Sunday, September 25, 2011

Cannot go to the bathroom.

Hello doctors. This is all new to me, but my daughter showed me how to set this blog question up. She told me about this spot and I think it is very neat that you provide this service.

Anyway, I am 67years, a man and I have been having increasing problems with having regular bowel movements. I feel completely stuffed up after eating a little bit of food at a meal. So I am not eating a whole lot. I think I eat a variety of foods. I enjoy vegetables and I drink a good bit of water.

I don't have any medical problems except for some high blood pressure, and that is controlled with Diovan. I have some allergy issues in the spring and a little in the fall. My doctor tells me that my cholesterol is good. My weight is ok I think. Otherwise, everything is just fine.

I have tried a few things to help. All of the old people are using Metamucil on tv. So I tried that. It helped a little. I tried some exlax but that made me hurt a little bit and i do not want to get hooked on that stuff.

I'm not sure what else to do even though there is a lot of stuff out there. Any tips?

Bob, Michigan.

DOC2 Here:

Bob I apologize for getting to your question today after posting it yesterday. I was kidnapped by a cadre of children who share my last name yesterday for a trip. So, here are my comments.

Constipation can be a terribly uncomfortable problem. It is well recognized that the likelihood of constipation increases over time as we get older, but let's set that aside because we have yet to discover the fountain of youth and couldn't do anything about that. (Of course there are people who say on the internet that they HAVE found the fountain of youth, but I think that they may be telling a fib.)

The mechanics of the GI tract are dependent on several factors: lubrication ("gastric juices"), mechanical movement ( spurred by vascular, muscular and nervous system involvement), some substances to go through it (food products), and good absorption of nutrients in the proper areas of the gut just to name a few.

You must be drinking enough water and not caffeinated products. (Some people say that coffee makes them have a bowel movement. This may be true, but it's not the caffeine that spurs it on.) Generally liquids spur movement. Another thing that spurs movement is regular food intake. Skipping meals is a no-no. Eating fibrous foods is important. Vegetables are important. Metamucil or other "fiber laxatives" are stand-ins for vegetables, but they are not the best. The payback is that fibrous foods tend to be gas-formers also. So, don't go overboard. CHEWING your food is important. This is especially important with foods that don't normally absorb very well (such as beef or pork products). What you want to think about when you eat with regard to constipation is "How can I help my gut turn this food into a paste?" I know, sounds far-fetched but it's true.

Physical activity is also an important part of keeping regularity.

I am going to shorten this post by pointing you to an excellent website on constipation. The URL is

This site is EXHAUSTIVE but easily understandable. Any lay person can walk away from the computer after looking at this site and know almost everything that they need to know about constipation.

I hope that this helps. Shoot me back a comment if you have any further questions, and I will help you sort through it.

Have a "regular" day!!

Saturday, September 24, 2011

Hydrogen Peroxide

Hey Docs,

I have a cut I got on my hand and it was on a fishing trip and I have been treating it with hydrogen peroxide for ten days now but it still seems red and won't close over. Is it infected? What should I do? I do not have any other medical problems.


Hello and thanks for your question. Doc1 here. Wound care. Simple. Really, it is, but with the MRSA ("flesh eating bacteria") and the Listeria outbreaks everyone is all about antiseptics and hand washing and wound cleansing and in this particular case you are a victim of some overzealous wound care. 

First of all, take a look at this link HERE, as you can see, after that initial use of Hydrogen Peroxide (H2O2) you are actually preventing healing of the wound because it is toxic to the new skin cells forming to heal the wound. It kills the bacteria, it kills the good cells. Use it once on initial injury then put it aside. 

Second of all, if your tetanus booster is not up to date (within ten years) then you need to get one. 

Third of all, and this is for other readers more than you... Notice what else is mentioned in the link..... The recommendation of wound cleansing with tap water. This is what we do in the ER too for all but the most contaminated and complex wounds.... Yes, I'm talking about wounds that we are going to suture (sew).... The key is irrigation under pressure and the method is to use a large syringe with an 18 gauge splash guard or similar and to really blast out the laceration. 

