Category: Other Diseases and Conditions

Golden retriever sleeping on a patterned rug beside a sofa

How to Keep Your Pets Safe and Calm This 4th of July

On By Dr. Scott RennieIn Other Diseases and ConditionsLeave a comment
My dogs hate fireworks and I was just discussing what we are going to do with our dogs tomorrow night during all the fireworks.  I will be working in the Urgent Care and my wife will be attending some 4th of July festivities with friends, so our dogs would be home alone.  We will make accommodations so that they will not be alone.  I came across an article that I thought was useful and timely regarding 4th of July safety tips for pet owners. By:
Denver Pets Examiner
When celebrating with family and friends this 4th of July, remember that fireworks and some common barbecue foods can be hazardous to the well-being of pets. Despite most firework shows being banned this year in Colorado due to fire dangers, fireworks will still be the biggest perpetrators of 4th of July issues for pets, the most common being pet noise phobias. The loud noises can cause fear and anxiety for pets of all kinds, including dogs and cats and even horses. It is best to keep dogs and cats a safe distance from the activity – indoors is best. For pets with severe noise phobias, a veterinarian can prescribe anti-anxiety drugs or sedatives to help ease the stress. Larger pets, like horses and other livestock, are extremely susceptible to noise phobias. While most pet owners are aware of noise phobias, many are unaware that unused fireworks can be poisonous if ingested by curious dogs or cats. Many contain hazardous chemicals like chlorates, potent oxidizing agents that are harmful to red blood cells and kidneys; soluble barium salts that cause a life-threatening drop in potassium; sulfur; and coloring agents, which can contain dangerous heavy metals. Gastrointestinal issues like vomiting, a painful abdomen and bloody diarrhea can result. The severity of the reaction will depend on the type of firework, the amount ingested and what type of coloring agents it contains. In severe cases, pets can suffer tremors or seizures, along with acute kidney failure, bone marrow changes, shallow breathing and jaundice (yellowing of the skin).

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

White capsules spilled from an open amber prescription bottle on a table

Allergic Antibiotic Drug Reactions – Am I Truly Allergic to Penicillin?

On By Dr. Scott RennieIn Other Diseases and Conditions5 Comments
shutterstock_124906745shutterstock_46021174I had a patient who came in recently with his parents because he broke out in a rash all over his body after starting an antibiotic for an infection in his throat.  The parents were obviously concerned that he was allergic to the antibiotic and wanted to know what to do to help him. Allergies to medications, especially to antibiotics such as penicillin are common, but it’s sometimes confusing to know whether or not it’s a true drug allergy, a skin rash from the infection or perhaps not an allergy at all.  Yesterday a patient told me that they are allergic to penicillin, and when I asked them what happens he takes it he said that he’s unsure – he just knows he allergic because his father was. I was alarmed that he thought he had an allergy to a potentially life saving medication only because a family member had long ago told him that they had an allergy to penicillin. About 10% of patients report an allergy to penicillin when asked, however most people who believe they are allergic can take penicillin without a problem either because they were never truly allergic or because there allergy to penicillin has resolved over time. Only about 20% of people will be allergic to penicillin 10 years after the initial allergic reaction if they are not exposed to it again during this time period. Definition:  Penicillin is a common antibiotic that is prescribed for strep throat, ear infections as well as pneumonia and many other infections.  It is part of a family of medications called beta lactams which include: Penicllin G, amoxicillin, ampicillin, oxacillin, cloxacillin, dicloxacillin, piperacillin, and nafcillin.  A patient who is allergic to one of these penicillin medications is presumed to be allergic to any of them in this group. The Reaction:  It’s very important to tell your medical provider in as much detail as possible what the reaction is that happens if you take the medication rather than just listing it as an allergy.  If your medical provider writes down that you are allergic to an antibiotic and it’s not a true allergy, this might mean that the next time they get an infection, you get a less effective or more toxic antibiotic. It’s important to distinguish between a true allergy and “adverse reactions.” Adverse reactions are unexpected reactions that occur after taking a medication which are common but not true allergies.  Some patients report an adverse reaction as an allergy because they don’t want to be given this medication in the future.  For example, I had a patient tell me that they could not take prednisone because they are allergic.  When I asked what happens if he takes it, he replied – “I don’t like the taste.”   Unfortunately there are a limited number of medications, and they are most often grouped into families.  If you are truly allergic to one medication in the family, this eliminates the possibility of taking any other medication in the same family.  An entire group of potentially helpful medications might have been withheld from this patient only because he doesn’t like the taste of one of them in this group.  Another example of a non-allergic adverse reaction is nausea and/or diarrhea.  By listing penicillin as an allergy because the patient gets nausea or diarrhea after taking might lead to antibiotic failure or resistance which can be costly and prolong illness. It’s important to keep in mind that the care that you receive by your medical providers when you are ill might be negatively impacted by an improperly labeled allergy in your medical records. Rashes:  There are different kinds of rashes that can occur after taking penicillin or other antibiotics.  Some rashes such as hives are raised, intensely itchy and they come and go over hours. Another type of rash is flat, blotchy and spread over days but do not change by the hour and are less likely to represent a dangerous allergy.  These rashes start after several days of treatment.  We call these rashes a drug induced exanthem.  Taking a photograph of your rash and bringing it to your doctor may be helpful if the rash changes. True Allergic Reactions:  hives, angioedema (swelling of the face/lips), throat tightness, wheezing, coughing, trouble breathing from asthma type reactions are all important to distinguish from “adverse reactions” as I mentioned above.  When you list a medication allergy, make sure you describe which of these symptoms that the medication caused.  These types of reactions only occur in 1-5% of people.  It is important to tell your medical provider if you have had any of these symptoms because a past history indicates that the patient might develop a more severe infection such as anaphylaxis in the future if given the medication again. Anaphylaxis:  This is a true medical emergency caused by a potentially life-threatening allergic reaction.  The symptoms involve the allergic reaction as well as low blood pressure, trouble breathing, abdominal pain, swelling of the throat or tongue and or diarrhea/vomiting. Penicillin Allergy Testing:  Testing for a penicillin allergy might be important ifin people who have a suspected penicillin allergy and require it to treat a life-threatening condition for which no alternative antibiotic is appropriate.  It may also be appropriate for people who have frequent infections and have suspected allergies to many antibiotics, leaving few options for treatment.  About 90% of patients tested will not have a penicillin allergy either because they lost the allergy over time or were never allergic in the first place.  We do not routinely do allergy testing in the primary care or urgent care setting, it is done under the supervision of an allergist. Cephalosporin Allergy:  Allergic reactions are less common than reactions to penicillin.  People with a penicillin allergy have a small risk of having an allergic reaction to cephalosporins.  Cephalosporins are a class of antibiotics closely related to penicillin.  Some of these medications include cephalexin, cefaclor, cefuroxime, cefadroxil, cepradine, cefprozil, loracarbef, ceftibuten, cefdinir, cefditoren, cefpodoxime, and cefixime. Treatment:  For true allergic reactions stopping the medications as soon as possible is obviously important.  The following is an example of what I might do for a severe allergic reaction, but it may differ if you go a different facility or depending on the circumstances. For mild urticaria:  Observation and consider diphenhydramine 25-50 mg PO/IM or 25mg IV For severe urticara:  Diphenhydramine 25-50mg PO/IM or 25mg IV, Corticosteroids/Solumedrol 80-125mg IV,  IV fluids and/or epinephrine at a dose of 0.3mg 1:1000 IM (Epi-Pen).  If giving epinephrine, I usually have the patient transported to the hospital because they will need monitoring for rebound allergic reaction once the epinephrine wears off. For Laryngeal Edema:  Give O2 by mask 6-10L For Anaphylaxis-like reactions:  Suction as needed, elevate legs, O2 10L by mask, IV fluids (NS or LR), and Epinephrine 1:1000 0.3mg IM (Epi-Pen).  For bronchospasm, add Albuterol MDI 2-3 puffs, Antihistamine: Diphenhydramine 25-50mg IM or IV and Corticosteroids/Solumedrol 80-125mg IV and await transport to the hospital For Hypotension:  Elevate legs, Oxygen by mask, use IV fluids, Epi-Pen and await transport to the hospital Vagal Reaction:  Elevate legs, 02 by mask at 10L, IV fluids (NS/LR wide open) For Angina:  02 by mask at 10L, IV fluids:  Administer slowly, Nitroglycerine 0.4mg sublingually; may repeat p5 min x 3 doses, Morphine 2mg IV and await transport to the hospital For hypertension:  02 by mast at 10L, IV fluids:  Administer slowly, Nitroglycerine 0.4mg sublingually, may repeat q5 minutes x 3 doses and await hospital transport For seizures: Suction/Protect Airway and monitor for obstruction by tongue.  O2 by mask if not vomiting.  If caused by hypotension, treat accordingly and if uncontrolled consider anticonvulsant such as diazepam and await hospital transport For hypoglycemia:  O2 by mask at 10L, IV fluids D5W or glucose tablet I recommend that patients who have known severe allergies to insect or bee stings carry an EpiPen with them. If you’d like more information about allergic reactions to medications, check out the American Academy of Allergy Asthma & Immunology website:  http://www.aaaai.org/conditions-and-treatments/library/at-a-glance/medications-and-drug-allergic-reactions.aspx   I hope that you have found this information useful.  Wishing you the best of health,

