Mystery Illness Seen in Washington State – AFM (Acute Flaccid Myelitis)


Very recently, a handful of patients (8 children) in Washington State have recently been diagnosed with AFM (Acute Flaccid Myelitis) which is a rare condition that affects the central nervous system (spinal cord) and cause weakness in arms/legs, and possibly facial droop/weakness, difficulty with moving they eyes, drooping eyelids and/or difficulty with speech or swallowing. As of September, 2016 – 89 people in 33 states were confirmed to have the rare illness according to the CDC website.

Diagnosis:  If you think you or a family member has this condition, you should seek consultation with a medical provider.  But how do you know if it’s AFM that is causing the symptoms?  A doctor may be able to diagnose AFM by doing a careful examination and sometimes an MRI may also be helpful in assisting in the diagnosis.  An examination of the spinal fluid (which surrounds the brain) may be collected by a spinal tap (lumbar puncture) procedure and may aid in the diagnosis.

There are also nerve tests that can be done which may also aid in the diagnosis however they have to be done at 7-10 days after the onset of the illness.

Causes:  There are a number of viruses which have been though to possibly be the causal agents in the disease including enteroviruses (including polio), West Nile Virus, Japanese Encephalitis, Saint Luis Encephalitis, and various adenoviruses.

AFM is not the only cause of weakness in arms or legs:  Other causes can include viral infections, environmental toxins, genetic disorders, or GBS (Guillain-Barre syndrome).  There are neurological disorders such as stroke (cerebral vascular accident) that can also cause weakness in an arm or leg or facial drooping so it’s important to seem medical attention immediately (call 911) if you or someone you know has these symptoms.

Treatment:  No specific treatment exists for AFM, however a neurologist (nerve specialist) may be consulted to help make recommendations and help with the diagnosis.

If you or your child is having problems walking or standing, or develop sudden weakness in an arm or leg, you should contact a medical provider right away.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


*This information comes from the CDC website About Acute Flaccid Myelitis


Trigger finger – aka Stenosis tenosynovitis



I often have patients who come into the clinic with complaints of a finger that gets stuck in the flexed position and when they try to straighten it, they have pain and the finger “pops” back into a straightened position instead of moving smoothly like usual.  Trigger finger is a form of tenosynovitis which is inflammation of a tendon and it’s protective layers.

Tenosynovitis :  A condition when the tendon  (strong band of tissue that connect the muscle of your hand to your finger bones) and the covering around it get inflamed.  It is most common in the hand and wrist but can occur in the ankle as well.


1)     Repeated use of the hand or wrist – same movement over and over again

2)     Infections – bacteria can spread to the tissues usually underneath the skin where the infection started.

Symptoms:  Pain and/or stiffness in the finger that is usually worse in the morning.  It can also cause a popping, catching or clicking sensation of the finger as it is brought into extension. Sometimes the finger can get locked into a flexed position without being able to straighten it.  Often a small bump at the base of the palmar side of the affected finger is able to be felt.   Sometimes there is swelling of the fingers or hand and trouble grabbing or gripping objects.  It’s most common in the thumb and middle fingers.

Testing:  Usually your doctor can diagnose tenosynovitis by clinical exam but they may decide to do some further testing such as an x-ray, ultrasound, MRI or blood tests especially if there is a history of trauma/injury or infection.

Treatment:  Treatment will depend on the cause however it is often treated with a steroid injection into the area of the affected tendon.  This may reduce the swelling and allow the tendon to move more smoothly.  It may also be treated with surgery or antibiotics if there is an infection.  Often rest is the best treatment along with ice to reduce the swelling to the area.  Putting a cold pack, or bag of frozen vegetables on the swollen area every 4-6 hours for 15 minutes at a time can be helpful.

Ibuprofen or naproxen can also help with the pain and inflammation but are usually not curative.  Finger stretches after the symptoms improve may be helpful to get your fingers back to moving normally.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


Diverticular Disease – Diverticulosis and Diverticulitis


When a patient comes in with abdominal pain or blood in their stool, one of the conditions that we consider is diverticulitis.  You may not have heard about diverticulitis so this will attempt to answer some questions about diverticular disease.

A diverticulum is a small pouch-like structure that sometimes forms in the muscular wall of the colon.  These little pouches often cause no pain and we become aware of them only after having a procedure such as a colonoscopy, flexible sigmoidoscopy, a barium enema or a CT scan.

What is diverticulosis?  Diverticulosis simply means that there are diverticula present.  Most people don’t have any symptoms and will remain free of symptoms throughout their life (about 15-25% of people develop diverticulitis which is more severe.  I usually think about diverticulum as small areas where the colon balloons out. These are potentially weak areas that might become inflamed or may rupture under pressure.

