Leading Medicine Winter 2021, Houston Methodist Baytown Hospital edition

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LEADING MEDICINE W INT ER 2021

Stroke Symptoms Unique for Women

STAY ON TOP OF YOUR HEALTH New Year, New You: Your Path to Weight Loss

YOUR LINK TO HEALTH INNOVATIONS, NEWS AND TIPS IN EAST HOUSTON/BAYTOWN


IN THIS ISSUE - WINTER 2021

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E xperiencing Erectile Dysfunction? It’s difficult to avoid advertising about drugs to treat erectile dysfunction (ED), which has increased awareness of a problem that many men may have felt uncomfortable discussing, even with their doctors. Learn about treatment options available for ED.

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H elping a Sprained Ankle Heal Ankle sprains are a minor injury, but a major pain. Get tips on how to treat a mild sprain and how to know when it's time to see an orthopedist. S troke Symptoms Unique for Women Women are at greater risk of stroke than men. Find out which risk factors contribute to stroke in women, stroke symptoms to watch for and when to get help.

S tay on Top of Your Health Managing your health should always be a top priority, even when there’s a lot going on in life. Here's what you need to know about staying healthy, lowering your risk for disease and choosing a primary care doctor.

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Stress and Your Stomach Stress, worry and anxiety can take a toll on your gut health. Learn about the connection between stress and common digestive conditions and ways to get relief.

N ew Year, New You: Your Path to Weight Loss If you’re ready to kick-start your weight loss efforts, learn more about your options and get help choosing the one that’s right for you. Don't Delay Recommended Cancer Screenings While the pandemic has put life on hold in many ways, it shouldn’t keep you from getting recommended cancer screenings. Find out how easy it can be to get checked.

AN EMERGENCY IS

STILL AN EMERGENCY

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f you are experiencing a medical emergency, don’t ignore your symptoms — especially if you have severe flu symptoms, such as high fever, difficulty breathing, shortness of breath or dehydration. Dr. Neil Gandhi With enhanced safety measures in place at Houston Methodist Baytown Hospital’s Emergency Department, you can rest assured your safety is our top priority. With flu season coinciding with the COVID-19 pandemic, it’s more important than ever to prioritize your health. Dr. Neil Gandhi, medical director of Houston Methodist Baytown’s Emergency Department, says many patients have delayed medical care due to coronavirus safety concerns. “Unfortunately, during the COVID-19 pandemic, we have seen many patients delay

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their medical care, even for serious conditions like a stroke or heart attack, which has led to concerning outcomes for them,” Gandhi said. “Had these patients come to the emergency department earlier, they would have received treatment sooner and had much better outcomes. Remember, we have strict COVID-19 safety protocols in place that make our hospital one of the safest and cleanest places to be.” Houston Methodist Baytown’s new ED, which opened in 2020, triples the capacity of the old facility and includes a spacious

Know Where to Go

waiting area and 42 private treatment rooms, which allow patients to be seen and evaluated in a quiet, private space. The staff consists of board-certified emergency physicians, who have all completed residency training in emergency medicine.

Visit houstonmethodist.org/er for information on emergency services. If you are experiencing a serious or life-threatening medical emergency, please call 911.


EXPERIENCING ERECTILE DYSFUNCTION? Talk to Your Doctor

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hese days, it’s difficult to avoid advertising about drugs and other therapies to treat erectile dysfunction (ED). The ads may make some people squirm, Dr. Chris but they’ve had at least Kannady one positive impact — increasing awareness of a problem that many men may have felt uncomfortable discussing, even with their doctors.

WHAT CAUSES ED?

“Erectile dysfunction is the inability to get or maintain an erection. The condition is most common, in men age 65 and older, but it may also affect younger men,” said Dr. Chris Kannady, a board-certified urologist with Houston Methodist Urology Associates at Baytown. ED can be caused by other health conditions, such as: Diabetes, vascular disease, atherosclerosis, stroke and kidney disease Depression Injury from an accident or because of prostate or bladder surgery Low testosterone levels Overweight or obesity Side effects of certain medications, such as blood pressure drugs, antihistamines and antidepressants. Alcohol and tobacco use, lack of physical activity and/or fatigue may also contribute to ED. Erectile dysfunction may also be triggered by stress, guilt or fear of sexual failure.