A penicillin allergy on the chart is one of the most common reasons a person ends up on azithromycin instead, which is a good part of why the Z-Pak became the default ask. I wrote about what I tell patients who ask for a Z-Pak.

Updated for 2026: This Is the Post That Aged the Worst

Of everything on this site, this is the topic where practice has moved furthest from what I wrote in 2012. Not refined. Moved. In 2012, a penicillin allergy label meant skin testing, or more often it meant nobody tested anything and you spent your life on second choice antibiotics. That was the standard and I described it as such. The current approach is different in a way that matters to you if you are carrying this label. For patients whose history is low risk, meaning a remote reaction, an isolated rash, a vague story nobody wrote down, or a reaction you only know about because a relative told you, the 2022 practice parameter from the allergy societies supports going straight to a supervised oral dose of amoxicillin. No skin testing first (1). That sounds reckless if you learned it the old way. The trial says otherwise. PALACE randomized low risk adults to direct oral challenge or skin testing first, and the rate of positive reactions was identical, half a percent in each arm. Both reactions were mild and settled with an antihistamine (2). Half a percent. That is the number to sit with. The label is wrong far more often than it is right.

The Ten Percent Cephalosporin Rule Was Wrong

Most of us were taught that if you are allergic to penicillin you have roughly a ten percent chance of reacting to cephalosporins, so avoid the whole class. That teaching is obsolete and it caused real harm, because it pushed patients onto broader and worse antibiotics for no reason. What actually predicts cross reactivity is not the class. It is whether the two drugs share a similar side chain. A meta analysis of over twelve hundred penicillin allergic patients found cross reactivity of 16.45 percent when the side chain was identical, 5.60 percent when it was somewhat similar, and 2.11 percent when it was not (3). Carbapenems came in at 4.3 percent. So the honest answer to whether you can take a cephalosporin is that it depends entirely on which cephalosporin, and most of them are fine.

Getting the Label Removed, and Making It Stay Off

This is something I can genuinely start in a video visit, and it is one of the more satisfying things I do. The work is the history. What happened, how long after the dose, how old were you, did anyone see it, did you need treatment for it. Most of the time the answer is a childhood rash during a viral illness that got blamed on the amoxicillin, and that is not an allergy. From there I can tell you whether you look low risk and route you to a challenge, or whether your story needs an allergist first. One caution from the follow up data. Six months after being formally delabeled, 6.6 percent of patients in PALACE were describing themselves as penicillin allergic again (4). The label creeps back. If you get delabeled, make sure it comes off your chart everywhere, tell your pharmacy, and do not reintroduce it at the next intake form out of habit.

