that Ventolin, commonly used for asthma, has a short half life. So once you open the foil package, you need to discard it after 6 months, even if you have not finished all of the inhalations. If you have severe allergies, you want to make sure your Epipen has not expired. This is also a good time of the year to have your carpets cleaned of all of the debris that accumulated over the winter and you can keep the windows open to make sure the carpets dry well.
2. Make sure you are up to date with your Tdap vaccine. You may know this vaccine as the Tetanus shot, Pertussis vaccine or whooping cough vaccine. This vaccine protects against 3 different infections. This time of the year, when we start gardening and hiking, this vaccine is important because it protects you against “Lockjaw” if you get a bad cut, burn or step on something rusty. Also Whooping Cough season is from June to September. It takes a few weeks to kick in, so you still have time.
3. This is also a good time of the year to clean out your medicine closet. Do not keep any medications that you are actively using. It is better to write down any medications that you are allergic to or have side effects from, then to keep the medication bottle hand for reference.
4. Now is also a good time to schedule those tests that you were forced to cancel due to the bad weather (mammogram, colonoscopy, blood work, PAP, physical, DEXA Scan, etc) before the steamy weather hits.
5. Make sure your sunscreen is not expired. Remember to apply it at least 30 min before stepping out for it to be more effective.
6. If you have not already, make sure you sign up for Obamacare. This is the first time in our nation’s history that everyone can have healthcare. Having insurance saves us all money, and more importantly keeps us healthy.
7. Also you should change your heating filters when you start using your AC. It may also be a good time to get you system cleaned/inspected if you did not do so in the fall.
8. As you get ready to be more active outside, make sure your sneakers are not worn out.
9. This is also a good time to start juicing, since a lot of your favorite fruits are coming in season.
10. Most importantly, this is a good time to focus on getting heart healthy. Whether you need to loose weight or not, you should be doing at least 30 min of a cardiovascular workout five times per week. Keep it fun, have friends join in, but do not work through pain. Exercise is also an effective way to help with anxiety/stress/depression and difficulty sleeping. And if you loose weight along the way, it is a plus.
Rittenhouse Internal Medicine™ has received the highest recognition from the National Center for Quality Assurance (NCQA). What this means for our patients
Thank you for voting Rittenhouse Women's Wellness Center Best Women's Health Care on the Main Line