What is diverticulitis?  Diverticulitis is inflammation of a diverticulum that occurs when there is a thinning or breakdown of the wall of the colon.   Diverticulitis is more severe than diverticulosis because now these pouches in the colon have become irritated/inflamed/stretched because of pressure within the colon or due to hard particles of stool that become lodged inside them.  The diverticulum now becomes painful and may rupture (meaning the wall of the colon may break down and cause stool and bacteria to enter the abdomen).   Diverticulitis may also cause bleeding within the colon because there are often blood vessels in the area where diverticulum occur and they can start bleeding when the area gets inflamed.

Symptoms of diverticulitis:  The symptoms really depend on how bad the inflammation inside the colon is.  The most common symptom is pain in the left lower abdominal area.  Sometimes patients may have blood in their stool, nausea, vomiting, constipation, or diarrhea.

Classification of diverticulitis:  Simple diverticulitis is more common and usually responds well to medical treatment without needing surgery.  Complicated diverticulitis (about 25% of the cases) usually require surgery to remove the area of the colon that has become inflamed or ruptured.

Treatment:  There is usually no treatment needed with diverticulosis (diverticulum that are not inflamed are generally not painful and don’t usually cause problems).  Many medical providers however recommend increasing dietary to decrease the chances of becoming constipated.  Constipation can increase the pressure within the colon that can in tern lead to diverticulitis.    Increasing fruits, vegetables, hydration and fiber have not been proven to prevent diverticulitis however.    We used to think that patient with diverticulosis should avoid seeds and nuts because we thought they may increase the risks for patients developing diverticulitis, however research has no proven that to be false.

Diverticulitis is usually treated.  The treatment that you receive for diverticulitis depends on the severity of the symptoms.  Mild abdominal pain caused from diverticulitis can usually be treated at home with a clear liquid diet and oral antibiotics.  If the patient develops a fever greater than 100.1 degrees F, worsening or severe abdominal pain or inability to tolerate fluids then hospital treatment is usually recommended.

Hospitalization:  If you need to be in the hospital for diverticulitis you will usually not be allowed to eat or drink until you start feeling better,  and antibiotics and IV fluids are given.  If you develop an abscess inside the colon then a surgeon may need to help drain the abscess by putting a tube through the abdominal wall.

Complications:  Peritonitis is a generalized infection within the abdomen that occurs if the colon ruptures (the wall of your intestines breaks).  An emergency operation is often required in these cases to remove the area of diseased colon and reconnect the un-affected colon back together.  Sometimes these two procedures are done at separate times (the removal is done first) so that the colon is allowed to heal before reattaching the two pieces together.

Surgical treatment:  Patients who don’t respond well after medical treatment or who have repeat attacks of diverticulitis may benefit from surgery to remove the diseased area of their colon.

Bleeding from diverticulitis:  Most of the time the bleeding stops without needing any procedures but sometimes a colonoscopy or other procedures may be necessary to get the bleeding under control.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


Epidermal Inclusion Cysts


Photo credit:

Patients will often come into the urgent care with a small skin lump that has become red and/or painful.  Often if they think back, they might recall feeling a small nodule under the skin in that same area perhaps months or years before it became swollen and red.  The epidermal inclusion cyst is one of the most common skin cysts and can occur anywhere on the body but they are more common on the face or upper body. Most of the time, these cysts do not cause any problems, but can sometimes be cosmetically unpleasing.

Other names for epidermal cysts:

1)   Epidermoid cyst

2)   Sebaceous cyst

3)   Keratin cyst

4)   Epidermal inclusion cyst

5)   Infundibular cyst

Appearance:  Epidermal cysts have a cyst wall that is make of skin cells of the outside layer of the skin called the epidermis.  The cyst wall is like a balloon that goes down into the second layer of skin called the dermis.  The cyst wall/balloon makes a protein found in the skin/nails called keratin that is usually white, cheesy or firm in consistency.   It is often foul smelling as well.

Cyst Rupture:  If the cyst wall ruptures underneath the skin (usually due to trauma or bumping the area unintentionally), the keratin (cheesy white material) comes out and is exposed to the surrounding tissues and is very irritating.  It can make the skin become red, swollen and painful.  It’s best to see your doctor instead of trying to “pop” or drain the cyst yourself.  Sometimes your doctor may recommend treating you with an oral antibiotic before opening the cyst if he/she thinks that the cyst has become infected.

