Am I Dying

by Christopher Kelly

  You spend most of the day sitting or standing in one place. Your heart pumps blood out to the body but doesn’t help as much with the return trip. If you’re not moving around, gravity traps fluid in your legs. Flexing your legs actually squeezes the fluid back up toward your heart, so move around for at least five minutes each hour. If you truly can’t manage that, try elevating your legs while sitting.

  The swelling occurs right before your period. The wild swings in hormones before your period do more than just affect your mood; they also cause your body to retain extra fluid. If it becomes bothersome, cut back on salty foods and elevate your legs whenever possible.

  You started a new medication. Certain medications have been associated with leg swelling, including amlodipine/Norvasc (for high blood pressure), steroids, estrogen, testosterone, and minoxidil/Rogaine. Just please don’t stop a medication without first calling your doctor.

  Make an Appointment

  You are with child. It’s normal to retain fluid during pregnancy, and most women notice ankle swelling during the second trimester. As you get farther along, the uterus actually becomes big enough to press on the vein that drains blood from the legs, making the swelling even worse. If, however, you notice a sudden increase in swelling, it could be a sign of a serious problem. If one leg is more swollen than the other, you could have a blood clot (which is more common in pregnant women). If both legs are swollen, you could have a rare complication of pregnancy known as preeclampsia, which is also associated with high blood pressure and kidney problems. You could also have a rare complication, known as peripartum cardiomyopathy, in which the heart muscle becomes weak. Call your obstetrician!

  You cut out the salt, your legs are up all day, and yet the swelling continues. Also, it looks like you have purple spiders on your legs. Sometimes, the veins in the legs become damaged and no longer do their job so well. They swell and enlarge, becoming visible under the skin, and blood and fluid get stuck in the legs. This condition, known as chronic venous insufficiency, is pretty common. You can take medications called diuretics, which purge your body of the extra fluid, and also try wearing compression stockings (think Spanx for your legs).

  You also have swelling in your thighs, hands, or face. If you’re retaining this much fluid, you could have a problem with your heart, liver, or kidneys. You need additional testing.

  The swelling is also red and painful to touch. You could have a skin infection, known as cellulitis, or a blood clot in a superficial vein just beneath the skin. Call your doctor for a same-day or next-day appointment. If you also have fever and chills, just head to the E.R.

  Get to the E.R.

  You have painful swelling in only one leg, and you recently had a leg injury or long trip. You may have developed a clot in a deep leg vein, called a deep venous thrombosis, that prevents blood from flowing out of the leg. As a result, the leg becomes swollen and often painful as well. A piece of the clot can break off and travel to the lungs, causing life-threatening problems. An ultrasound of your leg can confirm the diagnosis. If you have a clot, you’ll need to take blood thinners for at least three months.

  You are also short of breath. Problems with the heart, liver, and kidneys can cause fluid to accumulate throughout the body, usually starting in the legs and eventually reaching the lungs. Once there is excess fluid in the lungs, you become winded more easily and feel short of breath when you lie down at night. An alternate explanation is that a blood clot formed in your leg, causing swelling, and then a piece broke off and traveled to your lungs, causing shortness of breath. Either way, you need prompt medical attention.

  Tremor

  Got the shakes? Worried you’ll never be able to order soup at a nice restaurant again?

  You may have a tremor if part of your body exhibits unintentional, difficult-to-control shaking in specific circumstances. Although tremors usually affect the hands, they can also occur in the head, tongue, eyes, teeth, vocal cords (causing hoarseness), and legs. Tremors can occur at any age but generally start later in life.

  Tremors may occur only at rest, with improvement when the affected body part is intentionally used (resting tremor). In contrast, they may be silent at rest and appear only when the affected body part is used (action tremor) or approaches the final target of its movement (intention tremor).

  Although tremors may be a sign of a serious underlying disease, like Parkinson’s, most tremors are just bothersome nuisances in otherwise healthy people. So what explains your shakes?

  Take a Chill Pill

  Your tremor occurs only when you’re cold. We should explain right off the bat that shivers, though technically tremors, are completely normal in all warm-blooded animals. So, unless you are a reptile that has learned to read (in which case, please contact us immediately), you do not need to worry about shivering. The body shakes to burn calories, which generates heat and brings your body temperature back up to normal.

