Kauai – Hawaii Photo Journal

These are a few random photos from Kauai.  It’s one of my favorite places!

 

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Oahu Hawaii Photo Journal

These photos are from various locations around the island of Oahu.  Some are aerial shots and some are taken from land.

 

Trigger finger – aka Stenosis tenosynovitis

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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.

Causes:

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

Blog: https://doctorrennie.wordpress.com

Diverticular Disease – Diverticulosis and Diverticulitis

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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

Blog: https://doctorrennie.wordpress.com

Epidermal Inclusion Cysts

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Photo credit: http://en.wikipedia.org/wiki/Sebaceous_cyst

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

Blog: https://doctorrennie.wordpress.com