Hello Reno Families!

This is Leslie Greenberg.  I am a family physician in Reno, Nevada.  I attended University of Nevada School of Medicine and relocated back to my hometown in 2015.  I trained and practiced medicine in the Midwest (Indiana and Kansas) for 20 years before moving back West.  I consider myself a teacher and educator.  I  have  taught family medicine residents for 20 years.  I currently teach at the family medicine residency program in Reno and also see private patients.  I invite you to read my blog.  If you would like to become a patient, please call 775-682-8200.

Medical Disclaimer

Please remember that medical information provided by myself, in the absence of a visit with a health care professional, must be considered an educational service only.  This blog should not be relied upon as a medical judgement and does not replace a physician’s independent judgement about the appropriateness or risks of a procedure or condition for a given patient.  I will do my best to provide you with information that may help you make your own health care decisions.

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Abnormal cholesterol labs. What to do with elevated triglycerides?

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You see your physician and get a routine cholesterol panel.  The results show that your triglycerides are high.  What should you do?

Fasting lab work should show that your triglycerides should be less than 150. When triglycerides are higher than 150, it increases your risk of cardiovascular (CV) disease. If the levels are severely elevated (500 mg per dL or higher) add the risk of pancreatitis to the risk of CV disease.

What are risk factors for high triglycerides?

  • Metabolic syndrome
  • Type 2 diabetes
  • Obesity

What should you do if your triglycerides are between 150-500.  We suggest “lifestyle modification” as this decreases the 3 risk factors contributing to high triglycerides.  Sometimes I have patients list off to me what they are currently doing… and yet your body needs more healthful changes than you are currently doing.  This means that what you are currently doing is not enough to maintain good triglycerides and decrease your risk long-term of cardiovascular issues.  Decrease intake of carbohydrates, especially refined carbohydrates and increase physical activity.  Aim to have 30 minutes a day of moderate-to-high intensity physical activity.  Increase omega-3 fatty acid intake and increase protein intake.  These lifestyle changes will help improve exercise capacity and overall health. 

If your ASCVD risk (the risk of having a cardiovascular event in 10 years) is borderline or intermediate, then you and your physician can consider starting on a statin drug.  Here is an ASCVD risk calculator.

If you continue to have elevated triglycerides despite lifestyle changes and statins, high-dose icosapent, fibrates, omega-3 fatty acids or niacin can be considered. 

If you are admitted to the hospital with acute pancreatitis from hypertriglyceridemia, your physician may start an insulin infusion or do plasmapheresis.  The goal is to head this off at the pass. 

I hope this helps.

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Long covid or “post-acute sequelae of SARS-CoV-2

Oh my! Patients who have had the covid infection are often finding that they do not “bounce back” fast. In fact, a significant number of covid patients have lingering side effects

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The World Health Organization report found that up to 10% with COVID-19 still have symptoms 12 weeks (!) later.

  • What are the symptoms?
    • Excessive fatigue
    • Cough
    • Chest pain
    • Shortness of breath
    • Brain fogginess with difficulty concentrating and with memory

The persistence of these symptoms may lead people to leave their jobs and it is known that prolonged absence from a person’s workplace is detrimental to physical, social, mental and financial well-being.

Ask your physician if she can write for appropriate workplace accommodations and adjustments.  Maybe your job or work environment can be tweaked for a few weeks to help your symptoms improve. 

Primary care physicians and occupational medicine physicians can help advise human resources or management leaders on return-to-work strategies.

The long-term health effects from SARS-CoV-2 infection are unknown.  Ask your physician for help.

Better yet, if you are unvaccinated, get vaccinated.  The vaccine greatly decreases your risk of contracting covid-19 and thereby decreasing your chance of long covid. 

Take care of yourself.

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Acne treatment for teens

Being a teenager is difficult enough… even without acne. Acne treatments for teens are available over the counter and from the pharmacy. Here is my overall treatment plan with ingredients that can all be bought over the counter.

I want a treatment that the teen can do. This means it should not be expensive and should be able to be incorporated into their overall skin care regimen. Easy and inexpensive; that’s my plan.

Depending on your acne (is it whiteheads? blackheads? cystic? scarring?) your treatment may need to be individualized. The following acne treatment for teens is a good place to start.

What are you doing now for your skin? Is it working? Are you diligent and do it daily? What has worked in the past? Are you a female and acne is worse before your menstrual period? If so, oral contraceptives may help your skin greatly. See your physician for contraceptive prescription.

Back to your skin, the facial skin does not like to be roughed up. So, I urge patients to start with washing morning and night with a facial cleanser. Inexpensive ones are Dove, Basis, or Cetaphil. Then, pat the face dry. No roughing it up with a buff-puff or abrasive sponge.