This is the key to decontaminating superficial wounds, NOT soaking in betadine, NOT scrubbing, and not Hydrogen Peroxide (though mixed with water it IS great to dissolve blood clots out of matted hair). 

Hope this helps! Stop the H2O2 and this should heal right up. 


Wednesday, September 21, 2011

Pending Case: Clots and Clots


History: 43y/o Male 6’10”, 400lbs. (yes I am a big boy). BP 130ish/70ish, Last fasting glucose 94, total cholesterol around 180. On 120 mg Cymbalta and 6mg klonopin for panic disorder/agoraphobia/depression. 50mg? Aciphex for GERD and 7.5 mg warfarin for 2 Episodes of DVT’s & PE’s. First episode of PE showed no outward signs of DVT ( I was told a concussion I suffered a few days before the onset of the first episode was unlikely related). Took my Doc three weeks to finally believe me when I told him it felt like blood clots in my lungs. Second episode showed significant swelling in the leg to the degree that it was almost unbendable at the knee. Initial blockage was complete from the ankle to the groin. Last sonogram indicated complete blockage remains except for a small area somewhere in the middle of my leg. Told that DVT was likely caused by low cystine? (not sure of the spelling or the correct name) levels rather than the obesity or the typical Factor V or Leiden. At about 16 months after the last DVT the swelling has resolved to a baseline of about 110% - 120% of my unaffected leg. However I do have occasional periods where the swelling is increased. The swelling is intermittent and I have not determined a contributing cause. It just starts to happen. I am not wearing a compression stocking.

Question: In the past year I have had intermittent knee and hip pain in the leg with the repeated DVT. I have had the knee pain off and on since an injury 20 years ago. However, except for long car rides in which I am cramped I have never experienced hip discomfort, let alone pain. While I have read that hip pain generally is felt in the groin, mine is clearly on the side to side/butt area. The pain can be strong enough that I am unable to sleep on that side. I have not yet determined if the period of increased swelling in my leg matches up with the bouts of pain. Could this pain be related to the continued blockage and swelling? Or is it more likely my fat ass or even less likely, my age? One last possible clue. When I swim, as you may have guessed I am very buoyant, so I have virtually no weight on the hip. Yet the pain remains.

DOC2 here:
Yes, you are a big fellow, and at an age greater than 40 you certainly can have some joint problems without the added "benefit" of a DVT or the resulting swelling.

Let's run through the list of contributing problems:
1. Old injury
2. DVT
3. Lower extremity swelling due to the DVT
4. Obesity

You have a confluence of baddies that can impact that hip.

My best answer is that it's not necessarily a hip joint issue (although it certainly COULD be early arthritis of the joint). If you can point to a specific spot almost at the midline on the side of the hip, I would say that you most likely have a bursitis. A bursa is a thickened, fluid-filled sack that lies under tendons to allow for an easier slide of the tendon to reduce friction. When having to take on more stress these sacks can become inflamed, and the more you use the hip the worse it hurts regardless if you are weight-bearing or not. You intermittently take on more weight with the edema (swelling) of the leg than you are used to. (However, you could also argue that you already have more leg than your joint can or should withstand.) This increased stress can cause the bursa to become inflamed. Secondarily, the fluid from the swelling can enhance the inflammation. I found this picture on that does a great job of showing you the location of the hip bursae. (By the way, I don't endorse anything on that site. I just wanted to show you the picture.)

Hip anatomy showing the iliopsoas, trochanteric, gluteus medium and ischiogluteal bursae

So, what can you do about it? Resting the leg is important. Ice therapy can help sometimes. Your size is a problem, and you certainly need to lost weight. That's a fix in terms of chronic treatment of course and not an acute treatment, but it will matter a LOT for you now and down the road.