Who Should Not Be Challenged

None of the above applies if your reaction was serious, and this is where I want to be unambiguous. If you had hives, swelling of the lips or throat, wheezing, or a drop in blood pressure within minutes to hours of a dose, that is a different situation and you need an allergist, not a challenge. The same is true for the severe delayed reactions: blistering or peeling skin, sores in the mouth or eyes, a rash with fever and organ involvement, or a serum sickness type reaction. Those patients should never be given a test dose to see what happens (1). And any active reaction with mouth or eye involvement, blistering, facial swelling, or trouble breathing is an emergency room problem, right now, not a video visit.

The Bottom Line

Around one in ten people carries this label and the overwhelming majority of them are not allergic. Getting it removed is not a formality. It gets you better antibiotics when you actually need them. If your story is a rash you had as a child, ask about a challenge.

Sources

1. Khan DA, et al. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol. 2022;150(6):1333-1393. https://pubmed.ncbi.nlm.nih.gov/36122788/ 2. Copaescu AM, et al. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA Intern Med. 2023;183(9):944-952. https://pubmed.ncbi.nlm.nih.gov/37459086/ 3. Picard M, Trubiano JA, Phillips EJ, Blumenthal KG, et al. Cross-Reactivity to Cephalosporins and Carbapenems in Penicillin-Allergic Patients: Two Systematic Reviews and Meta-Analyses. J Allergy Clin Immunol Pract. https://pubmed.ncbi.nlm.nih.gov/31170539/ 4. Copaescu AM, et al. Risk of Self-Reported Penicillin Allergy Despite Removal of Penicillin Allergy Label: Secondary Analysis of the PALACE Randomized Clinical Trial. JAMA Netw Open. 2024;7(8):e2429621. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2822413

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Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Woman sitting in an armchair beside a rain-speckled window

Anxiety: Practical Tips and What Can Actually Help

On By Dr. Scott RennieIn Other Diseases and ConditionsLeave a comment
shutterstock_86293354Today a patient came in because she’s been feeling anxious because she’s had some heart palpitations.  She’s seen a cardiologist (heart specialist) and learned that the abnormal heart rhythm is intermittent atrial fibrillation (a usually non-dangerous rhythm) that has likely been brought on by the increased stress and lack of sleep lately.  When she gets the heart palpitations, she becomes more anxious, and the more anxiety that she experiences,  the more heart palpitations she has.  To her, it feels like an endless cycle that will never end. This patient’s anxiety is understandable.  We all experience stressful or potentially anxiety provoking details that occur in our lives.  How we deal with these thoughts and events is critically important because it often determines how we function from day to day. Feeling anxious can be a normal response to a stressful situation.  The adrenaline rush after we learn that a bear is in our campsite might help us escape the dangerous situation.  Feeling anxious for most of the day for long periods of time however is not normal. Symptoms:  Excessive worry or feelings of dread or being “on edge” may contribute to daily fatigue, and muscle tension.  Other common symptoms may include headaches, hives, heart burn, constipation, diarrhea, abdominal pain, chest tightness, difficulty sleeping, memory problems and an increase or decrease in appetite.  Sometimes a patient might have depression along with anxiety. Often patients come in to talk with me about treatment for their anxiety with medications.  I understand that feeling anxious is not particularly desirable, however in many circumstances, it’s normal.  Treating the anxiety is often most effective by addressing the anxiety provoking situation rather than masking the symptoms with medication.  Once the medications wear off, the anxiety returns and the cycle repeats itself. I think it’s important to distinguish the difference between anxiety and an anxiety disorder.  People who have “normal” anxiety may have worries from time to time, but these feelings do not interfere with daily life.  An example might be a parent worried about their child who is late coming home from a date.  I’m sure you can think of many other examples.  People with an anxiety disorder are often worried or anxious about a number of events or activities and these worries are out of proportion to the situation.  A parent might worry excessively about their child’s safety even when the child is at home with the family.  An anxiety disorder can make routine activities difficult to complete.  There are certain criteria that need to be met in order to make a diagnosis of an anxiety disorder and it’s my opinion that only a qualified health mental professional with training in anxiety disorders such a psychologist should make this diagnosis. Treatment:  Usually we tailor the treatment to the individual patient and what is causing the anxiety.  If the anxiety is caused by a certain life event, then learning how to address the feelings and concerns related to the event is often the most helpful way to decrease the anxiety.  Individuals who suffer from an anxiety disorder often require more treatment than those who have anxiety from stressful life events.  Some possible treatments for anxiety might include: 1)   Cognitive Behavioral Therapy (CBT): CBT focuses on the person’s behavior and patterns of thinking.  The therapist helps teach you how your thoughts contribute to your anxiety and how to decrease these negative or unpleasant thoughts when they occur. 2)   Eye Movement desensitization and reprocessing (EMDR): A particularly effective technique being used by psychologists who have had specialized training.  One of the procedural elements is “dual stimulation” using either bilateral eye movements, tones or taps. During the reprocessing phases the patient attends momentarily to past memories, present triggers, or anticipated future experiences while simultaneously focusing on a set of external stimulus. During that time, clients generally experience the emergence of insight, changes in memories, or new associations. The clinician assists the client to focus on appropriate material before initiation of each subsequent set. 3)   Medications: If medication is used to treat anxiety, you will need to see a primary care provider or psychiatrist.  If a patient has an anxiety disorder however, my opinion is that the patient should also be treated by a mental health provider such as a psychologist and/or psychiatrist.  Medications used to treat anxiety may include:
  1. Antidepressant medications such as SSRI or SNRI.  Examples of these medications include Fluoxetine, Citalopram, Paroxetine, Fluvoxamine, Sertraline, Escitalopram, Venlafaxine, Duloxetine, Desvenlafaxine, and Milnacipran.
  2. Buspirone is an antianxiety medication used to treat anxiety disorders
  3. Herbal medications such as kava kava and valerian have been used.  Kava Kava however has been linked to liver failure and is not recommended.  There is not enough evidence to show whether herbal medications are effective or safe for treating anxiety disorders.  Make sure to tell your medical provider if you are taking herbal medications
  4. Benzodiazepines such as Alprazolam, Chlordiazepoxide, Clonazepam, Clorazepate, Diazepam, Flurazepam, Halazepam, Lorazepam, Oxazepam or Prazepam are sometimes prescribed for short-term use only.  Because of the addictive nature of these medications, and because of safety concerns, I generally do not prescribe these medications frequently
If you or someone you know is suffering from an anxiety disorder (in contrast to experiencing anxiety as part of a life event), I strongly recommend that you seek help from a qualified mental health professional. Sometimes it can be challenging to know whether the anxiety you experience is the result of a “life event” or an actual disorder.  Most primary care providers can help you determine this or refer you to a mental health professional if further diagnosis is needed. To find a Psychologist in your area, you may use the American Psychological Association Psychologist Locator website:  http://locator.apa.org/ Helpful links for additional reliable anxiety related mental health information: National Library of Medicine (www.nlm.nih.gov/medlineplus/anxiety.html) National Institute of Mental Health (www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml) National Mental Health Association (www.nmha.org) Anxiety Disorders Association of America (www.adaa.org)   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Client lying face down with acupuncture needles placed along the back

Does Acupuncture Really Work? What the Science Shows

On By Dr. Scott RennieIn Other Diseases and ConditionsLeave a comment
SEP 29 2011, 10:07 AM ET 442
ALICE G. WALTON – Alice G. Walton is a health-and-science journalist who writes on medical issues, particularly those related to the brain and behavior. She holds a Ph.D. in biopsychology and is an editor at TheDoctorWillSeeYouNow.com.
Many of us have started to embrace the use of alternative medicine, but acupuncture, with its qi, yin, and meridians, still raises eyebrows While many practices in alternative medicine are slowly but surely making their way into the mainstream, acupuncture is one that still produces skeptical eyebrow raises. This phenomenon is partly due to linguistics. Scientists have worked to elucidate the mechanisms by which yoga, meditation, and various dietary interventions may work on the cells of the body, but there is something fundamentally more ancient-feeling about the language of acupuncture. Go to the NIH’s website on complementary and alternative medicine (NCCAM), and even here you’ll find a discussion that involves qi, yin, yang, and meridians. Is it possible to discuss acupuncture in a way that makes sense to even the most Westernized brains? The short answer is yes — but with the caveat there there is no single unifying explanation for how it works. While acupuncture has been demonstrated to be useful in pain management and in treating the nausea and vomiting associated with chemotherapy, other uses have had more mixed results when studied scientifically. Dr. Leena Mathew is an attending physician in Anesthesiology and Pain Medicine at New York Presbyterian Hospital/Columbia University Medical Center. She uses acupuncture as an “adjunct analgesic modality,” meaning that she uses it as a complementary treatment for pain in her patients should they require or prefer it. She and Dr. Josephine Briggs, director of NCCAM, discussed with us the most likely theories of the mechanisms behind acupuncture. For pain management, one idea is that acupuncture may be working via the gate control theory, first outlined by Melzack and Wall in the 1960s. This theory suggests that pain is transmitted through small nerve fibers from the skin through the spinal cord and on up to the brain. Also present are larger fibers which normally send inhibitory signals to the small pain fibers, which essentially “gates” or prevents a pain signal from being set off. When a painful stimulus comes in, however, the activity in the small nerve fibers overwhelms the large ones, so inhibition is released and the gates of pain opened. Where does acupuncture come in? Theoretically, the needles are placed in positions to stimulate the large nerve fibers, so that the small — painful — ones are inhibited. Mathew says that the same logic theoretically underlies why rubbing your elbow after you bang it helps alleviate the pain: you’re stimulating the inhibition that quiets the pain. Another possibility is that endorphins, the body’s famed “feel good” chemicals, are behind the effect of acupuncture on quelling pain. Mathew says that the happy little chemicals are released in response to a range of phenomena — distress, injury, running long distances, chocolate — and have the knack for acting like morphine on the body and brain. Studies have tracked levels of these molecules in the blood, and shown that acupuncture is linked to higher levels of beta-endorphin at the same time that patients are reporting decreases in their pain levels. Even more, when you inject people with the anti-morphine drug naloxone, the effects of acupuncture are reduced. But other theories better explain why acupuncture has been shown to work well on the nausea and vomiting (PDF) associated with chemotherapy. In the 1950s, the nerve reflex theory was proposed, suggesting that the body’s periphery (the skin) is connected to the internal organs through a reflex called the viscero-cutaneous reflex. “If you stimulate the periphery with acupuncture needles,” explains Mathew, “you can change the blood flow pattern to the stomach and abdomen, which could explain the effect on nausea and vomiting.” Acupuncture may also have an effect on the body’s stress response system, otherwise known as the hypothalamus-pituitary-adrenal (HPA) axis, which could be why acupuncture patients report lower stress levels and anxiety after treatment, at least in the short term. If you were wondering when the word “placebo” was going to enter the discussion, here it is — but it’s not what you think. What researchers now know about the placebo effect is that it isn’t some hokey “mind over matter” thing. The response is a robust, demonstrable physiological phenomenon, according to Mathew. When people are being “treated” with placebo, you can actually see the change in blood flow patterns in the cortices of their brains in fMRI. Some people are more responsive to the placebo effect than others, and there is no doubt that some of this effect is going on with acupuncture, and particularly heightened in placebo-sensitive individuals. Which leads to the final theory about why acupuncture may work on certain conditions. The very presence of human touch may have a lot to do with acupuncture’s healing power, Mathew suggests. “This is therapeutic touch,” she says. “As Westerners, we’re disconnected from this. We don’t want to touch patients.” But just as a mother calms a child simply through her physical/emotional presence, having another human being exert a well-intentioned touch may, in its simplicity, also do a lot to alleviate pain. This effect may have to do with the alleviation of fear and anxiety, things we know account for a huge portion of our perception of pain. Briggs adds to this idea by mentioning that some of the effects of acupuncture can also be seen when “sham” treatments like toothpicks are used, which can sometimes have an effect similar to acupuncture. This, she says, “tells us that a very important part of acupuncture’s effect is the ritual involved, which includes pressure, reassuring practitioners, and the patient’s expectation.” In other words, the act of acupuncture itself is at least partially what accounts for its effect. She adds that we need to start asking different questions about acupuncture, and using different language to discuss is. For example, she says that “meridians were developed by a tradition of people who didn’t dissect human body — meridians are not good a scientific question. But, ‘How does the practice change our perception of pain?’ is a good question. It’s quite plausible that pain pathways are modulated by emotion, pill placebo, etc., so it’s not surprising that reassurance of ritual or expectation is at play here. ” As Mathews points out, acupuncture is a “retrospective science, going on for 3,000 years. We know it works, we just don’t know why. It’s very hard to translate into Western language.” Still, it should be possible to do so, and we seem to have made some progress. Hopefully more researchers asking the right questions, and coming up with clever new techniques to address them, will help elucidate the mechanisms and unify the theories. Image: REUTERS/Mike Cassese.   **Addendum If you would like to locator an Acupuncturist/Oriental Medicine Provider in your area, one resource that I found helpful is the American Association of Acupuncture and Oriental Medicine Website:  http://www.aaaomonline.org/search/custom.asp?id=320

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Office worker holding his neck while seated at a desk

Cervicalgia – A Pain in the Neck

On By Dr. Scott RennieIn Other Diseases and Conditions2 Comments
shutterstock_142402684Patients frequently come into the Urgent Care clinic for problems related to neck pain.  It can be caused by a number of different factors including ligament or muscle strain, arthritis or a “pinched nerve.” It is quite common, and in fact 10% of adults have neck pain at any one time.  Most patients recover with conservative therapy regardless of the cause of the pain.  Understanding neck pain is much easier if you have a good knowledge of the structural anatomy of the neck. Brief description of the anatomy is outlined below: 1)   Cervical vertebrae:  Seven small bones the make up the cervical spine of the neck 2)   Spinal canal:  The structure through which the spinal cord (nerves) flow which is made from the cervical vertebrae as well as the supporting ligaments and overlying neck muscles. 3)   Cervical discs:  Between the neck bones, these tiny shock absorbers cushion one bone from another.  The inner part of the disc contains a gelatin-like material and when excessive pressure on the disc occurs, this gelatin-like material can protrude and cause what we call a “herniated disc.” Causes:  There are several causes for neck pain, some of which are mentioned here: 1)   Whiplash injury:  A traumatic event that causes sudden forward/backward movement of the cervical spine.  A motor vehicle accident is the most common cause. 2)   Cervical strain:  Injury to muscles of the neck that cause spasm of the neck and upper back muscles causes this type of pain.  It can be a result of physical stresses of everyday life including poor sleep habits, muscle tension from psychological stress, or poor posture. 3)    Diffuse skeletal hyperostosis:  Also called (DISH) is when there are abnormal calcifications in the ligaments and tendons along the cervical spine. 4)   Cervical spondylosis:  Abnormal wear and tear causes gradual narrowing of the disk space and loss of normal bone structure which often leads to bone spurs.  These spurs can increase the pressure on surroundings areas. 5)   Cervical discogenic pain:  The intervertebral discs of the neck function as shock absorbers that cushion the neck bones from one another.  If there are structural changes in these discs, it can cause pain. 6)   Cervical facet syndrome:  Pain involving the facet joints is common in people who repeatedly extend the neck (tilt the head backwards).  The facet joints are on the left and right of the vertebrae. 7)   Cervical radiculopathy:  When disk or neck pass pushes on or irritates a nerve root, this can cause pain, weakness or numbness/tingling of the neck and/or arm. 8)   Cervical spondylotic myelopathy:  This is narrowing of the spinal canal inside the bones of the neck, and is usually caused by either damage to the disks or degeneration from arthritis. Testing:  In order to determine the cause of the pain, your healthcare provider will examine your neck and look at the movement or range of motion to the neck and observe posture of the neck and shoulders.  In some cases there may be a radiological study such as an x-ray, MRI (magnetic resonance imaging) or CT scan (computed tomography) ordered.  The need for on of these tests depends on the patient’s history and physical examination. Treatment:  The individual treatment is tailored to the patient to help treat the underlying cause of pain.  Some possible treatments may include: 1)   Medications:  Ibuprofen, naproxen or Tylenol may be prescribed.  Other medications such as muscle relaxants or narcotics may also be prescribed depending on the circumstances. 2)   Heat:  Can be helpful for decreasing the muscle spasm in the neck.  Moist heat (from a shower, hot tub, or moist towel warmed in a microwave or with warm water) seams to work best 3)   Ice:  Can reduce the pain in many people.  Ice is applied directly to the painful area.  A bag of ice, frozen peas or a ice cubes in a plastic bag is often used, but avoid applying the blue ice that is used for coolers/camping to the skin as this can cause freezer burn. 4)   Massage:  By applying pressure on both sides of the neck and upper back, the neck muscles may be relaxed.  This is usually most helpful if done by a professional massage therapist. 5)   Stretching exercises:  Do not attempt exercises without being evaluated by a healthcare provider as they can actually make the problem worse if performed incorrectly.  Exercises can be performed to relieve stiffness and improve range of function. 6)   Stress reduction:  Neck tension can be increased due to emotional stress and can delay the recovery process.  To help with stress reduction, breathing exercises, meditation, progressive muscle relaxation, biofeedback, prayer or self-hypnosis are helpful for some patients. 7)   Posture:  It’s important to avoid extreme ranges of motion or positions that cause constant tension.  Avoid sitting in the same position for extended periods of time.  Also avoid placing backpacks, over-the-shoulder purses, or children on the shoulders.  Do not perform overhead work for prolonged periods of time.  Hold your head up and keep shoulders back and down to maintain a good posture.  Sleep with your neck in a neutral position by sleeping with a small pillow under the nape of your neck (while laying on your back).  Carry heavy objects close to your body rather than with outstretched arms. Other treatments: 1)   Osteopathic manipulative therapy (OMT)– physically manipulating the muscles, soft tissues and joints can help with neck pain 2)   Trigger Point Injection:  A local anesthetic such as lidocaine can be injected into an area of muscle spasm 3)   Accupuncture:  A needle placed into the proper body area by a healthcare professional who is trained in accupunture therapy can be helpful 4)   Electrical stimulation:  Transcutaneous electrical nerve stimulation (TENS) is a treatment that uses a mild electric current that is applied to the skin to decrease pain and increase mobility and strength.  Some people have found TENS helpful. 5)   Cervical traction:  The use of weights to pull the spinal column into alignment have been helpful for some people in the short term, however clinical studies have shown no long term benefits. 6)   Surgery:  Surgery has a role in relieving symptoms related to a pinched nerve in some cases.  Usually these patients have tried all prior treatment options before proceeding with surgery. To find an Osteopathic physician in your area, the American Osteopathic Association has a useful website:  http://www.osteopathic.org/osteopathic-health/find-a-do/Pages/default.aspx   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Woman seated on a sofa holding her knee with both hands

All About Knee Pain: What Every Patient Should Know

On By Dr. Scott RennieIn Orthopedic/Musculoskeletal, Other Diseases and ConditionsLeave a comment
shutterstock_94626553I often have people come to the Urgent Care who have problems due to knee pain. Pain that originates in the knee can be complex because there are quite a few areas within the knee that can cause pain. The knee is a “hinge” type joint that is at the greatest risk of injury, age-related wear and tear, arthritis as well as infection related arthritis. Causes: As I mentioned above, there are many causes of knee pain. Several are listed below: 1) Patellofemoral pain syndrome – Group of symptoms that is sometimes caused from overuse of the knee. It can affect running athletes, and is more common in women. The pain is usually in the front of the knee and is made worse with squatting, running, prolonged sitting or when climbing or going down stairs. We also call this Patellar tracking syndrome because it is related to the knee cap (patella) sliding out of the groove that it normally sits in. 2) Meniscal tears – The meniscus is a specialized shock absorber that provides cushion on both sides of the knee. They can become damaged or torn from an acute knee injury or from overuse that comes with age. They have a very poor blood supply, so they don’t heal very quickly 3) Bursitis – The knee is lubricated by joint fluid that is produced by a lubricating bursa (or sac). These bursa sacs can become irritated as a result of injury or even overuse. Inflammation of the bursa is called bursitis 4) Arthritis – This refers to inflammation of the cartilage covering the ends of the bones and undersurface of the knee cap. When it gets worn down, irritated or irregular, it can become painful and is known as arthritis. 5) Tearing of a ligament – The knee is held together by a combination of ligaments including the anterior and posterior cruciate ligaments as well as the medial and collateral lateral ligaments. These ligaments function to hold the bones together and prevent side-to-side or back and forth motion. 6) Muscle strain – If the muscles on the front or back of the knee area become injured, or in spasm they can cause pain around the knee joint. These muscle groups are the quadriceps (located on the front of the top of the knee) and the hamstrings (located on the back part of the leg). These muscle groups work to give support to and move the knee joint 7) Fractures – Broken bones around the knee can obviously cause pain 8) Infection – If bacteria get into the knee joint, this can cause pain, swelling and decreased range of motion 9) Gout – This is caused by the formation of uric acid crystals that build up within the knee joint and is less common in the knee than some other joints 10) Baker’s Cyst – a cyst in the back of the knee can cause pain Diagnosis: Since there are so many different possible causes of knee pain, it is important to make an accurate diagnosis to treat the underlying problem. In addition to getting a good history from the patient about their pain, a physical evaluation will be performed and sometimes knee x-rays, an ultrasound, or an MRI will be ordered. Additionally, a small sample of synovial fluid is sometimes removed from the knee using a needle. This fluid can be examined under a microscope and/or sent for culture to look for bacteria, crystals or signs of inflammation. Treatment: The individual patients injury will dictate the kind of treatment that they need to recover the fastest. Physical therapy is often used because it speeds recovery and regain motion. We also often recommend ice, elevation of the leg and muscle-toning exercises when appropriate. Sometimes a knee brace or immobilizer may be appropriate. Medications such as ibuprofen, Aleve or Tylenol may be appropriate for knee injuries. If infection is present, antibiotics may also be prescribed. If injury to the bone or ligaments is the cause, surgery can be helpful in some patients. Limiting certain activities: Speeding the recovery and helping prevent further injury sometimes involve limiting activities temporarily. Excessive pressure on the knee joint by the following activities should be avoided to help recovery: 1) Kneeling 2) Jogging 3) Squatting 4) Twisting and pivoting 5) Aerobics/Dancing 6) Playing stop and go sports such as basketball or racquet sports 7) Swimming with frog leg or whip kick techniques 8) Rowing machine 9) Stationary bike 10) Stair stepper 11) Leg extensions with weights   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Healthcare worker bandaging a patient’s injured hand

I Hurt My Finger or Toe: How Do I Know if It’s Fractured?

