Elevate Her- Gestational Diabetes

Gestational diabetes is a type of diabetes that develops exclusively in pregnancy when blood sugar levels are too high.

Gestational diabetes develops when hormones from the placenta interfere with your body’s ability to make or use insulin. Insulin breaks down the glucose from food and delivers it to your cells. It keeps the glucose levels in your blood at a healthy level. If insulin doesn’t work right or you don’t have enough of it, sugar builds up in your blood and leads to diabetes.

Anyone can get gestational diabetes during pregnancy. However, certain factors can increase your risk, including:

  • Heart disease
  • High blood pressure
  • Being obese or overweight before pregnancy
  • Personal history of gestational diabetes in previous pregnancies
  • Family history of Type 2 diabetes
  • Having prediabetes
  • Having polycystic ovary syndrome
  • Having previously delivered a baby weighing more than nine pounds
  • Being of a certain race or ethnicity, such as Black, Hispanic, American Indian, and Asian American
  • Being of an advanced maternal age

There are usually no obvious warning signs of gestational diabetes. Symptoms are too mild and often go unnoticed until your pregnancy care provider tests you for the disease. If you do have symptoms, they can include:

  • Frequent urination
  • Excessive thirst
  • Tiredness
  • Nausea

Gestational diabetes that isn’t carefully managed can lead to high blood sugar levels. High blood sugar can cause problems for you and your baby, including an increased likelihood of needing a C-section to deliver the baby. If you have gestational diabetes, your baby may be at an increased risk of:

  • Excessive birth weight
  • Preterm birth
  • Serious breathing difficulties at birth
  • Low blood sugar
  • Obesity and Type 2 diabetes later in life
  • Stillbirth

To diagnose gestational diabetes, your healthcare provider will test your blood sugar during pregnancy with a blood test. Often the first test is a screening. If you don’t pass the screening, a provider will order a second blood test which is more comprehensive and includes:

  • Glucose challenge test
  • Glucose tolerance test

If you have gestational diabetes, you will need more frequent checkups during your pregnancy. Treatment for gestational diabetes includes:

  • Lifestyle changes
  • Blood sugar monitoring
  • Medication, if necessary

Managing your blood sugar levels helps keep you and your baby healthy. Close management can also help you avoid complications during pregnancy and delivery.

Gestational diabetes isn’t entirely preventable. However, there are steps you can take to reduce your risk. Eating balanced and nutritious meals and getting regular exercise before and after your pregnancy are the best ways to reduce the risk of developing gestational diabetes.

To learn more about the OB/GYN services at Jamaica Hospital Medical Center’s Department of Women’s Health Services or to make an appointment, call 718-291-3276.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Asthmatic Bronchitis

woman holding her chest while coughingBronchitis is the inflammation of the bronchial tubes or bronchi, which carry air to and from the lungs.  It can be caused by a bacterial or viral infection or, in some cases, environmental exposures.

People with asthma are more susceptible to getting bronchitis because asthma can also lead to inflammation of the bronchi— Inflammation caused by asthma narrows the airways, making it easier for bacteria and viruses to become trapped and infect the bronchi.

When someone with asthma develops bronchitis, it is called asthmatic bronchitis (this is not an official medical diagnosis but a term used to describe people with asthma and bronchitis symptoms).

The symptoms of asthmatic bronchitis are similar to those of bronchitis, which are:

  • Wheezing
  • Cough with mucus
  • Chest tightness
  • Chest congestion
  • Shortness of breath
  • Excess mucus production

Common triggers of asthmatic bronchitis include:

  • Viral or bacterial infections
  • Pollution
  • Tobacco smoke
  • Certain medications
  • Allergens such as mold, dust, or pollen
  • Breathing in dangerous chemicals

If you are experiencing symptoms of asthmatic bronchitis, you should see a doctor.  Your doctor may ask questions about your symptoms, conduct a physical examination, or order tests.

Treatment for asthmatic bronchitis focuses on getting rid of mucus, reducing inflammation of the airways, and keeping them open. This can be achieved by using inhalers that contain bronchodilators and possibly corticosteroids. Treatment may also involve antibiotics or humidifiers.

