Common Ailments

Breakthrough

Posted on by writenp

My husband felt invincible after becoming fully vaccinated, but he got breakthrough Covid last month.  He thinks he caught it on a plane.  By then he was wearing a mask, just for show, really, and the comfortable cloth mask he wore was thin.  As was the mask worn by his seatmate who hunkered down in her hoodie during the two hour flight, refusing all snacks and beverages.  In retrospect, this was a huge red flag.  Because who turns down free Cheezits and Popcorners on Jet Blue? He had very little contact with anyone else before he became symptomatic three days later, so he is probably correct.

This is how it went down, with an onset that was slow and gradual: he started to get what he thought was a sinus infection, to which he is prone, followed by post nasal drip, some congestion and that was about it for a few days.  He began taking an antibiotic because of his long-standing sinus issues.  But unlike before, he didn’t get better after his third dose of Augmentin.  In fact he thought he might be feeling worse, more tired than usual.

I suggested testing and we kept googling (yes, even health care providers google, more than you’d think or maybe want to know) — sinus infection vs Covid symptoms, and Is it a cold or Covid?  Really it is impossible to tell because there are so many presentations and everyone is different.

I left, encouraging him to get tested but unaware that he was feeling progressively worse.  He bought a home Covid test and it was almost immediately, and very clearly, positive.  These OTC rapid tests are very reliable when the result is positive, especially in an area with high incidence.  (This was Florida.)  So we knew he had to self-isolate for 10 days from when he was first symptomatic. 

We kept in close touch and Facetimed.  I’d say he had about 2 ½ days of feeling quite miserable.  He had all the symptoms of a bad case of influenza: headache, fever, chills, fatigue, muscle aches, congestion and cough.  He never lost his sense of taste or smell nor did he have a sore throat.  He never experienced chest pain or shortness of breath but his pulse ox (which tells us how well the blood is being oxygenated) at the lowest was 92.  (Normal is 96-100, and we start to pay attention when it is heading down towards 90.)  When he started feeling better, his metrics improved accordingly.  We shudder to think what would have happened had he not been vaccinated.

At that time he was commuting to Florida about every other week for work and I spent an occasional weekend there.  I did not get sick even though we spent three days together unmasked indoors and in a car.  I took two OTC tests — one when I got home (three days past the first exposure) and one three days after that, both negative.  I never developed symptoms but if I had, and the OTC test was still negative, I would have gone for a PCR test. Of note, he had 2 Pfizer vaccines and I had 2 Moderna.

Having a background as I do in community health, it’s not lost on me that this breakthrough, likely caused by the Delta variant, will not become part of the data. I think this is the norm, unfortunately, rather than the exception and I’ll tell you why.  PCR testing is nowhere near as available and accessible as it needs to be. Really it should be on speed dial, 24/7, where someone will come to you and administer the test.  For free. Then we would have some real data.  But the reality is that, depending on the time of day, it can be difficult to get a timely appointment.  Plus going out is miserable when you don’t feel well and you run the risk of exposing other people.  

The next best thing is an OTC test for people who want to do the right thing and protect others.  Anecdotally I know of six individuals with breakthrough cases in my immediate familial, friend and professional circle.  All of them relatively young (well, under 65) healthy people. They all did the right thing.  To me it is apparent that breakthroughs are way more prevalent that the CDC would have us believe.  Maybe it’s because they don’t have the data but also likely due to a reluctance to say anything negative about the vaccines. Understandable given all the negative misinformation out there and the need to get more people vaccinated.  Sure it was always mentioned that the vaccines were not 100% effective at preventing symptomatic disease, but until Delta, people did think they were bulletproof. Maybe that’s just human nature.  And we were all very tired of masking and distancing.