Don’t Suffer in Silence

You don’t have to live with erectile dysfunction. To make an appointment with a urologist with Houston Methodist Urology Associates at Baytown, visit houstonmethodist.org/urology/erectile-dysfunction or call 832.556.6046.

TREATMENT OPTIONS

Fortunately, ED often can be treated successfully. “If you’re experiencing ED, the most important step you can take is to consult your doctor. They will ask about your medical history, conduct an exam and, if necessary, order laboratory tests to determine the underlying cause,” Kannady said. Once the cause is determined, a course of treatment can begin. Options may include: Lifestyle changes, such as quitting smoking or getting more exercise or sleep.

Changing medications, such as trying a different class of blood pressure pills. Counseling or psychotherapy, if the underlying cause is emotional. Drug therapy, including oral medications or injections. Mechanical devices that stimulate an erection by increasing blood flow. If these therapies fail, physicians may suggest surgery to repair damaged arteries or veins in the penis, or to implant a prosthesis.

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HELPING A SPRAINED ANKLE HEAL

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nkle sprains are a minor injury but a major pain. Because ankle sprains can happen during routine activity or active exercise, the condition can impact nearly anyone. A simple misstep can result in a sprain that can linger for several weeks.

Dr. David Mann

WHAT’S AN ANKLE SPRAIN?

An ankle sprain happens when ankle ligaments are stretched beyond their normal range of motion. Sprains can range significantly in severity and are often accompanied by pain, which can take several weeks or more to fully resolve. Mild sprains may be caused by overstretching or irritating ligaments while severe sprains can involve tearing of the ligaments. “Significant pain, severe swelling, bruising of the ankle or a popping sensation at the time of injury are signs that your ankle injury could be more than a simple sprain. Contact your primary care physician or orthopedist if you suspect a more serious problem,” said Dr. David Mann, a board-certified orthopedic sports medicine doctor at Houston Methodist Orthopedics & Sports Medicine at Baytown.

TREATING A SPRAINED ANKLE

For mild sprains, some basic first aid can help with healing and recovery. Use the RICE method for the first 48-72 hours to reduce pain and swelling. After the first few days, gradually increasing activity may help improve flexibility and movement following the injury. R = Rest Rest your ankle as much as possible during the first day or two to help promote healing. Avoid overworking the ankle and any activities that cause discomfort. I = Ice Ice reduces swelling and the initial pain of your ankle sprain. Apply a wrapped ice pack to the injured ankle for 10-20 minutes, using it every two or three hours in the first two days following an injury. C = Compression Compression helps reduce swelling and stabilizes an injured ankle. Use an elastic bandage or wrap or try a brace. “Several types are available that can provide added support to your injured ankle. Make sure it’s not too tight to avoid cutting off the circulation to your foot or causing discomfort,” Mann said.

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Help for Sprains and Strains

The Houston Methodist Orthopedic Injury Clinic at Baytown provides same-day appointments for the treatment of acute orthopedic injuries, including fractures and broken bones, sprains and strains, injured tendons, sports injuries, torn ligaments and painful or swollen joints. To schedule an appointment, call 281.427.7400.

E = Elevation Keeping the injured ankle above your heart helps reduce swelling and removes excess fluid from the injured area. Elevating your foot while relaxing or sleeping with a pillow underneath your ankle can assist in the healing process.

ROAD TO RECOVERY

“Following the first few days of a sprain, gentle stretching or light exercise, such as walking can help your recovery. In any healing process, listen to your body. If an activity causes significant discomfort or pain, stop and contact your doctor to avoid a more serious injury,” Mann explained.


STROKE SYMPTOMS UNIQUE FOR WOMEN A lthough the risk of stroke increases with age, it is possible for middle-aged and younger women to suffer a stroke. A stroke happens suddenly Dr. Olga Brusil without warning, and the results can be devastating. That’s why it’s important to recognize stroke symptoms and act quickly.

HIGHER STROKE RISK FOR WOMEN

“Women are at a higher risk for stroke than men, and this higher risk might be related to several factors,” said Dr. Olga Brusil, neurologist at Houston Methodist Baytown Hospital. Risk factors that may contribute to stroke include: High blood pressure during pregnancy increases the risk of stroke, with the highest risk during the third trimester and postpartum. Preeclampsia (a condition in which blood pressure rises sharply during pregnancy) doubles women’s stroke risk and quadruples the risk of high blood pressure later in life. “High blood pressure during pregnancy should be treated with medications and monitored closely,” Brusil said.

Birth control pills can increase the risk of stroke. The risk is small for women who don’t have other risk factors, but it is significantly higher for women who smoke, have high blood pressure or have a history of migraine headaches. Migraine headaches with aura (sensory disturbances, such as flashes of light, blind spots and other vision changes) may increase the risk of stroke in younger women. Atrial fibrillation can increase stroke risk among women over age 75.

RECOGNIZE STROKE SYMPTOMS

“Women are more likely than men to have atypical, vague symptoms, which can make it difficult to recognize when someone is having a stroke. They’re also more likely than men to brush off symptoms and delay getting help,” Brusil explained. It’s crucial to familiarize yourself with all the possible signs of stroke. If you or a loved one experiences any of the following symptoms, call 911 and seek immediate attention — even if you’re not sure it’s a stroke. Common stroke symptoms for both men and women: B – BALANCE Does the person seem dizzy? E – EYES Is there difficulty seeing clearly?

F – FACE Does the face look uneven? A – ARMS Does one arm drift down? S – SPEECH Does the person sound strange? T – TIME If you observe any of these signs, it's time to call 911.

Unique stroke symptoms in women: Confusion, disorientation or memory problems Fatigue General weakness Nausea or vomiting

TIME IS CRITICAL

During a stroke, the brain is deprived of oxygen when blood flow is cut off by a clot or ruptured vessel. Getting treatment quickly can save a life and even reverse the stroke. However, the most effective stroke treatments are only helpful when administered within three to four-and-ahalf hours of the onset of symptoms. Don’t delay getting medical help because you think your symptoms may turn out to be a false alarm. Call 911 right away. Sources: American Stroke Association and American Heart Association.

Expert Stroke Care

As a Gold Plus Primary Stroke Center, we are committed to helping people who suffer a stroke have brighter futures. To learn more about stroke care and rehabilitation at Houston Methodist Baytown Hospital, visit houstonmethodist.org/baytown or call 832.556.6535.

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STAY ON TOP OF

YOUR HEALTH 7 Ways to Improve Your Health

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anaging your health should always be a top priority, even when there’s a lot going on in life. This is especially true during a pandemic when it’s important to Dr. Pooja do what you can to stay Kulkarni healthy and safe. Focusing on preventive care can help you be prepared, and protect yourself and others. Dr. Pooja Kulkarni, a family medicine doctor with Houston Methodist Primary Care Group, says the goal of preventive care is to provide guidance for optimal health and well-being. “Taking steps to manage your health can lower your risk of disease and help you live a healthier life,” she said.

AN ANNUAL 1SCHEDULE CHECKUP

You may be reluctant to go in for a checkup when you’re feeling fine healthwise. But,

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being proactive about your health can prevent bigger, more expensive health problems down the road — and it can even save your life. Essential tip: Managing your health is easier when you build a relationship with a primary care provider who knows you and your health history. Did you know: Virtual visits allow you to see your doctor from the comfort of home via phone or computer.

2 KEEP UP WITH HEALTH TESTS Your doctor may recommend a cholesterol test, blood pressure screening, blood glucose test, mammogram, colonoscopy, prostate screening or other health tests. These tests can identify potential health problems so they can be prevented, treated or managed. Essential tip: Ask your doctor about recommended screening tests for you based on your age, health history and other factors.

Did you know: Screening tests increase the chances of detecting certain cancers early, which provides more treatment options because they can be addressed sooner.

3 GET A FLU SHOT

Vaccines provide protection for you and others against infectious diseases, such as flu, measles and pneumonia, which can be particularly dangerous for older adults and those with underlying health conditions. “It’s essential to get your flu vaccine and other vaccines recommended by your doctor,” Kulkarni added. Essential tip: Contact your primary care office to schedule flu shots and other vaccines for yourself and your family. Did you know: It’s not too late to get a flu shot if you haven’t already. Although it’s best to get your flu shot as soon as it’s available in the fall, getting a flu shot later still provides protection for the rest of flu season into April and May.


HOW TO CHOOSE YOUR PRIMARY CARE DOCTOR Staying on top of your health during these challenging times starts with having a quality primary care doctor. Here’s what to consider when determining the best one for you: B oard certification. Is the doctor board certified? This means he or she has proven expertise and can provide the highest quality care possible.

