random nose bleed covid

They're common, particularly in children, and most can be easily treated at home. Of course, the viral infection could also cause direct damage to the respiratory epithelium. It is better to use a nasal spray or inhale vaporized water to manage congestion after a nosebleed. A deviated septum occurs when the nasal septum has an abnormal shape or position. 25% of COVID-19 patients have lasting reduction in lung function. Find out why they happen and who is at risk. Associate Editor, MedPage Today Sometimes no taste and, Can this nasal dryness be a result from the Pfizer Vaccination? between patient and physician/doctor and the medical advice they may provide. Health's content is for informational and educational purposes only. Your Nose Bleeds Nonstop for 20 Minutes Most healthy people should be able to stop a bloody nose at home in 20 minutes or less. The ACE2 receptor is the site at which the spike protein of the virus gains entry into the host cell to commence viral replication. This is, Dr. Voigt notes, more common in little kids, but it does happen in adults sometimes. Random nosebleeds are always a nuisance, except maybe if you want to be Carrie for Halloween and don't have time to buy fake blood. When a nosebleed happens, Dr. Hopkins suggests doing the following: While nosebleeds are sometimesbothersome, they are usually not cause for concern, Dr. Hopkins says. News-Medical.Net provides this medical information service in accordance Earlier this week, a report in the New York Times highlighted the fact that around 36 reports of this rare blood disorder, also called immune thrombocytopenia (ITP), was submitted to the federal . The importance of these findings is not that they are life-threatening, or contribute to the morbidity, but that they are 1) distinct from anosmia or ageusia, and 2) present early in the course of the illness. To stop one, pinch your nostrils, don't blow your nose, and don't stick anything in your nose. Nosebleeds, bleeding from the mouth, and heavy periods can also occur. Most nosebleeds are not harmful, but it is important to see a doctor if it lasts more than 30 minutes or occurs alongside other symptoms, such as chest pain. Why the CDC Database Is Crucial to Vaccine Safetyand How to Use It Responsibly, CDC Recommends COVID Vaccines for Kids Under 5Here's When Shots Could Go in Little Arms, Why the FDA Restricted Use of Johnson & Johnson's COVID-19 Vaccine, Is the COVID-19 Vaccine Safe for Everyone? Theres just that rush of blood and a race to contain it. The research appears in Scientific Reports. Share on Facebook. If yours is deviated, meaning it leans to the left or right, one side of it can be more exposed to airflow than it usually would be, according to the Mayo Clinic. dry and itchy skin. Nosebleeds can come on suddenly for a variety of reasons, says Olivia Kalmanson, MD, an otolaryngology resident at the University of Colorado. How Gross Is It to Wear New Clothes Without Washing Them First? Some of this data was recently published in the medical literature, with a letter to the editor in Clinical Infectious Diseases by Andrea Giacomelli, MD, of the University of Milan, and colleagues, noting hospitalized patients admitted for COVID-19 "complained of olfactory and taste disorders.". If blood is still leaking after this, keep applying gentle pressure to either side of the nose for a further 10 minutes. Is a bloody nose a sign of COVID-19? When a nosebleed occurs, a blood clot will form to prevent excessive bleeding from the vessels. News-Medical. by I get nauseous and just have to lay down. A healthcare professional can seal the damaged blood vessels or use medication to stop the blood leaking. Digestive symptoms sometimes develop before a fever and respiratory symptoms. Cleveland Clinic is a non-profit academic medical center. In winter months when air is dry, use a humidifier (especially if you have radiant heat in your home). This often helps stop bleeding. Loss of smell or taste. I'm going through the same thing now. Nose-picking oftenirritates or scratches the nasal plexus, and that damage makes more nosebleeds likely. Policy. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. 3. Trauma. What is the latest research on the form of cancer Jimmy Carter has? Very dry environments can cause nosebleeds. He had severe nasal bleeding which did not stop for 4-5 hours. Compilation of the top interviews, articles, and news in the last year. Nasal dryness could be an early warning sign of COVID-19. National Heart, Lung, and Blood Institute (NHLBI), Centers for Disease Control and Prevention (CDC), Platelet Disorder Support Association (PDSA). What is the latest research on the form of cancer Jimmy Carter has? To be clear, frequent nosebleeds are much more likely to be a sign of something less serious than a bleeding disorder, Dr. Patel says. It is possible to remove a blood clot by gently blowing the nose when the nosebleed stops. Outlook brings to you today news from India along with top headlines, current news and live updates on politics, election, national issues, Covid-19 and news from the states. If you suffer from chronic nosebleeds, these tips mayhelp keep them at bay. An infection with the SARS-CoV-2 virus may cause new or worse symptoms. They interviewed 59 patients and found 20 reported at least one taste or olfactory disorder, while 11 patients reported both. It almost felt like a burning sensation. Sit straight up, apply pressure, be patient and dont stuff it. Goblet cells, which are found scattered among epithelia in the respiratory and intestinal tract, are viral targets, since they express ACE2. This combination will make the nose very dry, which allows little cracks to develop in its membranes, Dr. Voigt says. Nosebleeds often seem to happen out of the blue, striking at random. After discharge from the hospital it happened again after 2nd day but this time blood flow stopped in 5 minutes. very heavy bleeding that is leaking down the throat. These Could Be the Reasons Why, How To Help Your Baby or Toddler Clear Their Stuffy Nose, 6 Sore Throat Remedies That Actually Work. SELF may earn a portion of sales from products that are purchased through our site as part of our Affiliate Partnerships with retailers. 