You could use an over-the-counter anti-inflammatory medication such as naproxen or ibuprofen, but I shouldn't have to remind you that using these medications can be problematic for someone on Coumadin (warfarin) for a couple of reasons. First, you could alter the balance of warfarin in your body. Second, these medications can cause esophagitis or gastritis which could cause upper gastrointestinal bleeding in someone who is especially on coumadin. The Aciphex could protect you somewhat, but I wouldn't make a medication move without the recommendation of YOUR doctor.

I hope that this is helpful. If you have any further questions, shoot them back to me. Good luck to you. -DOC2

Sunday, September 18, 2011

Near Syncope Question from Sally

Hello Docs,

I am a female, 49 years old. 5’6”, 150 lbs. I am in good health and exercise regularly. I take Imitrex as needed.

This is something that I have been dealing with for most of my adult life. Occasionally my heart will race. It will start to beat very fast, my vision will dim but not to the point of blacking out though at times I think I will, and all of a sudden I will feel very week. This will sometimes happen after I stand up from bending over to pick something up or if, for example, I sniff suddenly to ward off a runny nose in allergy season. There are also times where I will wake up in the middle of the night with my heart racing.

This has never happened when I do any cardio activity.

What I usually do is sit, if I have been standing, or lie down if possible, then I hold my breath. It seems to work after a few tries. My heart will speed up just a little bit more and then one big heart beat and a pause. Then all is back to normal and I feel fine.

So here is my question – what the hell is it? Is there a test I should take or is this just normal and I live with it?

Thank you in advance for your input and advice.


Dear Sally, 

A few questions before we post your response...

What kind of studies have you had? Holter monitor? Cardiac stress test? An 'event monitor'? Have you seen a cardiologist? Have you ever passed out?


Dear Doc1, 
I have never passed out. I have never been to a cardiologist

When I asked my Doc about this, years ago, he didn’t seem very worried. Said something about Mitral valve prolapse and that I didn’t need to worry. If I wanted tests he would order them. Since he was not worried I was not either.

This only happens to me a few times a year.  I find it more annoying than alarming, but I do wonder if it something I should take more seriously.
Thank you,

Doc1 here. I spoke with my colleagues on the blog about your case and will start with my thoughts. I know they have some specific ideas in addition to mine...

I really would want you to get set up with a holter monitor or event monitor. The possibility that you could have SVT or PSVT is first and foremost on my mind. Impossible to diagnose by history alone, you need to get it on an EKG or a monitor strip and a Holter or Event Monitor might be the only way to do this in your case. 

As you can see from this link to a very good Mayo Clinic bit on tachydardia (rapid heart rate), symptoms such as you describe are the result of most of the tachy-dysrhythmias. 

And then there's this, a quote from the same article...

Stopping a fast heart rate
A fast heartbeat may correct itself, and you may be able to slow your heart rate using simple physical movements. However, you may need medication or other medical treatment to slow down your heartbeat. Ways to slow your heartbeat include:
  • Vagal maneuvers. Your doctor may ask you to perform an action, called a vagal maneuver, during an episode of a fast heartbeat. Vagal maneuvers affect the vagus nerve, which helps regulate your heartbeat. The maneuvers include coughing, bearing down as if you're having a bowel movement, and putting an icepack on your face.
The particularly interesting thing in your case is that a form of vagal maneuver seems to sometimes initiate AND abort your symptoms. I think a visit with a cardiologist is in order. If you have Mitral Valve Prolapse then an echocardiogram will tell us and the cardiologsit can then make a decision about whether to pursue monitoring to detect a possible SVT or PSVT problem. I'm going to let my colleagues in at this point.
Be Well