  You only shake when you’re smoking outside a bar at 3 a.m. We all have a physiologic (also called normal) tremor that is usually subtle but may become noticeable when you outstretch your hands (or try to thread a needle under a microscope). The tremor becomes further exaggerated with stress, fatigue, anxiety, and nicotine.

  You got your eyes from your mama and your tremor from your papa. An essential tremor usually begins in late adulthood and can be inherited from your parents. It is very common, affecting one in twenty people, and is an action tremor (worsens with use) that typically starts in your dominant hand but can spread to both hands. A glass or two of alcohol will usually tame an essential tremor and can be helpful for confirming the diagnosis; however, getting hammered is not exactly a sustainable treatment. Thus, if an essential tremor really interferes with your life, speak to your doctor about starting a medication like a beta blocker or primidone. You’ll need to weigh the benefits of suppressing the tremor against the possible side effects of the medication. It can also help to take the medication only on certain days, as your doctor may recommend.

  Make an Appointment

  That darn tremor makes it impossible to open the medication bottle. Several medications can cause tremor as a side effect, including stimulants (like amphetamines and pseudoephedrine), caffeine, asthma inhalers, some seizure medications, lithium, theophylline, and thyroid hormone. If you think one of your medications is causing your tremor, please do not stop it without speaking to your physician.

  You constantly feel hot and have also had weight loss, diarrhea, and/or palpitations. You may have an overactive thyroid, which sends your body’s metabolism into overdrive and can also exaggerate a physiologic (normal) tremor. Your doctor can do a simple blood test to check your thyroid hormone levels.

  You have a resting tremor, possibly alongside slow movements, rigidity, and a shuffling walk. Parkinson’s disease affects the brains of about a million Americans and causes progressive problems with movement. The classic tremor of Parkinson’s is a resting tremor described as “pill-rolling,” in which the thumb moves in a circular motion against the index finger. Other symptoms include body stiffness, problems with balance, a shuffling step, difficulty swallowing, and forgetfulness/dementia. Because Parkinson’s results from low brain levels of the chemical dopamine, the standard treatment is medications that increase levels back toward normal. If those don’t work, some patients benefit from the surgical implantation of a deep brain stimulator—basically a pacemaker for the brain. Although Parkinson’s disease usually occurs after age sixty, other conditions can cause similar symptoms (known as parkinsonism) earlier in life. One major cause of parkinsonism is the use of medications that block dopamine signals, like metoclopramide/Reglan and antipsychotics (haloperidol/Haldol, risperidone/Risperdal).

  Your tremor gets worse as you try to reach for your glass. An intention tremor gets worse not with use, but specifically as your hand gets closer to the object it is trying to reach. Often this tremor indicates a problem with the part of the brain known as the cerebellum, located in the
back of the head. Possible causes include multiple sclerosis, stroke, head injury, and alcoholism.

  You like to see the bottom of every bottle, and you shake whenever you stop drinking. If you drink a lot of alcohol (more than four to six servings on most days) and then suddenly stop, you may experience a tremor as a symptom of withdrawal. Other symptoms include headache, insomnia, sweating, and palpitations. The symptoms usually get better after a few days; however, severe withdrawal can be life threatening, and you should obviously go to the E.R. if you experience hallucinations, confusion, or seizures.

  You are under forty years old. You could have one of the tremors already described, but your doctor should also consider the possibility of Wilson’s disease, a rare genetic disorder that causes irreversible brain and liver damage due to copper accumulation. Patients can have resting or intention tremors; one classic type is the wing-beating tremor, in which the raised arms flap like wings. Other symptoms may include muscle stiffness, yellow skin, vomiting, abdominal pain, fluid accumulation in the abdomen and legs, difficulty speaking, and personality changes.

  Although it’s rare for the tremor to occur without these other symptoms, it’s worth checking for Wilson’s if you’re young and have a tremor, since the disease can be fatal if untreated. Simple blood tests can screen for this condition. The treatment usually consists of avoiding high-copper foods (like nuts, mushrooms, chocolate, dried fruit, and shellfish) and taking medications that bind any excess copper in the body.

  Get to the E.R.

  Your tremor starts suddenly, or you also have weakness, difficulty speaking, confusion, or high fever. New-onset tremors can sometimes be a sign of life-threatening conditions, such as severe imbalances in your blood’s electrolytes (like magnesium or calcium), strokes, or serious infections. Get to the E.R. fast.

  Joint and Muscle Pain

  EDITED BY ANCA DINU ASKANASE, M.D., M.P.H.

  The adult human body contains 206 bones and over 300 joints, which connect bones and provide stability, cushioning, and frictionless movement. Ligaments are tissues around joints that provide additional support, while tendons are tissues that connect muscles to bones.

  Arthritis occurs when joints become inflamed or worn out. There are many different types of arthritis, which are typically classified as noninflammatory (the result of wear and tear, as in osteoarthritis) or inflammatory (the result of immune cells attacking joints, as in rheumatoid arthritis and lupus).

  “Myalgia” is the medical term for muscle pain. Think how impressed your friends will be when you walk out of the locker room and confidently declare that you need some ice because “that game really gave me myalgias.” These too can result from overuse, autoimmune disease, and many other problems.

  So is your joint or muscle pain a sign of worse things to come? Could it be from a tick bite you got last summer? Or is it a sign you’re just getting old? Should you pop some pain relievers or call up your doctor for some X-rays?

  Take a Chill Pill

  You’re training for an Iron Man competition and experience pain in your joints or muscles. We recommend an active lifestyle that includes regular exercise—ideally at least twenty to thirty minutes per day—but don’t go crazy and overdo it. Make sure you gradually work yourself up to any big challenge. Stretch before and after your workouts, and if you notice pain after exercising, first try basic measures like icing, massaging, and resting the affected joints. If you’re still suffering, you can pop some nonsteroidal anti-inflammatory drugs, or NSAIDs. The most popular NSAIDs are ibuprofen/Advil/Motrin and naproxen/Aleve/Naprosyn. Of note, NSAIDs can cause problems in people with kidney or heart disease. If you have severe pain, difficulty with movement, or persistent pain despite rest and medications, call your doctor. You could have a more serious condition, known as rhabdomyolysis, in which muscle tissue actually breaks down after very intense exercise.

  Your fingers or toes change color when they’re cold or you’re stressed. You may have Raynaud’s phenomenon. In this fairly common condition, which affects one in twenty people, both cold temperatures and emotional stress make the blood vessels in your hands become so narrow that your fingers turn white and then blue. In some cases, you may also experience pain. Symptoms can occur in the toes, ears, nose, and even nipples too.

  If you get an attack, try to warm up the affected area. At other times, focus on prevention by avoiding cold temperatures (such as reaching into freezers), wearing warm gloves (possibly with hot packs inside), not smoking, and minimizing medications that shrink blood vessels. The major medications to look out for include decongestants (phenylephrine, pseudoephedrine), migraine medications (triptans, caffeine), and stimulants (methylphenidate/Ritalin).

  Although Raynaud’s phenomenon is usually not a big deal, it can sometimes be associated with an autoimmune condition like lupus or scleroderma. Mention it at your next doctor’s appointment, as you may need additional tests.

  If your symptoms are really bothersome and can’t be prevented, your doctor may prescribe a calcium channel blocker, a medication that helps keep vessels open. If your fingers stay blue and painful for more than thirty minutes, you may have a different kind of blockage in your blood vessels and should get to an urgent care center or E.R.

  Make an Appointment

  You twisted or injured a joint, which then became swollen and painful. If the pain is tolerable and the joint can be easily moved, you may simply have a strained ligament. You can try to wait and see if your symptoms improve with RICE: rest, ice, compression (tightly wrap the injured area with a bandage), and elevation. If your symptoms persist for more than one or two days, see your doctor for a detailed physical examination. If the pain is severe, the joint can’t move normally (or support your weight), or you have loss of sensation near the injury, you probably have a more serious problem, like a fracture, torn ligament, or ruptured tendon. If you can’t get a same-day appointment with your doctor, go to the E.R. for a complete examination and some X-rays.