Benzoyl peroxide (BP) is available over the counter in 2.5%, 5%, and 10%. The stronger it is the more likely your skin will turn red, dry, and scaly before it becomes accustomed to it. BP helps kill the bacteria on your skin that causes acne. BP also helps your skin not become resistant to other topical medications for acne. BP can bleach your hair, clothing, towels, and bedding: so be aware of that. Often skin is sensitive to BP (and gets red, dry, and scaly), so consider using it every other day or every third day for a few weeks, until your skin is used to it and then you can increase the frequency to every day.

A topical retinoic acid derivative, adapalene, is also available over the counter. This can be used nightly (after your face is washed and patted dry). I suggest you use adapalene every other night and BP the nights you do not use adapalene.

Acne treatment for teens is great, but also it is important to wear sunscreen. Acne treatments can make the face more sensitive to light and more likely to burn. Pick a noncomedogenic sunscreen that is meant for the face. Neutrogena and Eucerin make a facial sunscreen that feels and smells good (and is also available without a prescription!).

Your teenager may be seeing acne advertisements. Most of these contain the ingredients above, but in a much more expensive format.

As always, see your physician for more individualized skin care help. Most primary care physicians can easily take care of acne. There are 1000 ways to help acne, this is just my routine first step: easy and inexpensive.

I hope this helps.

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Contraception decreases unwanted pregnancies. Get your birth control under control.

Watch this short, compelling video by a fellow physician…

-what are your contraceptive choices?

-how to ask your physician for what you need?

-Will your insurance pay for a year of birth control at a time?

-What are options of emergency contraception?

-Recent legal setbacks of Roe v Wade

-How to get involved…

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Should you have a carotid artery ultrasound?

Should you have a carotid artery ultrasound?

Some concierge physicians offer carotid artery ultrasound with their “executive physical.”  This is NOT a suggested test for most patients.  The general adult population should NOT get a carotid ultrasound to rule out carotid artery stenosis.

Do not screen for carotid artery stenosis.  The *USPSTF found that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. Insignificant problems can be found that did not need to be found and then procedures (that have risk) may be done on patients who do not benefit from them. Just because a test is available does not mean that you should have it.

Who should get a carotid artery ultrasound?  Patients with neurological signs of symptoms from possible carotid artery stenosis or patients with history of transient ischemic attacks (TIA) or strokes.

What would you do if you had carotid artery stenosis?  Possibly surgery called carotid endarterectomy (reaming out the artery).  Less invasive interventions are to start on statin medication, antiplatelet medications, manage hypertension and diabetes, and lifestyle modifications. 

*The USPSTF (US Preventive Services Task Force) is an organization that researches what testing has been shown to have benefit, is neutral, and which causes harm.

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Should you get a carotid artery ultrasound?

Should you have a carotid artery ultrasound?

Some concierge physicians offer carotid artery ultrasound with their “executive physical.”  This is not a suggested test for most patients.  The general adult population should NOT get a carotid ultrasound to rule out carotid artery stenosis.

Do not screen for carotid artery stenosis.  The *USPSTF found that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. 

Who should get a carotid artery ultrasound?  Patients with neurological signs of symptoms from possible carotid artery stenosis or patients with history of transient ischemic attacks (TIA) or strokes.

What would you do if you had carotid artery stenosis?  Possibly surgery called carotid endarterectomy (like reaming out the artery).  Start on statins, antiplatelet medications, manage hypertension and diabetes, and lifestyle modifications. 

*The USPSTF (US Preventive Services Task Force) is an organization that researches what testing has been shown to have benefit, is neutral, and which causes harm.

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Hypothyroidism. What is it? Why is it important?

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Hypothyroidism is when the thyroid gland produces inadequate thyroid hormone production. 

Why is this important?  I consider the thyroid the gas pedal of the body.  The body needs get-up-and-go to function well.

How prevalent is hypothyroidism?  It affects one in 300 people in the US.

Who is at risk for hypothyroidism?  Women (7 times more than men), those with autoimmune issues, and older patients

What are the symptoms? Fatigue. Weight gain. Constipation. Dry skin. Intolerance to cold. Voice changes.

Should you be screened for hypothyroidism?  If you feel fine, the guidelines are to NOT to check thyroid labs. 

What happens to hypothyroid pregnant patients?  Women who are pregnant need to have their thyroid labs checked.  Pregnant women often need their weekly dosage increased by 30%.

How to replace thyroid hormones?  It’s easy!  Take a pill daily.  It is best to take the pill on an empty stomach and no food within 30 minutes of medication ingestion.

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Do you have painful intercourse?

Burning Man 2020

Dyspareunia is the medical word for persistent or recurrent pain with sexual intercourse.  This affects 10 to 20% of American women.  Dyspareunia can be deep or superficial.  Sexual pain can cause relationship distress, decreased quality of life, anxiety and depression. 

What are the risk factors for dyspareunia? 