DOC2 said...
DOC2 here. The other interesting thing is that your trigger seems to come from a change in posture. In other words, you bend down and then stand. Sniffing as a trigger is interesting as well. You have what seems to be a "dysautonomia" or a disorder that causes you to have an excessive response to this postural change. It is normal to have an increase in heart rate due to (usually) a low blood pressure that follows the straightening of the body from a bent or stooped position to a standing position. The normal response is that the elevated heart rate happens until the blood pressure equilibrates enough to perfuse the brain and then its rate comes back down to normal. It sounds to me that you have POTS (postural tachycardia syndrome). This is a WIDE topic that covers a range of symptoms and signs. Sometimes it is exhibited by an accelerated heart rate and a change in blood pressure, sometimes not. Sometimes it causes dizziness, sometimes not. Because it also encompasses an abnormal response in the tone of the blood vessels (which help control blood pressure), my thought is that your propensity to have migraines and the symptoms that you have described above are closely linked . If you came into my office, here's what I would do. First, a simple EKG. Would probably be normal, but possibly not. If not, I would send you to a cardiologist. If normal, I would recommend that you have a Holter monitor placed (which is an EKG that you wear around while you do your daily activities). If you're symptomatic around your period, I would try to time it about the same time (assuming that you may be still having a menstrual cycle) or ask you to consider mimicking the events that seem to cause the problem to see if it can be caught. The Event monitor is a Holter that records on a continuous loop and you basically hit a button to tell the monitor that you are having symptoms so that it will save that moment. A tilt-table test might be in order as well. This can help check for the postural problems that I outlined above. You may be able to capture the cause with this as well. The odd part to me is what DOC1 has described above, and that is that you also have a pretty typical pattern to EXTINGUISH a supraventricular tachycardia (SVT or PSVT). This would not be necessarily the rhythm you would have it were JUST a postural tachycardia syndrome. So, you might have TWO things going on here. Is mitral valve prolapse a possible player here? Sure it can be. Are there treatments available out there to aid in the event that you have some kind of autonomic problem? Sure. Do they work? ... sometimes. Should you get it looked at? I would. If symptoms persist or worsen over time, then you might put yourself at risk. You don't have much control over yourself after you pass out. That's my advice, and i don't think that you could ever go wrong investigating this further. Will you yield any helpful results? Sometimes not. I hope this makes sense. If I need to clarify, shoot me a message back.


Thursday, September 15, 2011

Weight Loss Question

Hello Docs,

I am having trouble losing weight. I tend to yo-yo on the weight thing. I have tried Weight-Watchers and Nutri Systems, but I get so hungry I eventually binge and end up back where I started. What are options for me besides surgery? I am female and 40 years old. I am 5' 4'' and weigh 260 pounds. I have no other medical problems. I have had a recent complete physical including a thyroid check. I'm healthy but fat! What to do?



Dear Cynthia,

Thanks Cynthia for your question. There are as many ways to approach weight loss these days as there are people trying to lose weight. Weight Watchers and Nutri-System are great programs, but when it comes down to the essentials it takes two things to lose weight: good diet and regular exercise. The reason that most diets fail is because there is (believe it or not) too much self-reliance or (worse) reliance on friends to be a support structure for continued success.
You've done a good job by getting a primary physician to see you and get some routine lab work. However, the usual amount of time your primary provider has to devote to you (especially if you are an established patient) is going to be about 15 minutes. In my practice, I have found that it takes about 30-45minutes of time just to get a good history from the patient to make a plan about any further diagnostic testing or a treatment plan.
If you are ok physically, then you need to get a strong team together to help you succeed. A physician or other provider can often be a good source for accountability by following up at regular intervals. A dietitian can help you get on the right track instead of trying to wade through a sea of diet books and philosophies. Lastly, a good personal trainer can often be your best cheerleader. You might even consider a psychologist or psychiatrist if you think that there are issues that may be hindering your success.
Sometimes weight loss medication can help get you from the bad habits to the good habits. I often tell my patients that weight loss medication can help you lose weight even if you sit on the cough, but they are BETTER used as a means of helping you make a transition to a healthier lifestyle. Otherwise, they will be a miserable failure.
I would recommend that you seek the guidance of a physician who practices "bariatric medicine" (notice that I didn't say "bariatric surgeon"). If you look on the website for the American Society of Bariatric Medicine for a listing of physicians in your area that specialize in this expertise, then you may find the perfect partner in your weight loss goal. The website is Good luck to you!!! _DOC2