OVID-19 safety measures. C Does the primary care doctor’s office have safety measures in place, such as enforcing social distancing and implementing disinfectant protocols for the staff? Convenience and accessibility. How accessible is the doctor? Access to virtual visits, text-toschedule, online scheduling and

multiple locations across the Greater Houston area make a difference when you see your doctor on a regular basis.

We’re Here for You

Our physicians are safely seeing patients in-person and virtually with safety measures in place to protect patients from COVID-19.

Stay connected with your health by subscribing to our e-newsletter. Visit houstonmethodist.org/blog-stay-connected to sign up to receive the Houston Methodist On Health e-newsletter.

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TAKE MEDICATIONS AS DIRECTED

Following your doctor’s instructions for taking medications is an essential step in managing diabetes, heart disease, asthma and other conditions. Unfortunately, up to one-half of all prescribed medications are not taken as prescribed, according to a study in the American Journal of Accountable Care. “Take your medications as directed and notify your doctor if you're having any difficulty managing your medications,” Kulkarni said. Essential tip: Have an honest conversation with your doctor or pharmacist to address any questions or concerns about your medications. Did you know: Talk to your doctor if you’re having side effects or other concerns about your medications, including costs. Your doctor may decide to make adjustments to the dosing or prescribe a different medication that works better for you.

5 TALK ABOUT MENTAL HEALTH Millions of people are affected by mental health issues, including anxiety, depression and mood disorders. Talking about what’s going on and getting help with therapy or medications can help you start feeling better.

Essential tip: Your primary care doctor can assist with mental health concerns, including screening for depression. Did you know: In a poll by the American Psychiatric Association, 68% of Americans reported feeling anxious about the possibility of family or loved ones getting COVID-19. If you feel overwhelmed or unable to function, talk to your doctor.

6 MAKE HEALTHY CHANGES

If you need some motivation and support for making changes, such as losing weight or quitting smoking, talk to your primary care provider first. He or she can provide guidance to help you get started and support with tools or medications to help you be successful. Essential tip: Your chances of success go up when you have medical support for quitting smoking or losing weight. Did you know: If you’re overweight or obese, losing 5% of your body weight can have some big benefits for your

health, including lower cholesterol, lower blood pressure, reduced inflammation, reduced cancer risk and improved diabetes management.

7 DON’T DELAY HEALTH CARE

You may be inclined to “wait it out” and delay getting medical care when something is wrong. However, it’s important to seek medical care when you have concerns about your health. When in doubt, get it checked out. Essential tip: Don’t hesitate to call 911 for emergency medical help. For nonurgent health issues, make an appointment with your primary care doctor and write down some questions and notes about your symptoms. Did you know: Worrying about the costs of health care shouldn’t be a barrier to your health. Detecting a health issue early can help avoid bigger problems later on, saving you money and improving your life in the long run.

Make an Appointment

Schedule an appointment with a Houston Methodist primary care doctor in Baytown or a surrounding community by visiting houstonmethodist.org/pcg/baytown or calling 713.394.6724.

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STRESS AND YOUR STOMACH Tension Takes a Bite Out of Your Digestive System

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tress, worry and anxiety can take a toll on your stomach: Just think back to how you felt the last time you went on a job interview, got pulled over or awaited the results of a medical test. Those nervous butterflies in your belly were hard to ignore. “The enteric nervous system, a collection of neurons in the gastrointestinal tract, makes Dr. Yassir up your gut’s ‘brain.’ This system works with Ashraf the endocrine system, which is responsible for hormones that affect metabolism and how the digestion and elimination process works,” said Dr. Yassir Ashraf, a gastroenterology-hepatology specialist with Houston Methodist Gastroenterology Associates at Baytown. The entire system is very sensitive to moods — and stress is a major contributor to many digestive problems. Here’s a look at common conditions and how they’re affected by stress: Irritable bowel syndrome (IBS) is an intestinal disorder that’s marked by cramping, gas, bloating and a change in bowel habits. Stress doesn’t cause the condition, but some IBS sufferers find that it brings on flare-ups. “This may be because the colon is partly controlled by the body’s autonomic nervous system, which responds to stress,” Ashraf said. Heartburn occurs when the lower esophageal sphincter muscle relaxes, allowing stomach acid to back up into the esophagus. According to the National Heartburn Alliance, stress can cause problems with the way food makes its way through your digestive system, causing food to move upward instead of down. Research shows that heartburn sufferers who recently experienced a lifechanging event were more likely to develop severe symptoms.