How epidermal cysts are removed:  If the cyst needs to be removed, your doctor will try to remove the entire cyst including the cyst wall.  Remember, the cyst wall is what makes the keratin (that cheesy white material inside the cyst).   If the cyst wall is allowed to remain underneath the surface of your skin, it may start making more keratin which can cause the cyst to come back.

Usually we make an incision over the cyst and separate the underlying skin from the cyst wall and try to remove it in one piece.  If the cyst has ruptured (which is most likely brought the patient in), the cyst is removed in a piecemeal fashion with an attempt to get all of the keratin, and cyst wall out.  The doctor may irrigate the  wound with sterile solution after the procedure.  The skin is usually left open and not stitched.  The doctor may place a small piece of packing gauze under the skin where the cyst was and then put a bandage over it.  This will allow the wound to drain while it’s healing.  The wound is usually examined by a medical provider every 2-3 days to check on the healing process and part or all of the packing gauze will usually be removed.

The reason that your medical provider may put some sterile gauze inside the wound and ask you to come back to be reexamined instead of just putting some stitches over the wound is because sometimes these areas can be infected with bacteria and if the skin is closed right away with sutures, the bacteria will have a small pocket under the skin to grow and form an abscess.  If the wound is allowed to heal from the inside out, there is less chance of an abscess forming and wound healing can happen more quickly.

When to have a cyst removed:  If it’s small and doesn’t hurt and isn’t painful/red/swollen, it probably doesn’t need to be removed.  I might recommend removing a cyst if:

1)   It keeps getting red and irritated or infected

2)   It’s getting larger quickly

3)   It’s in a place that rubs against your clothes or jewelry and gets irritated

4)   If it becomes red, inflamed or painful

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


Seborrheic Dermatitis – Dandruff, Cradle Cap and Adult Seborrhea










Photo credit:

Photo credit:

Photo credit:


Seborrheic dermatitis is a common skin condition that occurs in infants and adults and can cause redness, greasy scales, skin flaking along the eyebrows and itching.  It is one of the most common skin conditions that I see as an urgent care physician.

Seborrheic dermatitis (also called seborrhea) is an inflammation of the skin that usually occurs in areas that have an abundance of oil glands such as on the scalp, face, around the eyes, ears, neck, and even the diaper area.  In men, it’s more common in areas where there is hair on the face.  Infants often have seborrhea on their scalp that is known as cradle cap.  A mild form of seborrhea is known as dandruff and that is when it is confined to the scalp in children or adults.  Some symptoms may be:

1)   Skin scales – white or yellow and usually oily/greasy

2)   Itching

3)   Mild redness

4)   Skin lesions or plaques

The exact cause of seborrheic dermatitis is unknown but there is some evidence that it seems to flair up in times of stress, hormonal changes or during particular seasons (ie. During extreme cold or warm weather).  It is more common in those people with weakened immune systems, in people who have oily skin, or certain neurological conditions such as Parkinson’s Disease.

Diagnosis:  Your healthcare provider is usually able to diagnose seborrheic dermatitis by examining you and taking a history.  A biopsy (sample of skin that is surgically removed and sent to a doctor to examine under a microscope) is rarely needed.

Treatment:  Usually tailored toward the individual patient and what part of the body is affected.  Some possible treatments include:

1)   Medicated shampoos such as Neutrogena T-Gel or T-Sal, Head and Shoulders or Nizoral are commonly prescribed.   These shampoos usually contain Salicylic acid, Coal Tar, Zinc, Selenium Sulfide, Ketoconazole, or Resorcin.  Even if you do not have dandruff, these shampoos may be used on the face and/or other body areas and usually work best if they are left in place for 5-10 minutes before rinsing.

2)   Topical Steroid creams, lotions, foams or shampoos:  Low, medium or even high potency steroid creams are sometimes prescribed to help decrease the inflammation depending on the severity and where the rash is. Usually the lower potency creams are used on the face (such as Desonide 0.05% lotion).

3)   Antibacterial creams:  Sometimes topical antibacterials such as Sodium Sulfacetamide with sulfur are prescribed.

4)   Antifungal creams:  Ketoconazle 2% cream, and Ciclopirox 1% creams are commonly used.

5)   Other anti-inflammatory medications such as pimecrolimus cream or tacrolimus ointment are sometimes prescribed for use on facial seborrhea.

6)   Dermatologists sometimes recommend a compound or mixture of a combination of a steroid cream along with an anti-fungal or antibacterial agent.