On By Dr. Scott RennieIn Other Diseases and ConditionsLeave a comment
shutterstock_136665947Patients frequently come into the urgent care after injuring a finger or toe and are concerned about the possibility of a fracture. A finger or toe fracture is when a person breaks a bone within their digit. There are different types of fractures, and they are described based on how the bone breaks and whether the broken bone actually sticks out of the skin or not. Symptoms of fracture: 1) Pain 2) Swelling 3) Bruising 4) Stiffness 5) Weakness of the finger/hand or toe 6) The finger or toe looks bent in an abnormal position Testing: You healthcare provider will examine your finger or toe and obtain an X-ray Treatment: The treatment depends on the type of fracture and where it is. Some possible treatments may include: 1) Medication for pain such as Ibuprofen or Tylenol 2) Splinting or “buddy taping” 3) If the fracture is severe with a bone sticking out of the skin, you will need antibiotics and referral to a bone specialist (orthopedic physician). 3) After the splint can come off, your healthcare provider may recommend you work with a physical or occupational therapist. The therapist can show you exercises to strengthen your finger muscles and keep the fingers from getting stiff. Length of time to health: Finger/Toe fractures can take weeks to months to heal, depending on the type of fracture. Home therapy: to help the bone heal rapidly we generally recommend the following: 1) No smoking 2) Keep the cast or splint from getting wet, and keep it clean 3) Keep the finger splinted and immobile to decrease movement   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Mother comforting a child in bed beside a running humidifier

My Child Has a Barking Seal-like Cough: Is It Croup?

On By Dr. Scott RennieIn Infectious Disease, Other Diseases and Conditions, RespiratoryLeave a comment
shutterstock_109784702A variety of respiratory illness in children can cause what we cause croup.  We see children with croup in the urgent care frequently, mostly during the winter months.  It occurs mostly in infants and young children between 6 months and 3 years of age.  We don’t see it often in kids that are older than 6 years of age.  Most of the time croup is mild and can be treated at home, but sometimes it can become serious and need immediate medical care. When to seek help:  A child with severe or worsening croup should be evaluated immediately because croup can be a life-threatening illness .  Some features of worsening or severe croup include: 1)   Drooling or difficulty swallowing 2)   Difficulty breathing 3)   Inability to speak or cry due to difficulty taking a breath 4)   A whistling sound when breathing, or noisy-high pitched breathing while sitting or resting 5)   Sucking in of the skin around the ribs or abdomen with breathing 6)   Pale or blue-tinged skin It’s important for parents not to attempt to drive their children to their medical provider if they are struggling to breath or are having severe croup symptoms.  Instead, calling 911 and having emergency medical care assist in the treatment on the scene where the child is located and help with transport is critical in this potentially life-threatening situation. Causes:  A viral infection with influenza or para-influenza are the most frequent causes although most of the time these viruses people with these viruses don’t get croup.  The infection can lead to swelling of the voice box and windpipe and as the infection progresses, this can cause the windpipe to become swollen and narrow. Bacterial infection can also cause croup or trachiitis but this is usually more severe and requires a different treatment than a viral infection. Symptoms:  Usually it starts with congestion and runny nose and then can progress to a characteristic “barking cough,” and hoarseness.  Symptoms seem to be worse at night in most children.  Fever can develop in patients as well as a rash and redness to the eyes.  Swollen lymph nodes are common.  As the upper airway narrows due to swelling from the infection, high-pitched, noisy breathing (called stridor) can develop.  If the child becomes anxious, the breathing often becomes more difficult because the agitation can increase the narrowing.  The effort to breathe faster and harder is tiring and some children become exhausted and in severe cases, they might not be able to breath on their own. A blue-tinge to the skin (called cyanosis) can develop if airflow to the lungs is restricted.  Cyanosis may first be noticed in the fingers and toenail, ear lobes, tip of the nose, lips and tongue.  This is uncommon in croup, but can happen in severe cases. Severity:  Croup is often graded in terms of severity as mild, moderate or severe.  A brief description of these grades is listed below: 1)   Mild:  Child is alert and may have a barking cough.  Stridor (high-pitched noisy breathing) is not present at rest, but may be notable as the child coughs or cries.  There are not retractions (severe abdominal or chest movements with breathing) 2)   Moderate:  Children with moderate croup may have stridor at rest.  They may also have retractions (severe abdominal or chest movement as they breath).  They may look uncomfortable. 3)   Severe:  Child with this grade of croup has stridor and chest/abdominal retractions at rest.  The child struggles to take each breath and may appear anxious, agitated or fatigued.  A patient with severe croup should generally not be seen in the primary care or urgent care and be seen in the emergency room.  These patients may be transported to the hospital by ambulance. Diagnosis:  Usually the diagnosis is made clinically and is based on the child’s symptoms including barking cough, and stridor.  X-ray or other laboratory work is rarely needed. Treatment:  The type of treatment generally depends on the severity of symptoms.  Generally moderate to severe symptoms suggest the child should be seen by a healthcare provider. Mild croup: most often is able to be treated at home without difficulty.  Use of a mist humidifier or sitting in the bathroom with parents with the shower running (to produce steam) may be helpful.  Other treatments such as allowing the child to breathe cold air during the night by opening a window or door, treatment of fever with Tylenol or Ibuprofen, and elevating the child’s head slightly may also be helpful. Moderate to severe croup:  Usually moderate to severe croup should be evaluated by a healthcare provider who is able to handle an urgent respiratory illness.  Severe croup can be life-threatening, and treatment should not be delayed.   We will use humidified air or oxygen as needed, intravenous fluids if there are signs of dehydration, and even place a breathing tube or assist in oxygenation by applying a non-rebreather mask over the child’s mouth so the oxygen is delivered in a higher concentration.  We also monitor the child’s oxygen levels, breathing rate, heart rate, skin color and the alertness of the child closely. Medications for croup:  In the clinic, we often prescribe a single to multiple doses of dexamethasone which is a steroid medication that decreases the inflammation of the airway (windpipe and voice box area).  If there is stridor or the croup is severe, we will sometimes give nebulized treatments of racemic epinephrine (aka adrenaline).  This also reduces swelling in the airway and actually starts working faster than dexamethasone.  Racemic epinephrine works for a short period of time (two hours or less) and may be given every 15-20 minutes for severe symptoms.   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Woman holding her wrist beside a laptop at a home office desk

Finger and Hand Pain: Is It Carpal Tunnel Syndrome?