Get Relief

There’s no need to suffer with digestive problems. To schedule an appointment with a gastroenterology specialist with Houston Methodist Gastroenterology Associates at Baytown, visit houstonmethodist.org/baytown or call 281.422.7970.

Indigestion can trigger bloating or nausea, belching, gas and diarrhea. It’s often caused by eating too much or eating too fast, consuming high-fat foods or eating during stressful situations. It can also be a sign of gastroesophageal reflux disease (GERD) or ulcers. Indigestion tends to get worse during stressful times and improves in times of relaxation. “Stress can worsen underlying health conditions and trigger unhealthy eating and smoking, both of which are known to worsen indigestion,” Ashraf explained.

EASE ANXIETY — AND BELLYACHES You can’t always avoid stress, but you can manage it and help ease your stomach woes. Some key strategies include: Exercise. Regular activity helps reduce stress, control weight, regulate bowel function and improve your overall well-being. Just make sure to exercise before eating or wait at least one hour after a meal. Biofeedback. This mind-over-matter technique helps you learn to control certain body functions that may have

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fallen into an abnormal pattern — including bowel function — and bring them back to normal. Biofeedback also helps reduce muscle tension and slow heart rate, promoting a relaxed state. Relaxation and breathing techniques. Try yoga or meditation, taking slow, rhythmic breaths to lessen stress and, in turn, cramps and pain.


NEW YEAR, NEW YOU Your Path to Weight Loss

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any people use the new year to kick-start their efforts to lose weight, but often find it tough to stay on track over time. If you’ve faced similar challenges, and Dr. Laura Choi need to lose more than a few pounds, maybe it’s time to consider a new approach in the new year. The Houston Methodist Center for Weight Loss & Bariatric Surgery at Baytown offers a variety of services Dr. Kendell ranging from medical Sowards nutritional counseling to bariatric (weight loss) surgery. “Our weight loss program begins with helping patients understand the factors that led to their weight gain and their options,” said Dr. Laura Choi, a boardcertified bariatric surgeon and medical director of the Center for Weight Loss & Bariatric Surgery at Baytown.

WHEN TO CONSIDER WEIGHT LOSS SURGERY

If you have a body mass index (BMI) of 35 or higher and are struggling with obesity, you’re not alone. Obesity affects millions of adults in the U.S. For those who also have obesity-related conditions, such as type 2 diabetes, high blood pressure, unhealthy cholesterol levels and sleep apnea, losing weight can be a lifesaver. “Weight loss surgery can help you achieve significant weight loss and improve weight-related health problems,” said Dr. Kendell Sowards, boardcertified bariatric surgeon at Houston Methodist Baytown Hospital.

WHO IS ELIGIBLE FOR WEIGHT LOSS SURGERY?

People who have a BMI of 40 or above and haven’t been able to lose weight with other methods, are good candidates for bariatric surgery. “Patients whose BMI is in the 35-40 range are also eligible, if they have medical conditions that are caused by or associated with obesity,” Choi said. It’s important to understand what’s involved with weight loss surgery before starting on the journey. The surgery helps you cut your intake of calories, but there’s more involved.

A MULTIFACETED APPROACH

The center’s team of experts provides comprehensive care throughout your weight loss journey. Our team includes: Board-certified bariatric surgeons skilled in minimally invasive weight loss procedures. They will help you understand which type of surgery is best for you. Bariatric coordinators answer your questions about the weight loss surgery process. Registered dietitians give nutrition assessments before surgery and dietary advice after surgery. Counselors offer mental and emotional support before and after surgery. Exercise physiologists help with exercise advice and tips. “We partner with you so you can make healthy lifestyle changes needed to achieve long-term success,” Choi said.

WEIGHT LOSS SERVICES AND PROGRAMS In addition to bariatric surgery, the Houston Methodist Center for Weight Loss & Bariatric Surgery at Baytown offers a full range of weight loss services and programs, including: StepLITE is a program for people who want to lose a few pounds and need help getting started. The program includes a diet plan and weekly check-in and group sessions with licensed professionals. Medical Weight Management is a three-phase weight loss plan that begins with a medically supervised, low-calorie diet program and progresses to a personalized meal plan to help you maintain weight loss.