  • younger age
  • white race
  • lower socioeconomic status
  • just had a baby
  • perimenopausal
  • postmenopausal
  • depression
  • anxiety
  • low sexual satisfaction
  • history of sexual abuse
  • irritable bowel
  • fibromyalgia

What will your doctor do?  She will take a thorough history.  When did it start? What makes it worse? Is the pain superficial or deep? What has helped in the past?  A physical exam should be done to visually examine the external genitalia and to perform an internal vaginal exam.  Expect to show your physician where the pain occurs.

What are common reasons of sexual pain?  Inadequate lubrication, vaginal atrophy, pelvic floor dysfunction, vaginismus (spasms of the vaginal walls), endometriosis, or vulvodynia. 

What is vulvodynia?  This is chronic genital pain lasting at least 3 months.  Pain can be triggered by touch like when inserting a tampon or attempting sexual intercourse or it can be unprovoked.  This can have generalized pain or localized.  The pain may feel like burning, aching, tearing or stabbing. 

What is vaginismus?  Vaginismus is an involuntary contraction of the pelvic floor muscles with attempted vaginal penetration.  This often leads to fear or anxiety about penetration causing more pelvic floor constriction.  Some patients have incidents before the pain such as traumatic sexual experiences or medical conditions and some have no antecedent risk factors. 

What can you do about sexual pain?  Make a log of the associated symptoms with sexual pain.  See your physician. Be prepared to discuss frankly about your condition and to have a physical exam.  Multidisciplinary treatment of this condition may include psychotherapy, sexual therapy, cognitive behavior therapy, vaginal lubricants, sequential vaginal dilators, or botox injections.

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Irritable Bowel Syndrome: What should you know?

Irritable Bowel Syndrome: What should you know?

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What is it?  Irritable bowel syndrome (IBS) is a varied group of gastrointestinal conditions that is not fully understood.

What causes IBS?  Psychological factors do not cause IBS.  But IBS can make anxiety or depression worse.  Many with IBS have anxiety related to the unpredictability of gastrointestinal symptoms and their IBS may negatively affect their life.

What are the symptoms of irritable bowel?

              Recurrent abdominal pain for more than 6 months, occurring at least 1 day per week with 2 or more of the following symptoms

              Pain better or worse with defecation

              Change in stool frequency

              Abnormal stool frequency (more than 3 times/day or less than 3 times/week)

               Abnormal stool form (hard or loose and watery)

               Mucus with stool

               Abdominal bloating

                Abdominal distention

What is needed to diagnose IBS? 

Patients should not have alarm symptoms: blood in stool, abdominal mass, jaundice, enlarged lymph nodes, rectal pain, vomiting, or weight loss, or night sweats. 

Your physician may order labwork: CBC, thyroid labs, celiac serology, C-reactive protein or fecal calprotectin.  Testing for pathogens in the stool may also be done to rule out infectious diarrhea. 

You may be referred to a gastroenterologist for a colonoscopy.  Colonoscopy is NOT NEEDED to diagnose irritable bowel syndrome. Biopsies may be taken to rule out inflammatory bowel disease (Crohn’s or ulcerative colitis).

What is the treatment for IBS? 

There is no definitive treatment for IBS.  Treatment focuses on relieving symptoms (constipation or diarrhea) and making patient’s quality of life better.  Healthy eating with more fiber and probiotics may help.  Loperamide (Imodium) may firm up loose stools.  For those with constipation, there are many treatments: fiber, Miralax, lactulose, Dulcolax, senna.   There are also prescription medicines available from the pharmacist for constipation-predominant IBS.

I hope this helps.

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Can you afford your medications?

One of the reasons that patients do not fill their prescriptions are due to increasing medication costs. 

I have begun asking my patients “Is the cost of any of your medications a burden for you?”  This fast screening question at the time of your visit helps greatly.  Physicians or medical assistants should review the medicines you currently take.

What can you do?

  1. Have your physician review your medications
  2. Do you still need to take the medication?
  3. Can you change to a less expensive medication or a generic version?
  4. Consider using a 90-day prescription to reduce copayments.  As an aside, this may also increase ease of use in that having medications at the house is easier than going to the pharmacy every month.
  5. Look up the medicine online to find the name of the manufacturer.  Then, see if there is a discount program with the pharmaceutical manufacturer for that medicine.  At times these discount programs are easy to complete and some require your tax return from the year before.
  6. Look online to see if your medication is available at a large chain pharmacy on their “$4/month list.” 
  7. Use websites and apps such as singlecare.com or goodrx.com that provide comparative costs between pharmacies and coupons for prescription medications
  8. Consider cutting a stronger medication in ½ (to get the desired strength).
  9. Does your physician’s office have a social worker to help navigate these issues?

At our family medicine residency office, we have a social worker who helps patients who need more intensive support (such as navigating insurance plans, determining eligibility for additional insurance coverage, and applying for pharmaceutical medication assistance programs).  

I hope this helps.

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