Cure:  Unfortunately there is no cure for seborrheic dermatitis. It is a chronic life-long condition. It may go away for months or years and then return (relapse).  We usually focus on controlling seborrhea often by using a combination of the strategies for treatment listed above along with decreasing known triggers such as emotional stress, extreme cold temperatures and decreasing body weight.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


Rectal Bleeding – A discussion about possible causes











Photo credit:

Photo credit:

One of the more common problems that bring patients into the doctor believe it or not is seeing blood in the toilet, on the stool or on the toilet paper after having a bowl movement.  Since I’ve had a few patients recently who have come in because of this problem, I thought I’d discuss some possible causes.

Healthcare providers take this issue seriously because sometimes blood noticed after having a bowl movement can be a sign of colon or rectal cancer.  Fortunately, most of the time the causes of rectal bleeding is not cancer however.

Causes of rectal bleeding:

1)  Hemorrhoids:  Swollen blood vessels can occur in the rectum or anus and cause itching and/or pain and can sometimes bleed.  Usually hemorrhoids produce a blood that is described by patients as being a “bright red color.”  It may sometimes coat the surface of the stool or may drip into the toilet and turn the water red or be noticed on the toilet paper.  Hemorrhoids do not have to be painful – in fact painless rectal bleeding at the time of having a bowl movement is common in hemorrhoids.

2)  Anal Fissure:  If the lining of the anus has a tear, it can cause bleeding and sometimes there may be pain with having a bowl movement.

3)  Other causes such as infection, colitis (which could be due to an auto immune disease such as ulcerative colitis or Crohn’s disease), colon polyps or colon cancer can also cause bleeding.  If the bleeding comes from higher in the digestive system such as in or above the stomach, the blood may look dark black or have a tarry appearance.

Diagnosis/Testing:  In order to find out the cause of the bloody stools, your healthcare provider may perform some tests or refer you to a specialist to help determine the cause.  They will take into account the information you provide, your past history and symptoms as well as your age.

1)   Rectal exam:  Your healthcare provider will usually examine the rectum and look for a source of bleeding such as a hemorrhoid or anal fissure.  This may also include a digital rectal exam (where to doctor inserts a gloved and lubricated finger into the rectum to feel for possible rectal cancers).

2)  Anoscopy:  Your doctor may use a small plastic device with an attached light to get a better look for the source of bleeding.  Most of the time this is not painful (although perhaps a bit uncomfortable) and can be done in the office.

3)  Sigmoidoscopy:  This is a procedure that is usually done in an outpatient treatment center and the patient is usually not sedated.  There are rigid or flexible sigmoidoscopes.  Usually a flexible sigmoidoscope is used.  A flexible tube (it is approximately 70cm long and 1cm wide) with a tiny video camera and a light is inserted into the anus and gently into the colon while air is inserted into the colon to enlarge the area and help the doctor get a better view.  Often a biopsy (small sample of colon tissue) is taken with the use of a tiny biopsy tool.  The sigmoidoscopy allows visualization of the anus, rectum, sigmoid colon and top of the descending colon.  It does not allow visualization of the entire colon so it may miss seeing cancers, polyps or sources of bleeding in some areas.

4)  Colonoscopy:  This procedure is similar to the sigmoidoscopy but allows the doctor to examine the entire colon using a longer flexible tube. The Colonoscope (about 140cm in length) is able to reach the areas seen by the sigmoidoscope and also allows visualization of the transverse colon, ascending colon and cecum.  The patient is usually sedated during this procedure.

When to seek help:  It is impossible to know the cause of rectal bleeding without an examination, therefore everyone who has rectal bleeding should talk to their healthcare provider to help determine the cause and what examination is needed.  Even though there are common causes of rectal bleeding that are not cancerous, bleeding can be caused by cancer or precancerous conditions.

Precancerous polyps may be present in the colon for years before they become cancerous and may be removed safely from the colon, preventing them from becoming cancer.  These polyps may cause symptoms which are very similar to an innocent hemorrhoid.

I’ve met patients who have ignored rectal bleeding for years because they thought it was because they had a hemorrhoid and it turned out to be cancer.  With increased age comes an increased risk for polyps and colon cancer .

Colon Cancer Screening:  For patients who is at average risk, colon cancer screening is started by checking the stool for small amounts of blood (which may be hidden) each year starting at age 50.  It is also recommended to have your first colonoscopy at age 50 (unless you have other risk factors for colon cancer) and every 10 years thereafter unless you are at increased risk based on your family history or a previous diagnosis or biopsy result.