But picture this.  I am flying home, double-masked (cloth over surgical) and notice many children with “colds” on the plane.  Lots of coughing and sneezing.  These families were returning home from vacation.  Were they going to have their child tested in Florida at the first sniffle and then isolate in a hotel room waiting for results and possibly a longer isolation?  No.  They needed to get home and get back to their lives.  Maybe they thought, ostrich-like, if there was no test, there was no Covid, or maybe they didn’t think about it at all.   I don’t know if the parents were vaccinated and of course, I don’t know if these children actually had Covid.  But they certainly could have, given the circumstances.  I wonder how many people on the plane later got sick.  

Would requiring a negative test or proof of vaccination decrease transmission during travel? Might a mandate like that also increase vaccination rates?  To me it’s clear that it would, but not without a great deal of pushback and negative impact on the airline and travel industries.  Apparently it’s hard enough to get some people to keep their masks on when traveling. It’s easy to imagine that such a mandate would simply transfer the disruptive behavior of anti-maskers on planes to the lines at the airport when the non-compliant are prevented from boarding.

There are no easy answers.  While some of us would do a great deal to end this pandemic, there are still some who doubt its very existence or have gone down the rabbit hole of misinformation, unlikely to surface.  For now, this much I do know: the fully vaccinated are not invincible and should continue to be careful when the situation warrants, especially when travelling or in areas with high incidence.  Stay safe out there, and do the right thing.

Hobbled: Running, Plantar Fasciitis and My Mom

Posted on by writenp

One of my earliest memories is of my mother instructing me how to propel myself on a swing to soar above the then cement-covered playgrounds of New York City. “Stick your legs out and pump!” she coached three-year-old me. I didn’t know what “pump” meant and she had no understanding of aerodynamics. It didn’t go well.

Like many runners, I did not grow up athletic. In fact, I come from a family of remarkably uncoordinated couch potatoes, particularly on my mother’s side. This did nothing to stop my mother from attempting to teach me physical skills she herself did not possess, such as the afore-mentioned swinging.

One concussion and many skinned knees later, I accepted my lack of athletic prowess. After all, I was in good company. Hardly anyone in my family knew how to swim, let alone skate, ski, or play tennis. You’d think it had to do with lack of money but my father, the lone exception, grew up poorer than anyone, yet knew how to swim and skate. He learned to swim by being thrown by his buddies into New York City’s East River. I know. Amazing he was able to procreate after swimming in that toxic soup.

According to family legend, my mother sank like a stone when thrown into a local pool as a teenager and had to be pulled out ignominiously by the seat of her raggedy bathing suit. I have to assume being thrown into a body of water was a rite of passage back then. Lacking my father’s innate abilities, my mother was unfazed, and determined that I learn how to swim.

When teaching me by the side of the local pool didn’t pan out — “Kick your legs, and alternately stroke with your arms, taking a breath every other stroke!”– my mother scrimped to send me to a day camp specifically to learn to swim. I contracted a bad case of swimmer’s ear on day one and had to sit out pool time for the remaining two weeks.

Cutting her losses, my mother set her sights next on bike riding. Quickly she realized this kind of tutelage required a degree of coordination and strength far beyond her own. This was especially true when the child in question had no sense of balance. Someone was bound to get hurt.

My father finally managed to teach me how to ride without training wheels when I was eight, a feat akin to teaching Koko the gorilla American Sign Language. Soon after, I got bumped by a car when I attempted to cross the street between two parked cars. (Hey that’s how we rolled in the Bronx.) Lacking the self-preserving reflexes possessed by most humans, I failed to put my arms out to break my fall. For weeks I sported a grotesquely fat lip and lost the tooth I hit 10 years later.

Catholic school did not help me improve my athletic skills. The backs of my legs always sported welts from misadventures in jumping rope. Jumping-in eluded me and forget about Double Dutch. The dreaded dodge ball in gym was a little bit “Lord of the Flies” in terms of lax supervision and Piggy, I mean I, knowing neither how to throw nor to dodge, was often the worse for wear.

I found my people when I left the nuns and went to a “special” public high school with a concentration in science. You had to take a test to get in and it had nothing to do with physical fitness. Our most popular team was math team. My dodge ball days were over.

In college, there were two major obstacles for the non-athletic — the dreaded swim test and a gym requirement. The swim test, though well intentioned, was a source of severe anxiety to certain demographics. Namely, the poor, the foreign and the phobic. We had not learned to swim as children and could not believe we had to do so now.

There was no choice but to take the introductory swim class. Yes, it was a bit like that rite of passage my parents endured. But at least it counted toward the mandatory gym credits. I found it was a major advantage not to be phobic and to have English as a first language. I actually learned to swim the required three strokes as well as tread water after jumping off the deep end, a feat never to be repeated.

I’m drawing a blank on how I managed the remaining college gym requirements This might have something to do with repeated head trauma sustained during introductory volleyball — I couldn’t help closing my eyes when the ball was in flight.

I know I tried to be more active during those four years. Inspired by a boyfriend at the time, I even attempted “jogging” for the first time. I barely got to half a mile before I had to sit down on the curb, out of breath and half suspecting I might be having a heart attack.

Fast forward 25 years or so. My daughter joins the cross country team her first year of high school. Inspired by a not well-received wish to show solidarity, I start to run. And I like it. I took it slow and was gratified to find that my prior life of sloth left me pristine knees and hips compared to experienced runners.

I started doing some races. Controverting popular running wisdom, I began with a very hilly 10 K and finished (that alone was my goal) in a little over an hour. The vomiting at mile 3 was just an added bonus. Running became my way to relieve stress, to think, and to keep middle age weight gain under control while still eating (and drinking) what I wanted. This past summer, I toyed with the idea of a half-marathon and upped my distances, getting to 12 miles.

I felt strong and fit. Clearly I was overconfident. Ran perhaps more than I should have one weekend with friends who were marathoners. Or maybe it was the neon Easter-egg colored minimalist shoes that didn’t give enough support but were so cute. The next time I ran, I felt this searing pain in my heel about 2 miles in that would not permit me to continue my run. I hobbled home.

Plantar fasciitis (PF). Once thought to be an inflammatory condition, currently the etiology was being debated. There was no consensus on best treatments. It depended somewhat on whether you consulted a podiatrist or sports medicine orthopedist, how far you were willing to go (injections of platelet rich plasma, anyone?), and how much you were willing to pay.

As a health care provider, I tried what the literature suggested and what I in turn had suggested to my patients. Non-steroidal anti-inflammatories and prednisone, an oral steroid, didn’t help, which gave credence to the latest thinking that PF might not be an inflammatory response to injury. I did all the proscribed stretching exercises daily. I took up yoga again. (Downward dog is the perfect stretch for plantar fasciitis.) Decided to eschew steroid injections based on my research and orthotics based on prior bad experience.

I believed the cause in my case was a sprained ankle about six weeks prior that I ran on too soon. The ankle was weak and threw off my gait. So I started cross training at the gym to build up strength. Faithfully stretched, used a foam roller and massaged my foot with a frozen rubber ball daily. Wore the snazzy Strasburg sock at night (https://www.amazon.com/strassburg-sock).  Got fitted for more supportive (albeit slightly less cute) shoes at a running store.

Almost six months later, it is definitely getting better. Some days I have no pain at all. I can run four miles outdoors, five on the treadmill with minimal discomfort. I’m back, baby.

I often wonder what my mother would have made of this newfound running obsession and my recent struggles. She wouldn’t have understood it but she would have put her two cents in. “Propel yourself forward while swinging your arms,” she might have called out, undeterred as always by her lack of personal experience. “Shorten your stride and increase your cadence. And don’t forget to stretch.”

Thanks, Mom. I think I got this.

#plantarfasciitis #RunningInjuries, #unathletic, #HobbledNoMore #RockingThatStrassburg Sock

 

Skin Stuff: or, Yellow Salve Revisited

Posted on by writenp

This is one of my more clinical posts, addressing common skin disorders. If you are interested, feel free to suggest more topics in the comments section.

Cold Sores

As a small child, I developed what our local GP called impetigo on my lips. My mother put this yellow salve on it. I still remember its slightly sweet taste and grainy consistency. I couldn’t stop licking it off.  Salve – it’s such a medieval-sounding name. I’ve not sure if she got it by RX or if it was something the pharmacist just whipped up.  As I remember, it did nothing but dry out the lesions which took about a week to go away. (If you look online for yellow salve, it seems to be making a comeback as an alternative treatment, but I’m not sure it’s targeted towards cold sores or even whether it is indeed the same yellow salve.) Trouble was, this wasn’t impetigo, it was herpes labialis, or your common cold sore.  Kids can develop this in infancy, often by being kissed by someone infected, or contact with the lesions of a playmate. It’s caused by a virus related to chicken pox and shingles, hence the blisters, and has cycles of dormancy and recurrence. It can be brought on by illness, i.e., a cold, stress, or too much sun. If you’ve had it, you become hypervigilant about the first sign of a tingle, the harbinger or “prodrome,” as we say in the biz, of an outbreak.  Best way to diagnose it is through a viral culture. If the clinical presentation is not obvious, I do both a bacterial and viral culture and see what grows out. Treatment has come a long way, and if begun at that first tingle, goes a long way towards stopping a full-blown outbreak which can be very painful, disfiguring, and embarrassing.

For adults, I prescribe valacyclovir (generic Valtrex), the huge 1000 mg lozenge-shaped pills. Take two of them at the first sign and then another two 12 hours later.  So four should treat an outbreak, which is a good thing because they are very expensive, over $10 per pill. Insurers prefer the cheaper anti-viral, acyclovir, which does not work nearly as well.   I also recommend OTC Abreva (www.abreva.com), a cream that can be applied as often as you like. Since it is white, you might want to save this for when you are not out in public.  You can also buy an OTC clear lysine gel which you can use when you are out and about.  Why would you want these extra measures?  If you are already a cold sore sufferer, you know. Those lesions hurt and are unsightly, and you just want to do everything you can to make them go away.   Health care providers are not immune to this desire to overtreat their own outbreaks.  A dermatologist once told me she herself used a topical steroid cream to reduce inflammation.  This is controversial because a steroid can decrease immunological response. Her point was that a lot of the pain and swelling is caused by inflammation and the steroid addressed that.  If you are unlucky enough to suffer from cold sores, make sure you have your provider write you a script for the 1000 mg valacyclovir pills, maybe eight, with a lot of refills. And always carry two pills around with you.

Preventing Skin Cancer and the Problem of Vitamin D

What I (often) tell my kids about skin care is wear sunscreen every day, at least 30 SPF, limit exposure from 12-3pm, wear a hat and sunglasses when in bright sun, and get a yearly full body check by a dermatologist.  Some posit that this kind of vigilance against skin cancer – a good thing – has led to a widespread Vitamin D deficiency – a bad thing.

Vitamin D is a fat-soluble nutrient essential for calcium absorption, bone health, heart health and especially important for those with autoimmune diseases.  It has been advised to get at least 10 minutes of unprotected sunlight daily so your body can make vitamin D.  This is controversial because of the association of sun exposure with skin cancer. Medicine is seldom black and white. We don’t know how much sunlight is safe, and most dermatologists will tell you, no amount is safe.  I always advise it’s best to get your vitamins through food in most cases, although that’s difficult with vitamin D. Web MD lists food sources of vitamin D: http://www.webmd.com/osteoporosis/features/the-truth-about-vitamin-d-vitamin-d-food-sources), some of which include fortified foods (where the vitamin is added). For a while, most primary care providers were checking vitamin D levels as part of regular screening blood work. You might recall lots of people were deemed deficient and were advised to take megadoses for a period of time. (I was shown to be mildly deficient but chose not to do this. Not a fan of megadoses of anything.)  Now the USPSTF (United States Preventative Services Task Force) recommends against this screening, citing there is not enough information to assess benefits vs harm in testing of adults without symptoms.

Acne

When teens are just breaking out a little bit, simple solutions are the best.  I tell them: don’t overwash, and use a mild cleanser like Cetaphil (www.cetaphil.com). Don’t scrub or use harsh astringents. First try benzoyl peroxide cream (Clearasil: www.clearasil.com) applied to the zits at night. Takes about six weeks to see results, so be patient.  Next step is adding a prescription antibiotic cream, like clindamycin, and mixing the two together. There are premixed creams such as Duac and Benzaclin but insurers are getting less inclined to pay for them.  Some people do well with Differin (www.differin.com) which is a retinoid, similar in the way it works to Accutane or Retin A, but milder, and with fewer side effects. Now you can buy it over the counter. After topical creams, providers try six-week courses of oral antibiotics such as doxycycline, minocycline, or azithromycin. These can work well, but like all antibiotics, they have potential side effects. If the RX topical treatments are not working after six weeks, I recommend seeing a dermatologist.

Diaper Rash

Diaper dermatitis happens to all babies at one time or another, usually after a bout of diarrhea.  At home, treatment is frequent diaper changes, using a diaper balm, allowing the area to air-dry when feasible.  Sometimes, though, the rash is severe, beefy-red, causing obvious discomfort. This is when your child should be seen by a provider. Often, when it gets this severe, there is a fungal component. Usually I can see the rash is deep red, with small affected areas in addition to the main one, called “satellite lesions”.  I prescribe the anti-fungal nystatin cream, and sometimes a steroid cream as well if there is particular discomfort. I advise using the nystatin after each diaper change for 3 days, cleaning with warm water instead of wipes, exposing the diaper area to air as much as is possible.  Not too often, but sometimes, the problem is a bacterial infection, the impetigo I mentioned in the beginning of this post.  In the diaper area, it can manifest with rather large blisters and is called bullous impetigo (which can also appear in other places).  The treatment is antibiotics, usually oral if a large area is affected.

Eczema

Eczema or atopic dermatitis, usually starts in infancy, manifesting as rough dry, reddish patches which can be itchy. It can be mild or severe and is an allergic response to the environment or food and linked to other allergic disorders, such as asthma.  Severe cases are very itchy and can result in secondary bacterial infections from scratching.  Steroid creams are used to treat the outbreak but prevention is best and here’s why: steroids can adversely change the appearance and texture of the skin, making it thinner and at times, darker, which can be permanent, if used for more than two weeks, twice a day.  At times parents need to be educated about this because the steroid cream works so well, they want to use it all the time to keep their child comfortable. If the steroids aren’t helping, there are newer topical meds, such as Elidel and others in this class, approved for children over two years old. At this point, though, I advise having the child seen by a dermatologist. There have been some safety concerns about these newer drugs, including a possible link to certain cancers, but nothing has been proven at this point.

For prevention, I advise only using mild unscented soap, such as Dove for sensitive skin (www.Dove.com), every other day, washing with only water on the days in between. Moisturizing is key. A&D ointment works very well, but some people dislike the rather medicinal smell; others actually prefer it because it makes it seem more like a healing medication. Also good is Aquaphor (www.aquaphorUS.com) or plain old petroleum jelly, which is basically the same thing. The good news is you can use these ointments as much as you want (or can stand, since they can be messy). A little goes a long way. The problem with scented baby oils or lotions is that the scent itself can cause an allergic reaction. Also important is using a detergent for bedding, towels and clothing that is free of perfume and dyes and not using dryer sheets, which can cause a reaction to predisposed people.  If you notice you or your child has an outbreak following a certain food, cut it out. You can get allergy testing down the road but most allergists prefer to wait until children are aged three or older.

There are plenty more skin conditions that could be addressed, but I will stop here. If you have any skin topics you’d like me to cover (or any other clinical topics), put your suggestions for future topics in the comments section below.  No promises, though, and please, no personal medical queries – see your own provider for that.  If you prefer more “Tales From the Clinic” patient stories,  let me know that too.

 

Healthy Thoughts: What This Blog is All About

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There are a lot of health-related blogs out there, so what makes this one different?  Imagine if you will that you have a close relative or friend who is a nurse practitioner.  You would probably feel free to ask her or him anything about your current state of health as a matter of course. Off the cuff, spur of the moment,  things you might not ask your doctor because of embarrassment or time constraints or fear of seeming silly.

My patients often tell me nurse practitioners are easy to talk to because they listen. And I do make it a point to give my full attention when a patient is describing symptoms or as we say in the biz – complaints. That word may have a negative connotation outside of health care but it’s a simple way to describe what brought you in to see a health care provider.

Even nurse practitioners have restricted time-slots (alas!) so there are questions that you might not get to ask during an office visit. Unless you have a relative or friend who’s an NP. Then you can send emails to that person with the subject line “eye” or “kidney” or “weird symptoms.” And you will get answers.

Now before you get the wrong idea – this blog is not going to be a forum for your specific health questions.  Rather, I will discuss all the kinds of questions patients, relatives, friends, and yes, even strangers, have asked me about their health. Chances are, some of these topics will speak to you personally.  I will share with you my health practices — what I do to stay healthy, what I advise my family to do, as well as share my thoughts about health care today, including how to utilize the system to optimize your health. My goal is to improve health through knowledge, from a nurse practitioner’s perspective.

But that is not my only motivation.  The URL for the website is www.mynursepractitionerwrites.com because, well. I was a writer before I was a nurse practitioner.  And sometimes, certain patient encounters resonate with me, becoming almost lyrical in the truths they reveal about both the patient and provider. It happens when the humanity of each person comes through despite the trappings, time constraints and mechanisms of modern-day healthcare.  It’s the reason  I renamed my site, “Tales From the Clinic.”  Some of the content is clinical, for sure, and some of it reflects the meaning I find in patient stories.

Please take a look at the menu bar to find content that interests you, and if you find it helpful, or just fun to read, please subscribe to my blog at the bottom of the menu drop-down. Thank you.

© 2016-2020 Eileen Healy Carlsen, FNP-BC (board certified nurse practitioner in Family Health)

The Dreaded UTI

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You notice in retrospect that you’ve been peeing more than usual. You tell yourself you’ve just been drinking more water lately. Then you notice a little twinge in your lower abdomen (what we call the supra-pubic region). You begin to suspect (okay, reluctantly admit) you are getting a urinary tract infection (UTI). (Note, this post is about UTIs in women.)

What to do? It depends a bit on your age, but everyone should drink lots of water, at least 20 oz. an hour. Recently the long-held belief that cranberry juice has a bacteriostatic effect and can nip a UTI in the bud has been disputed due to lack of scientific evidence. But it doesn’t do any harm so I do start drinking a cup of pure cranberry juice (not sweetened cocktail) an hour.

Women up to perimenopause (so teens to 40-ish) should see a health care provider if the symptoms persist more than a day, or worsen. The reason is that an annoying UTI can more easily turn into a serious kidney infection (pyelonephritis) if left untreated, and is especially common in younger women. Symptoms of pyelonephritis include lower back pain (bilateral or one-sided), pelvic pain, fever and chills. Any of these symptoms require prompt medical attention. It is very important that a urine sample is collected. Your provider will do a quick “dipstick” test that can indicate if you have an infection, and then, send your urine specimen out to the lab for a culture and sensitivities test. This second step is vital because UTIs can be caused by a variety of bacteria that require different antibiotics. (This is the reason I rarely will prescribe an antibiotic for a UTI over the phone. It’s is in the patient’s best interest to come in, if only to submit a urine sample.) Also if your infection is just getting started, the dipstick might be negative or inconclusive but the culture will usually demonstrate an infection if you have one.