To schedule an appointment with a doctor at Jamaica Hospital Medical Center, please call the Division of Pulmonary Medicine at 718-206-5916.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Postpartum Breast Engorgement

Young beautiful mother breastfeeding her newborn baby boy, while father working on laptopThe body undergoes various physical changes in the first few days after giving birth, including the production of breast milk in preparation for breastfeeding.

As your milk “comes in,” you may experience breast engorgement, which occurs when the breasts become painfully swollen or overly full due to an increase in blood flow, fluid, and milk production.

Postpartum breast engorgement typically happens within the first week after giving birth; however, it may also occur as late as day nine or 10. When breasts are engorged, you may experience:

  • Pain or tenderness of your breasts
  • A mild fever
  • Swelling of both breasts
  • Hardness or firmness of the breast
  • Breasts that are warm to the touch
  • Flat or hard nipples

These symptoms should go away within a few days if you are breastfeeding, but you can also manage them by:

  • Using a warm compress to encourage milk let down
  • Applying a cold compress to relieve pain and swelling
  • Hand expressing a small amount of milk to relieve pressure (Do not express too much milk as this may signal the body to produce more)
  • Wearing a supportive bra
  • Taking physician-approved pain medication
  • Breastfeeding regularly (if you have chosen to breastfeed)

It’s important to note that you may still experience engorgement even if you have chosen not to breastfeed. If you decide not to breastfeed, your body will recognize that it doesn’t need to produce milk, and over time, your milk supply will dry up.

Managing symptoms of breast engorgement is crucial. Prolonged symptoms may indicate more serious health issues, such as mastitis. If symptoms persist for several days, contact your doctor or lactation consultant as soon as possible.

 

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Patient Testimonial – Agostino Romano says, “If it wasn’t for Dr. McKenzie, I’d be dead”, after Dr. Katherine McKenzie Saved His Life.

“If it wasn’t for Dr. McKenzie, I’d be dead”, is what Agostino Romano said after his experience at Jamaica Hospital Medical Center. Mr. Romano has been a patient of Dr. Katherine McKenzie for the last four years. He was first seen by her to treat perforated appendicitis in 2021. During this time, Dr. McKenzie observed that Mr. Romano wasn’t responding well to standard treatment. She suspected an underlying malignancy and investigated further. Dr. McKenzie diagnosed Mr. Romano with a rare and aggressive cancer called Burkitt’s lymphoma.

Mr. Romano received treatment for the cancer and has been in remission. He returned to see Dr. McKenzie for surgery, an abdominal wall reconstruction with a component separation in 2023. He recovered and is doing well. He continues to see Dr. McKenzie every four to six months. He is back at work and has been able to resume his passions which include cooking and sharing Italian food. He has even made trips to see his family in Italy.

“I wouldn’t go to any other hospital. I’ve formed a bond with them,” Mr. Romano said of Dr. McKenzie and her team. Born in Italy, Mr. Romano lives with his wife of 30 years in Ozone Park, Queens. Despite the surgeries and cancer diagnosis, Mr. Romano keeps a positive perspective: “I have nothing but great things to say, even in the dark times.”

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is an eye disease that can blur your central vision. It occurs when aging damages the macula, the part of the eye that controls sharp, straight-ahead vision. The macula is part of the retina, the light-sensitive tissue at the back of the eye.

Age-related macular degeneration is a common condition and the most common cause of severe loss of eyesight among people 50 and older. It is important to realize that people rarely go blind from it. However, losing your central vision makes it harder to see faces, read, drive, or do close-up work like cooking or fixing things around the house.

There are two types of age-related macular degeneration, dry and wet.

Most people with age-related macular degeneration have dry AMD, also called atrophic AMD. This is when the macular gets thinner with age. Dry AMD happens in three stages:

  • Early
  • Intermediate
  • Late

Wet AMD, also called advanced neovascular AMD is a less common type of late AMD that causes faster vision loss. Dry AMD can turn into wet AMD at any stage, however, wet AMD is always late.

The most common symptoms of age-related macular degeneration can include:

  • Blurry or fuzzy vision
  • Difficulty recognizing familiar faces
  • Seeing straight lines appearing wavy
  • A dark, empty area or blind spot appears in the center of a person’s vision

The presence of tiny yellow deposits in the retina called drusen is one of the most common early signs of age-related macular degeneration. It can mean the eye is at risk of developing more severe age-related macular degeneration.

Several risk factors that can contribute to developing age-related macular degeneration include:

  • Eating a diet high in saturated fat
  • Smoking
  • High blood pressure or hypertension

To diagnose age-related macular degeneration, an eye doctor will look at your medical history and perform an eye exam. They may also perform other tests to help diagnose AMD, including:

  • A visual acuity test
  • Pupil dilation
  • Fluorescein angiography
  • Amsler grid

Specific treatment for age-related macular degeneration is determined by your eye doctor based on:

  • Your age, overall health, and medical history
  • The extent and nature of the disease
  • Your tolerance for specific medications, procedures, or low-vision therapies
  • The expectations for the course of the disease
  • Your opinion or preference

There is no current treatment for dry AMD, however, vision rehabilitation programs and low-vision devices can be used to build visual skills, develop new ways to perform daily living activities, and adjust to living with age-related macular degeneration.

The main treatment for wet AMD is an injection of medications called anti-VEGF agents. VEGF stands for vascular endothelial growth factor.

There is no cure for age-related macular degeneration. However, research shows that you may be able to lower your risk of AMD, or slow vision loss from AMD by:

  • Quitting smoking
  • Getting regular exercise
  • Maintaining healthy blood pressure and cholesterol levels
  • Eating healthy foods that include leafy green vegetables and fish

AMD happens very slowly in some people and faster in others. If you have early AMD, you may not notice vision loss for a long time. It is important to get regular eye exams to find out if you have AMD.

If you’re experiencing symptoms of dry or wet AMD, you can schedule an appointment at Jamaica Hospital Medical Center’s Ophthalmology Center by calling (718) 206-5900.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Podiatry: What Your Feet Can Tell You about Your Health

Our bodies present many signs and symptoms to show us that we are sick, such as a runny nose, fever, and body aches. However, your feet can tell us a lot about our health, including:

  1. Dry, flaking, itchy, or peeling skin may be signs of a thyroid condition or a fungal infection.
  2. Foot numbness may be a sign of circulation problems such as peripheral artery disease (PAD), peripheral neuropathy associated with type 2 diabetes, other neurological problems, arthritis, or long-standing alcoholism.
  3. A foot sore that won’t heal may be a sign of diabetes or peripheral vascular disease. In addition to causing nerve damage, high blood sugar might also damage the blood vessels that supply nerves, causing circulation problems that prevent healing.
  4. Swollen ankles and feet may be signs of heart failure, kidney disease, liver disease, or a blood clot. Painless swelling in the feet is gravity in action. If your heart, liver, or kidneys aren’t working properly, you will have excess fluid in the body that leaks into your tissues and drains down to the feet.
  5. A suddenly, intensely painful, and swollen big toe may be a sign of gout, inflammation caused by a buildup of uric acid that forms crystals in the joints.
  6. Pain in the foot when walking or exercising that goes away when resting may be a sign of a stress fracture or osteoporosis.
  7. Sore toe joints in both feet may be a sign of rheumatoid arthritis.
  8. Frequent foot cramping may be a sign of dehydration and nutritional deficiencies.
  9. Heel pain may be a sign of plantar fasciitis, the strain of the ligament that supports the arch in your foot.
  10. Yellow toenails may be a sign of a fungal infection, such as athlete’s foot.
  11. Balding or hairless feet and toes may be a sign of circulation problems, such as peripheral artery disease.
  12. Foot or heel pain upon standing or rising in the morning may be a sign of arthritis or plantar fasciitis.
  13. Frequently cold feet may be a sign of hypothyroidism, peripheral artery disease, or Raynaud’s disease, a condition where blood vessels spasm and constrict when experiencing cold temperatures.

Some ways you can care for your feet include:

  • Wash and examine your feet daily
  • Keep the skin on your feet moisturized
  • Treat any callouses and corns
  • Trim toenails weekly or as needed
  • Wear protective clothing on your feet
  • Maintain blood flow to the feet

If you are experiencing any of these foot ailments, contact Jamaica Hospital Medical Center’s Queens Podiatry Center at (718) 206-6713-6712 to make an appointment.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Pulmonary Hypertension

Woman painful grimace pressing the upper abdomenPulmonary hypertension (PH) is a condition that develops when the blood pressure in the pulmonary arteries, which carries blood from the right side of your heart to your lungs, is too high.