People at increased or high risk:

If you are at an increased or high risk of colorectal cancer, you should begin colorectal cancer screening before age 50 and/or be screened more often. The following conditions make your risk higher than average:

1)  A personal history of colorectal cancer or adenomatous polyps

2)  A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s)

3)  A strong family history of colorectal cancer or polyps

4)  A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


What is a Pressure Ulcer (AKA Pressure sore)?

shutterstock_89421025bed-soresPhoto credit:

A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months.  He’s diabetic and has lost feeling in the bottom of his feet.  He’s had these pressure sores in the past but has trouble getting them to heal up.

Pressure sore:  Areas of skin that have been damaged by pressure such as sitting or lying in one position for a very long period of time.  They can also be called “bedsores.”  The are more commonly found in areas of the body where the bone is near the surface of the skin such as on the hips, elbows, ankles and back/buttocks. The skin and soft tissues become damaged because not enough oxygenated blood can get to the area to promote healing usually due to the compression of the damaged skin and soft against hard bone tissue.

Appearance:  The sores change in the way they look depending on how long they’ve been present and how much damage has been done.  In the beginning, the sore appears as a small red patch of skin, and if not treated, the skin will break down and cause a hole or crater to form (we call this an ulcer).

Stage 1:  The skin is intact without ulcers but when you push on the skin it does not change colors to indicate good blood flow.  Usually, healthy tissue will be pink and when you push on the area with your finger you can notice it will become less pink and in a couple seconds the pinkness will return.  This does not happen in the damaged skin at this stage – it may have a darkly pigmented color.

Stage 2:  There is an open, shallow ulcer with a red-pink color at the base of the wound.  Sometimes there may be blisters present which are either intact or ruptured.

Stage 3:  Structures beneath the skin such as fat may be exposed but at this stage, you should not see bone, tendons or muscle tissue.

Stage 4:  Structures beneath this skin including bone, tendon and muscle may be seen in the bottom part of the ulcer

People at Risk:  Some patients are more at risk than others of getting pressure sores.

1)   Patients who cannot move very well because they have a medical problem.  These people may sit or lay in one position for a long time.  They need help to move to a different position so that the skin doesn’t form sores.

2)   Older people are more prone to pressure sores because they often don’t move around as much and their skin is more fragile and thinner than a younger person.

3)   Patients who have diabetes or nerve problems in their feet may not feel when a small pebble or area gets into their shoe or pressure pushes on the foot causing injury.

4)   Patients in the hospital or nursing home are at especially high risk for many of the factors noted above – increased age, decreased mobility, and other complicated medical problems.

Prevention:  Some things can be done to lower the chances of getting pressure sores

1)   Repositioning the patient’s body every two hours so that they are not lying on one area where the skin is being crushed, pinched or pressure is building

2)   Putting pillows between the ankles and knees to decrease the pressure on the skin over these boney areas

3)   Raising the head of the bed when the patient is lying on their side to decrease the pressure on the hip bone

4)   Getting special foam or soft mattresses that decrease the pressure on the areas of the body that have the most pressure on them

For patients in wheelchairs:

1)   Use a special cushioned seat if possible to prevent pressure on the sacrum

2)   Every hour tilt forward or to the side to release pressure on the seat

3)   If ankles or heels press on the chair, use foam padding to protect against sores

4)   Check skin regularly for signs of pressure or ulcers

Treatment:  Pressure sores are treated differently depending on the stage of ulceration and how severe the damage to the skin is.

1)   If there is mild erythema, the treatment is generally off-loading the area but decreasing the amount of time that this area is compressed by body re-positioning, and/or using pillows to cushion the area.  We also use transparent films over the ulcers to protect the areas.

2)   In patients who have diabetes, adequately managing blood sugars to keep them under good control is very important.  Elevated blood sugars impede wound healing.

3)   If there is dead or dying skin or soft tissues, this often needs to be removed to help prevent infection.

4)   Special bandages may be needed to keep the healing tissue moist but prevent tissue maceration (from being too moist). Sometimes the dressings that we use to treat wounds can be very expensive.

5)   Antibiotics may be prescribed if there is a wound infection

6)   Medication for pain may also be prescribed

There are some tools to score the pressure and grade the healing process.  These are helpful for patients who come back for repeat visits to wound care clinic or their primary care provider and there is a need to grade the healing by giving them a score.  Some clinical features that are examined include:

1)   Amount of Exudate

2)   Skin color surrounding the wound

3)   Peripheral tissue swelling

4)   Peripheral tissue firmness around the wound

5)   Amount of granulation (healing) tissue

6)   How much epithilization is present

It’s important to optimize the nutritional status of patients with wounds.  Particularly for patients who have Stage 3 and 4 ulcers, they need enough protein and calories to help heal these wounds.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO