Internal Medicine Blog
- 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.
- 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.
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