Swelling Up with Solutions

http://www.aafp.org/afp/2013/0715/p102.html?aafpvlogin=7281773&aafpvpw=&URL_success=http%3A%2F%2Fwww.aafp.org%2Fafp%2F2013%2F0715%2Fp102.html

Above is an American Family Physician article from this summer outlining lower extremity edema. The article nicely delineates the algorithms for unilateral/bilateral edema, and also has some excellent photos as reminders.

A few summary tips if you cannot access the link:
1. Obviously, don't forget the #1 priority with unilateral lower extremity edema is to rule out DVT. Document a full history complete with a thorough risk factor assessment. Please comment below if you have had success with the new "direct referral DVT doppler" program outlined at the May 2013 provider meeting.
2. Use the skin (hemosiderin deposits) to help you document venous insufficiency.
3 Table 3 of the (often forgotten) medicines that can cause bilateral edema is a helpful reminder. Note that beta blockers, calcium channel blockers, and clonidine are prime culprits!
Reading this article can swell your medical diagnostic ability, so please peruse it.

Know the Limits of Your Science

At many of the past provider meetings and often face to face, I have repeatedly stated that when taken on a "macro" view, medical science is woefully inadequate and is often playing "catch up" to current tick borne diseases. As such, not only should caution be applied to the actual tick lab interpretation, but one should be cognizant that the pool of knowledge is shallow. To paraphrase Donald Rumsfield in the early 2000's, "the real danger is not what you don't know, but what you do not know that you do not know."

The bottom line is that with tick diseases, there are numerous "unknown unknowns."

As proof of this, consider the below linked article describing- yet again- another tick entity.

http://www.aafp.org/news-now/health-of-the-public/20130708bmiyamotoi.html

Add to the mix the fairly recent discovery of a new tick viral disease, outlined here:

http://www.cdc.gov/ncezid/dvbd/heartland/index.html

As such, what is a provider to do in these uncertain waters? While there are no absolutes, I think it is prudent given the evolving nature of tick disease etiology that one ensures:

- Caution with "shotgun labs." Aside from the usual caveat emptor with Lyme and tick titer interpretations, don't let the white blood cell count of 13,000 ( viral...or something else?) deepen your diagnostic dilemma.

-Rigorous documentation of "pertinent normals." No doubt, this blind spot in medical understanding is being easily exploited by chronic pain sufferers, disability seekers, and anxiety ridden people whipped into a frenzy by the evening news. This tsunami of "rushing to assume the sick role" means your note has to well document normals, such as no fever, no rash, rash less than 5cm (for Lyme), no arthralgias, no Bells, etc. In other words, "dot your i's and cross your t's" if you are witholding medicines, because society is requiring that validation.

-Clear discharge instructions assume an even more vital role here, especially since from an urgent angle we may see the tick bite before true tick disease develops. Note that many of the novel tick zoonoses often manifest as severe "prostration", to the level of hurting daily functioning. Aside from the usual headache, fever and rash, it may be prudent to warn patients of these issues also in your written discharge note. 

-The first article cites the need for a longer period of doxycycline (more of a 2 week Lyme type regimen than the "presumed RMSF" 1 week regimen). So, if you are writing for a "tick illness" seriously consider going for 2 weeks instead of one week. If you are crossing the Rubicon and treating, then treat with the proper regimen.