Take the First Step Toward a Healthier Life

To learn more about weight loss surgery or to schedule an appointment at the Houston Methodist Center for Weight Loss & Bariatric Surgery at Baytown, visit houstonmethodist.org/weight-loss-surgery or call 832.556.6046.

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DON'T DELAY RECOMMENDED

CANCER SCREENINGS

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ostponed and canceled events have become the norm during the COVID-19 pandemic. But when it comes to your health, delaying tests or treatments may have negative consequences in the long run. Cancer isn’t stopping or slowing down in this pandemic, and that’s why we need to be vigilant about cancer prevention and screening. Dr. Cesar De “Early detection is key to identifying cancer Las Casas when it’s most treatable, which is why it’s important to keep up with appointments and continue to follow your doctor’s recommendations for cancer screening tests,” said Dr. Cesar De Las Casas, hematologist-oncologist with the Houston Methodist Cancer Center at Baytown.

DON’T SKIP SCREENINGS

There are plenty of excuses for not following through with recommended cancer screenings, but ultimately your health is at stake. Here are some common excuses and ways to overcome those hurdles:

“I don’t have time.” When you’re juggling many responsibilities and prioritizing your to-do list, scheduling a mammogram or colonoscopy may not rank high on the list. However, you should always prioritize your health, even when life is busy. You may be surprised by how quickly you can get it done and move on with the rest of your day.

“I don’t want to feel uncomfortable.” The fear of pain or embarrassment is a common reason why people don’t get screened regularly. You might be worried about discomfort during a mammogram or the inconvenience of

preparing for a colonoscopy. Finding out what to expect can help remove the unknowns and relieve those fears. Even if you do feel uncomfortable for a short time, it’s a small price to pay for the peace of mind you get from knowing your results.

“I don’t need a cancer screening test.” You might be thinking you’re too young or healthy to even worry about cancer. If you don’t have a family history of cancer, you might assume you have no risk of developing cancer yourself. However, there are many more factors that can affect your cancer risk, and that’s why routine cancer screenings are recommended to detect cancer early, before you have symptoms,” De Las Casas said.

“I’m worried about COVID-19.” At Houston Methodist, we’re taking every precaution to prevent the spread of illness and make your visit as safe as possible. Some of the ways we’re protecting patients and staff include: Screening all patients when scheduling appointments and upon arrival. Wearing masks and other personal protective equipment. Implementing additional sanitation processes for disinfecting equipment and surfaces.

CONNECT WITH YOUR DOCTOR

Don’t let fear or embarrassment keep you from getting the screening tests you need. If you have concerns about your risk for cancer, you should talk to your doctor about a screening schedule that’s right for you. See “Cancer Screening Tests” for guidance from the National Cancer Institute.

Compassionate Cancer Care If you or a loved one has been diagnosed with cancer, call 346.292.2060 to schedule an in-person or virtual appointment with a specialist with the Houston Methodist Cancer Center at Baytown or visit houstonmethodist.org/cancer-baytown to learn more about our services.

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CANCER SCREENING TESTS The following chart includes National Cancer Institute screening recommendations for people at average risk for cancer. Your doctor may recommend a screening schedule based on your health, age and other risk factors. SCREENING TEST

AGE

FREQUENCY

Cervical cancer screening

Starting at age 21

Every 3-5 years

Mammogram

Talk to your doctor starting at age 40

Every 1-2 years

Colonoscopy

Starting at age 50

Every 10 years

Lung cancer screening

Current or former smokers ages 55-74

Every year

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SEEING A PRIMARY CARE DOCTOR Is Still Important

For everything from annual checkups to managing chronic conditions, taking care of your health should always be a priority. Houston Methodist primary care doctors are still available to provide personalized care for you and your family — safely. We offer a variety of convenient ways to get care from us, from same-day sick visits to extended hours at select locations. And, you can be confident that we are taking every necessary precaution to keep you safe during your visit, including: Screening all patients and seeing COVID-19 patients virtually only — allowing us to treat everyone safely

Ensuring social distancing in waiting rooms

Wearing masks while providing care

Offering video visits with your doctor

Enhanced cleaning of equipment and surfaces

Adding evening and Saturday hours to space out appointments

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