Pulmonary hypertension causes blood vessels in the lungs to become narrowed, blocked, or damaged. The heart must work harder than normal to pump blood into the lungs because of these problems. This can cause damage to the heart and lead to symptoms including:

  • Chest pain or pressure
  • Shortness of breath
  • Fatigue
  • Dizziness or fainting
  • Heart palpitations
  • Edema or swelling of the feet, legs, or abdomen

Pulmonary hypertension can lead to serious complications such as:

  • Bleeding in the lungs
  • Heart failure
  • Heart enlargement
  • Arrhythmias or irregular heartbeats
  • Pregnancy complications
  • Liver damage
  • Anemia

The causes of pulmonary hypertension depend on the type of pulmonary hypertension you might have. Here are the five classifications of PH based on their causes:

  • Group 1: Pulmonary arterial hypertension (PAH) –The causes of PAH can be idiopathic (an unknown cause or caused by an underlying health condition) or genetic. PAH can also develop due to illegal drug use, congenital heart defects, or certain medical conditions such as lupus.
  • Group 2: Pulmonary hypertension caused by left-sided heart disease- This is the most common type of PH. The causes include left heart failure or left-sided heart valve disease.
  • Group 3: Pulmonary hypertension due to lung disease and/or hypoxia- This develops due to pulmonary fibrosis or the scarring of the lungs, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), or prolonged exposure to high altitudes.
  • Group 4: Pulmonary hypertension due to pulmonary artery obstructions or blockages in the lungs– Blockages or obstructions may include blood clots in the lungs or tumors that block pulmonary arteries.
  • Group 5: Pulmonary hypertension caused by other disorders or health conditions- These disorders or health conditions can include kidney disease, blood disorders such as sickle disease, or metabolic conditions such as thyroid disease.

 The risk factors for developing pulmonary hypertension include:

  • A family history of blood clots
  • A family history of pulmonary hypertension
  • Living at high altitudes
  • Use of illegal drugs
  • Smoking or using tobacco products
  • Exposure to asbestos
  • Taking certain medications designed to treat depression or cancer
  • Age (PH is usually diagnosed in adults between ages 30 and 60. The risk increases as you get older.)

Pulmonary hypertension is diagnosed by a healthcare professional through various tests, such as an echocardiogram, which measures the pressure in the pulmonary arteries. Additional tests may include blood tests, chest X-rays, and electrocardiograms (ECG or EKG). Your healthcare provider will also assess your medical history and symptoms to determine if you have pulmonary hypertension. Treatment options for pulmonary hypertension may include medication, lifestyle changes, or surgery.

If you are experiencing symptoms of pulmonary hypertension or are at risk, please call the Division of Pulmonary Medicine at 718-206-5916 to schedule an appointment.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Dental Fillings – Different Types and What to Expect During Your Procedure

Dental fillings are a type of restorative dentistry treatment used by dentists to repair cavities or fix minor chips and cracks in your teeth. Other names for dental fillings include:

  • Tooth fillings
  • Cavity fillings
  • Dental restorations – this term refers to treatments that restore teeth, such as fillings, inlays, onlays, bridges, and crowns

Your dentist will discuss treatment options to determine which type of dental filling is better for your situation.

There are many different types of dental fillings and they fall into one of two categories: direct or indirect.

Direct fillings are created by dentists and placed in your mouth without the need for a dental laboratory or temporary restoration. They only require one office visit.

Common materials for direct fillings include:

  • Amalgam
  • Resin composite
  • Glass ionomer

Indirect fillings are made by a dental technician in a lab before your dentist places them in your mouth. Most indirect fillings require two office visits, one to take dental impressions and another to put your restoration. If your dentist uses computer-aided design/computer-aided manufacturing or CAD/CAM technology, they may be able to create and place your indirect filling in a single appointment.

Inlays and onlays are two common indirect fillings that dentists use when a tooth has too much damage to support a filling but not enough damage for a dental crown. An inlay or onlay fits into your tooth structure like a tiny puzzle piece.

Common materials for indirect fillings include:

  • Gold
  • Porcelain

During the dental filling procedure, your dentist will:

  1. Numb your tooth with local anesthesia
  2. Remove damaged or decayed tissue from your tooth using specialized instruments
  3. Fill the hole with dental filling material
  4. Use a dental curing light to harden the material (only for resin composite)
  5. Polish and smooth any rough edges
  6. Check your bite to make sure it feels normal

The exact steps may vary depending on the material your dentist uses and what type of filling they place.