On By Dr. Scott RennieIn Other Diseases and ConditionsLeave a comment
shutterstock_86604217Many patients come to the Urgent or their primary care office with complaints of hand/wrist pain, numbness, tingling or a combination of these symptoms.  They often wonder if it could be due to carpal tunnel syndrome. Carpal Tunnel Syndrome:  characterized by pain and numbness in the fingers and hands, and sometimes in the arms.  It happens when the median nerve in the wrist becomes pinched or squeezed.  The median nerve travels through a small “tunnel” in the wrist that is formed by bones and a ligament.  It’s a setup for this nerve to become pinched due to our normal anatomy, but may be worse in some people or due to certain conditions.  There is some thought that the nerve gets pinched possibly due to one or more of the following: 1)   Tissues that surround the surrounding tends in the tunnel harden 2)   Tendons that go through the tunnel get swollen 3)   People hold their hands in a position that causes the tunnel to get smaller. Parts of the hand affected by the median nerve: 1)   Thumb 2)   Index finger 3)   Middle finger 4)   Half of the ring finger 5)   The parts of the palm closest to the thumb Symptoms:  Pain, and tingling in the thumb, index, middle and ring fingers.  These symptoms may be present in one or both hands.  Rarely, the pain can travel up the wrist and forearm and even cause tingling past the elbow to the shoulder. The symptoms are usually worse at night.  Activities that may trigger carpal tunnel syndrome include: 1)   Typing 2)   Reading 3)   Driving 4)   Holding a phone 5)   Sleeping at night – many people bend their wrist while sleeping Testing:  Nerve conduction studies or Electromyography can measure the speed of the electrical nerve conduction of the median nerve or show whether muscles of the hand and wrist are responding appropriately to the electrical signals.  Most of the time the surgeons want these tests to be performed before they will consider surgical treatments for carpal tunnel syndrome. Treatment:  they are tailored to the individual patient and may include: 1)   Wrist splints keep the hands in a neutral position, where the wrists are not bent forward to backward 2)   Surgery is offered to patients who have severe symptoms and that involves cutting the ligament that stretches across the wrist to form the carpal tunnel. 3)   Steroid shots or pills:  The steroid medications that we use short-term are a group of medications that control inflammation and swelling.  Sometimes we will inject a steroid directly into the carpal tunnel, but this is usually done by a hand specialist because of the risks of getting the steroid directly into the median nerve. 4)   Osteopathic manipulation: There are techniques that an Osteopathic Physician (D.O.) may perform that can actually help increase the space inside the carpal tunnel ie. “carpal bone mobilization.”   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Mother examines a rash on a child’s abdomen while seated indoors

The Viral Rash – Exanthem

On By Dr. Scott RennieIn Infectious Disease, Other Diseases and Conditions3 Comments
shutterstock_137048072A rash caused from a virus that is widespread and usually occurring in children is called a exanthem.  The first four listed below are the “classic” childhood viral rashes, but we recognize others that can also cause virus, some of those are also listed below (see 5-7): 1)   Rubeola is also known as the measles and is caused from the measles virus and produces reddish macules and papules behind the ears and at the anterior hairline, coalescing and spreading over the neck and trunk and finally affecting the arms/hands and legs/feet. 2)   Rubella is also known as German measles and is caused by the togavirus.  The eruption presents with pink-red macules and papules on the face and spreads down the body over 24 hours.  The rash begins to fade after 1-2 days in the order of appearance and disappears completely in 2-3 days. 3)   Erythema infectiosum is caused by parvovirus B19 and has confluent reddish and swollen patches on the cheeks, with sparing of the bridge of the nose and areas around the eyes.  These so-called slapped cheeks fade over 1-4 days.  The rash may spread to the trunk, arms and legs and may change to look like a lacy reticular pattern.  This rash may be itchy. 4)   Roseola infantum is caused by HHV-6 and HHV-7 and has non-itchy, rose-pink 2-3mm discrete macules and papules that blanch on pressure and are surrounded by white halos.  The eruption is usually first seen on the trunk and then spreads to the arms and legs. 5)   Chicken pox or shingles is caused by the Varicella zoster virus 6)   Mumps is caused by the mumps virus 7)   Rhinovirus which also causes the common cold can cause rash 8)   Hand-foot-mouth disease caused by Coxsackie virus can cause painful ulcers in the mouth, and the rash in the mouth begins as 2-8mm reddish macules and papules that progress through a short vesicular stage to form a yellow-grey ulcer with a reddish halo. Oral lesions usually resolve in 5-7 days.  The skin rash is characterized by 2-3mm reddish macules or papules with a central gray vesicle that usually appear shortly after oral lesions.  The hands are more commonly involved than the feet. Immunizations have decreased the numbers of measles, mumps and rubella but we still see these infections in the medical clinic. Description:  Usually pink or red rash without a typical pattern. It may have red spots that are slightly raised.  It usually isn’t very itchy. They may be faint pink or more extensive, and usually blanches (goes white) with pressure.  If you place a drinking glass against the rash, you may see it disappear through the glass. Some other symptoms that may be present along with a viral rash include low-grade fever, headache, sore throat, malaise, nausea, diarrhea or joint pain. Treatment:  There is no treatment for a viral rash.  The rash will disappear as the body recovers from the infection. When to get medical help: 1)   The rash does not blanch with pressure 2)   The rash is extremely itchy 3)   The patient is very sick or you are concerned about a serious illness   I hope that you have found this information useful.  Wishing you the best of health,

Related Reading

Measles is the one on this list that stopped being historical. If that is what brought you here, start with the current post rather than this one. Measles Is Back: What Clinicians Need To Watch For When to Use Telemedicine vs. Urgent Care: How I Spot the Sick One Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.