Monday, June 23, 2014

How To Remove a Tick

Tick removal is easy – you might need to have some help since ticks have a way of attaching in inconvenient places. The key goal is to remove the entire live tick gently without it regurgitating potential pathogens (Lyme and worse).

I like the technique in this excellent video but rather than use tweezers I prefer tick pliers. I use these in the office with little danger of beheading the tick.

There is often redness at the site of the bite and there might be a black center that lingers for days. If the tick was removed in one piece, the black area does not contain tick fragment but is dead tissue from the tick saliva. An enlarging red area, hardness or pain merits an office visit as does a bull’s eye rash. By the way, the bull’s eye rash can be anywhere, not just the site of the bite.

Above all – no bathroom surgery! There is no reason to engage sharp implements.

Monday, June 16, 2014

Mosquito Bites

Mosquito bites are a fact of summer. The typical reaction is immediate swelling at the site of the bite followed by redness about twenty minutes later. A firm itchy nodule develops over the next 24 to 36 hours and will last about 7-10 days.

People who have never been exposed to a particular species of mosquitos don’t develop reactions to the initial bites. Subsequent bites result in the appearance of delayed local skin reactions. After repeated bites, immediate swelling occurs. With further exposure, the delayed local reactions wane and eventually disappear, although the immediate reactions persist. People who are repeatedly exposed to bites from the same species of mosquito eventually also lose their immediate reactions. The duration of each of these five different stages differs, depending on the intensity and timing of mosquito exposure.

Large local reactions to mosquito bites have been named the Skeeter Syndrome. Large local reactions develop within hours of the bite, progress over 8 to 12 hours or more, and resolve within 3 to 10 days. The area can blister and looked bruised. Severe large local reactions can be accompanied by low- grade fever and malaise. It can be difficult to differentiate between allergic inflammation caused by mosquito bites and inflammation caused by secondary bacterial infection after scratching the bites. Large local reactions typically begin within hours. Secondary bacterial infections typically begin within days.

The goal of treatment of local reactions to mosquito bites is to reduce symptoms. The first line of therapy is a non-sedating antihistamine such as certirizine (Zyrtec). A topical steroid cream can be very helpful to reduce itching and swelling; prescription products are more powerful and may be more effective. If the bite causes eye swelling that interferes with vision, lip swelling that interferes with eating or drinking or it’s difficult to use a limb, oral steroids can be used.

Prevention is the best medicine! Cover up, avoid going out at dawn and dusk and avoid wetlands, tall grass and brush. Insect repellents are appropriate for emergency use.

Monday, June 9, 2014

Why Worry?

Worrying is a useless habit. It does more harm than good and is a waste of time and emotion. It makes one anxious, impatient and exhausted. It annoys other people. Worrying is a learned behavior and as such, can be unlearned.

The worry habit has its basis in tension, stress or abuse. In response, one learns to be on the lookout for the next problem. Worriers think they are protecting themselves and others from danger: the more I worry, the safer I will be. Of course, this is completely false.

A worrisome thought is a warning signal that may be appropriately alerting you to danger. Rather than escalate your concern, examine the thought. What are you really worried about? Is it something in your control? If in your control, what is the worst thing that could happen? Is it likely and probable? Is there an action that you can take to resolve your worrying? If not in your control, do I gain anything by worrying about it?

You are not making anyone else happier by worrying about them; indeed worry makes you unhappy. Unrealistic fears lead to bad decisions.

Worry is a choice and a habit. Bad habits are not easy to change; the first step is recognition.

Mark Twain: ‘I am an old man and have known a great many troubles, but most of them never happened.’

Monday, June 2, 2014

Carrying the Laundry

If I could only ask one question to assess someone’s overall health it would be:  can you walk up and down a flight of stairs carrying a laundry basket? If you can accomplish this task I know that you have reasonable cardiovascular capacity, good balance, good core strength, reasonable vision, joints (knees, hips, shoulders, elbows, hands and feet) that work and adequate higher mental function. The fact that you even have a laundry basket in use indicates self-care.

When deciding if a patient’s knee problems require further evaluation I will ask about stability on the stairs. The risk of fall indicates the need for immediate orthopedic referral rather than conservative care.

Shortness of breath during activities can indicate a lack of blood flow through the coronary arteries. Walking on a flat surface is not taxing enough to provoke symptoms in mild disease – but a flight of stairs can trigger angina. I am not as worried about people who become short of breath visiting friends in fifth-floor walk-ups if they are not accustomed to so many flights of stairs.

Balance and core strength go hand in hand. Tied in with balance is proprioception (knowing where in space you are). Carrying a load requires back, abdominal, shoulder and arm strength. Keeping track of which step is next requires balance and the ability to know which step is the last. We all know what happens when we miss the last step – or think that there is one more.

Doing the laundry is a higher-level executive function. Inability to properly sort dirty clothes, operate the equipment, and finish the multi-step tasks could indicate cognitive decline. On the other hand, not doing the laundry could be because higher level functioning has not yet developed (e.g., college students).

I learn a lot about my patients during our few moments of chatter at the start and end of the visit. Lot of information is gleaned through seemingly casual banter.