If you have anxiety about visiting the dentist, ask about sedation options. Sedation dentistry helps keep you calm and comfortable during your procedure.

If your teeth need a check-up, you can make an appointment with one of our board-certified dentists at Jamaica Hospital Medical Center’s Dental Center by calling 718-206-6980.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

What is Induration?

Induration is a deep, thickening of the skin from edema, inflammation, or infiltration, including cancer.

Signs of indurated skin include:

  • Skin that feels firmer to the touch than the surrounding skin
  • Skin that appears thick
  • Skin that looks smooth and shiny

The indurated areas commonly appear on the hands and face, but can also be found on the chest, back, abdomen, breast, or buttocks.

The primary underlying causes of skin induration include:

  • Specific types of skin infection
  • Cutaneous metastatic cancers
  • Panniculitis
  • Hives

The precise physiological process that results in many conditions that cause skin induration includes inflammation and infiltration of the skin by certain types of cancer cells.

Several types of skin infections with symptoms of skin induration include:

  • An abscess
  • An inflamed cyst
  • Insect bites that become infected

The diagnosis of skin induration is made by palpation or the feeling of the area, assessing whether the raised area feels hard and resistant.

Treatment of skin induration varies depending on the underlying cause. Treatment options include:

  • For an abscess, the treatment option may be antibiotics, incision, or drainage
  • For inflammatory disorders, such as scleroderma or lichen sclerosus, immunosuppressants or steroid creams can be used.

Supportive care for skin induration conditions can vary greatly, depending on the underlying cause. Examples of supportive care for skin conditions can include:

  • Warm compresses
  • Analgesia
  • Elevation of the affected extremity to help reduce swelling

If you are experiencing any signs of skin induration, you can schedule an appointment with a doctor at Jamaica Hospital Medical Center’s Ambulatory Care Center, please call (718) 206-7001.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Signs and Symptoms of Stroke in Women

Men are more likely to have a stroke. However, women have a higher lifetime risk and are also more likely to die from a stroke.

The Centers for Disease Control and Prevention (CDC) estimates that one in five women will have a stroke. Women have a higher lifetime risk of stroke because they tend to live longer than men. They also have unique risk factors, including:

  • Pregnancy
  • Preeclampsia
  • The use of hormonal birth control
  • Hormone replacement therapy
  • Obesity
  • Migraine with aura, which is more common in women
  • Atrial fibrillation (AFib), which is more common in women over 75 years of age

Many symptoms of stroke are common in both men and women, including:

  • Sudden difficulty seeing in one or both eyes
  • Sudden numbness or weakness of the face and limbs, most likely on one side of the body
  • Sudden difficulty speaking or understanding
  • Sudden and severe headaches with no known cause
  • Sudden dizziness, difficulty walking, or loss of balance or coordination

Women may report symptoms that are often not associated with strokes in men. These symptoms can include:

  • Nausea or vomiting
  • Seizures
  • Hiccups
  • Shortness of breath
  • Pain
  • Fainting or loss of consciousness
  • General weakness

Because these symptoms can signify a different condition, it can be difficult to connect them immediately to a stroke. This can delay treatment and slow recovery.

The American Stroke Association recommends an easy strategy for identifying the symptoms of a stroke. If you think you or someone around you may be having a stroke, you should act FAST:

  • Face – ask the person to smile. Does one side of their face droop?
  • Arms – ask the person to raise both arms. Does one arm drift downward?
  • Speech – ask the person to repeat a simple phrase. Is their speech slurred or strange?
  • Time – if you observe any of these symptoms, it is time to call 911 or your local emergency services.

When it comes to a stroke, every minute counts. The longer you wait to call emergency services, the more likely it is that the stroke will result in brain damage or disability.

Jamaica Hospital Medical Center has been accredited as a Comprehensive Stroke Center (the highest designation of stroke care) by the Joint Commission. Whether you’ve survived a stroke or may be at risk of experiencing one, you can schedule an appointment for neuroendovascular screening, stroke rehabilitation, or any other form of stroke treatment that we provide. To schedule an appointment, please call 718-206-7001.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.