Seeing a health care provider is important because the physical exam dictates the care. If I see a young women with all the symptoms of a UTI, including suprapubic tenderness, I will rule out pelvic inflammatory disease (PID) with a quick pelvic exam and send some tests out for STIs (sexually transmitted infections) like chlamydia and gonorrhea which can mimic the symptoms of a UTI. (I always do a pregnancy test too and a positive result will dictate further treatment.) I am going to treat her for a UTI, regardless of what the dipstick says. And if the pelvic exam is suspicious, I will treat for those STIs separately as well while we await lab results. It’s called treating empirically. If I suspect a possible kidney infection, I’ll use a certain type of antibiotic called a fluoroquinolone. If not, I’ll use a medication called nitrofurantoin because of the problem of bacterial resistance to some commonly-used drugs. If the culture and sensitivities test I ordered indicates a different antibiotic is needed, I will call the patient and change it. I always tell my patients to call if they are not much better in three days or if they feel worse, and to go to the ER if the symptoms of a kidney infection develop.

For women entering perimenopause, or if they are menopausal or post-menopausal, fluctuation in estrogen can make them more susceptible to cystitis which is inflammation of the bladder. Cystitis may or may not be caused by a bacterial infection. These women can try the water and cranberry juice for a few days as long as the symptoms don’t worsen and there is no fever or back pain involved. Ibuprofen also helps with the inflammation. It’s never a mistake however, to go to your health care provider at the first sign of a UTI at any age.

There are some things all women can do to prevent UTIs:

  • Keep hydrated and don’t hold urine in when you feel the need to urinate. (‘Holding it’ for too long can definitely cause a UTI.)
  • Wipe from front to back after a bowel movement
  • Urinate ASAP before and after sexual intercourse.

Hope this helps the next time you have an “uh oh” moment.

Of Flu Shots and Z Packs

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Everybody gets sick but some get sick more often than others.  As health care providers most nurse practitioners enjoy a robust immunity bolstered by constant contact with germs and sometimes people (usually children) coughing or sneezing in our faces. There are preventative measures anyone can take to reduce your changes of getting sick.  Handwashing is key.  I make it a habit to thoroughly wash my hands as soon as I enter my house, in addition to the usual instances. Being up to date on immunizations, including a yearly flu shot is probably the second most important thing you can do. The third is lifestyle — eating healthy food, staying hydrated and well-rested.  Even if you do all these things, you could get sick.  And most of the time, unfortunately, there isn’t a quick fix.  I am amazed at the people who present with a day or 2 of cold symptoms and demand an antibiotic — usually, and specifically a “Z-pack.”  I always take the time to discuss the likelihood of a viral illness, home measures to help you feel better and the healing power of time. Many people will listen politely and repeat their request, citing that the last time they were sick, this did the trick.  I review the potential side effects, sparing no detail.  Then I usually suggest they wait for a few days, sometimes giving them a “prescription to hold” so they don’t have to come back.  We both know they are going to fill it right away but it’s my way of taking a stand for what we call antibiotic stewardship.  What’s particularly curious is these same people who are so quick to put an antibiotic into their system will refuse a flu shot because of potential side effects (very few and benign) or because “the last time I got the flu shot, I came down with the flu.”  Which is of course impossible.  It’s an inactivated vaccine.  They could have been coming down with a cold at the time of the injection (I discourage getting the shot if you are feeling at all under the weather at the time.), or caught some other virus in the waiting room.  The funny thing is, health care providers, for the most part, practice whet we preach.  We get the flu shot every year and we resist taking antibiotics unless we are sure we have a bacterial infection, which is the only kind of infection antibiotics can resolve.