  You’re over sixty and have had months or even years of pain in one or two joints. Wisdom comes with age, but unfortunately so too does osteoarthritis, or OA. This condition is especially common after age sixty and results from cumulative wear and tear on joints. Those most likely to be affected are the knees, hips, hands, and spine. The pain typically gets worse with activity and improves with rest.

  If you frequently use certain joints in repetitive movements (you’re an athlete or dancer), you may experience OA at an even younger age. Extra weight also stresses load-bearing joints (like your knees and hips) and accelerates damage to joints.

  Your doctor will order an X-ray (and possibly MRI) of the affected joints. The initial therapies usually include medicated creams (containing NSAIDs), physical therapy, and exercise. Your doctor or physical therapist may also recommend a splint or brace to help stabilize and strengthen your joint. Some people swear by capsaicin cream, which contains hot chili pepper oils and can numb pain (but also causes stinging when first applied). Weight loss can also reduce joint stress and improve pain.

  If creams don’t work, you can try NSAID pills. (See here.) For people with continued pain, an injection of steroids (or other substances, like blood plasma) directly into the joint may also help. If you’re still suffering despite all of these measures, your only remaining hope may be joint replacement surgery.

  You have multiple painful joints, which are usually at their worst when you first wake up in the morning. Your pain may be related to an autoimmune disease, which causes an inflammatory arthritis that gets worse with rest and improves with use. A common example is rheumatoid arthritis, or RA, which most often strikes women between the ages of forty and sixty. RA is typically symmetric, meaning it affects the same joints on both sides of the body (usually the hands and toes). It is sometimes associated with painless bumps around the elbow or forearm. Because RA is an autoimmune disease, it may also cause fever, weight loss, fatigue, eye redness/pain, and pain in the lining of the lungs and heart.
Your doctor will perform blood tests and X-rays to make the diagnosis. If you’re diagnosed with RA, don’t panic: there are many medications that can dramatically improve your symptoms and slow down joint damage.

  You also have itchy, scaly plaques on your elbows, knees, or scalp. One in three people with psoriasis (see here) also experiences inflammatory arthritis, related to abnormal targeting of joints by the immune system. (Interestingly, it’s even possible to have psoriatic arthritis without any skin lesions.) Another common issue is swelling and pain in the tendons and other tissues around joints, which causes your fingers or toes to look like sausages. Your doctor may recommend pain relievers or more powerful medications that partially suppress your body’s immune system and limit further joint damage.

  You have fever, chills, headache, cough, and pain in many of your muscles and joints. You may have the flu (even if you got your flu shot this season). Most people recover within a week by resting, drinking plenty of fluids, and taking pain medications like acetaminophen/Tylenol. Your doctor may also prescribe an antiviral medication (oseltamivir/Tamiflu) if you’ve had symptoms for less than forty-eight hours. Be aware that the flu can cause serious, life-threatening complications, such as pneumonia, so if you’re feeling really terrible (high fevers, nonstop cough, and so on) and can’t get a same-day appointment, visit an urgent care center or E.R.

  You also have bloody diarrhea and belly pain. You may have an autoimmune disease that affects both your intestines and your joints, such as celiac disease or inflammatory bowel disease (which includes Crohn’s disease and ulcerative colitis). In celiac disease, the joint pain usually goes away with a gluten-free diet. In inflammatory bowel disease, the pain often responds to medications that calm down the immune system.

  You’re over fifty and wake up with pain and stiffness in both shoulders or hips. You may have a condition known as polymyalgia rheumatica, or PMR, which usually occurs in a person’s seventies (almost never before fifty) and is more common in women. In this condition, the immune system attacks the joints and muscles in the shoulders and hips, leading to pain and stiffness. For most people, symptoms improve dramatically after taking low-dose steroid pills. About one in five people with PMR have a related condition known as temporal arteritis, which causes problems with the arteries on the side of the face, resulting in headaches, scalp tenderness, jaw pain while chewing, and blurred vision. The vision problems can progress and become irreversible if the condition is not promptly treated with high-dose steroids.