4. If any of your noses blood vessels become irritated and exposed in the process, voil, bloody nose. With immune thrombocytopenia (ITP) in particular, the body's immune system attacks and destroys its own platelets, per the NHLBI, and produces fewer platelets than normal. Last medically reviewed on August 27, 2019, While nosebleeds do not always indicate a serious problem, there are different types. This can be caused by: Nosebleeds that need medical attention can come from deeper inside the nose and usually affect adults. In most cases, nosebleeds are not serious and do not require medical attention. Nose bleeds are common and are generally not a cause for concern. 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If youve recently been taking either kind, any injury to your noses blood vessels might cause bleeding when it otherwise wouldnt or bleed more than youd expect, Dr. Voigt says. Seen initially as a cause of viral pneumonia during the chaos of an explosion of cases in China, its now emerging as an enigmatic pathogen capable of harming the body in a myriad of unexpected, and sometimes lethal, ways. It is best to wait until the bleeding stops completely before blowing out the blood clot. "The first thing to do is sit upright (or to sit your child upright)," Dr. Chaaban says . Nosebleeds aren't necessarily a major health concern, unless they are frequent or severe. Nasal dryness could be an early warning sign of COVID-19. If youre still bleeding at the 20-30-minute mark, its time to talk to a medical professional. The first thing to do is sit upright (or to sit your child upright), Dr. Chaaban says. Clinical manifestations range from common cold-like symptoms and bronchitis to more severe disease such as pneumonia, severe acute respiratory distress syndrome, multi-organ failure and even death. The illness may occur as a direct result of viral infection, as well as the bodys response to it. It almost smells like I am breathing in a chemical. Heres a snapshot of some of the symptoms Covid-19 causes, including some you might not have heard about. FDA characterizes the reporting system as "a valuable tool" for keeping tabs on patient safety after vaccines go to market. It can also be a result of bleeding from larger blood vessels in the back of your nose that may require further management. It's been known to occur with other vaccines too, Dr. Bussel added. Chest Pain: Is It Heart Attack or Nutcracker Esophagus? frequent need to urinate. Youll need an extra tissue for this one, just in case. In the future, he said he would like to see research on whether COVID-19 patients have smell loss at a greater frequency than people with the same symptoms, without COVID-19, as well as tracking patients to see if it only occurs in mild cases or if it occurs in all patients. Opens in a new tab or window, Visit us on YouTube. Another symptom of a deviated septum is congestion, which can also increase the risk of nosebleeds. Following the same three steps, it is possible to stop the nosebleed. Nonsteroidal anti-inflammatory drugs are another form of medication that can increase the risk of nosebleeds. Advertising on our site helps support our mission. As Dr. Bussel told Health in February 2021, only 19 of the reports to VAERS represented "clear cases" of ITP. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. Mucus reduction could also cause strange sensations in the nasal cavity, in which case virus-induced this could also herald COVID-19 earlier than other symptoms. I had hospitalized him and we had to pack the full nose for 3 days. Sometimes no taste and other times things tasted different like chemicals and or certain foods would burn my throat . You may need to stay in hospital for a day or two. A nosebleed can rarely be caused by a tumor, but this usually comes with other symptoms. Dont pick your nose. How to treat and sleep better with a stuffy nose, Are sinus infections contagious? And dont relieve pressure before the time is up to check, as you may restart the bleeding. Yikes, here comes the blood! Musk Made a Mess at Twitter. The good news? Benign (aka noncancerous) growths of blood vessels, known as hemangiomas, can crop up in your nose and bleed, Dr. Voigt says. When You Should Worry, How to Stop Bleeding in Small and Deep Cuts. Learn about the causes and treatment options here. Opens in a new tab or window, Visit us on LinkedIn. If your child suffers from nosebleeds, theyll probably grow out of it by the teenage years, he says. This may at least partially explain the enhanced bleeding risk observed in some groups of patients with COVID-19.. These proteins were associated with respiratory difficulties, but high levels of TPA had stronger correlations with mortality. "We . You can also help keep the lining of your nose moist with petroleum jelly, antibiotic ointments, or saline nasal spray, says the Mayo Clinic. As nervous as it might make you feel, a nosebleed in most cases should go away on its own. MNT is the registered trade mark of Healthline Media. If that doesnt help, the Mayo Clinic suggests pinching your nose shut again for 10 to 15 more minutes, then seeking emergency care if it still doesnt quit after that. Can diet help improve depression symptoms? Reinfected? Please use one of the following formats to cite this article in your essay, paper or report: Thomas, Liji. Policy. But in reality, the average nosebleed doesnt last more than 20 minutes. See a doctor regarding your nosebleeds if they don't stop after using over-the-counter and at-home methods or interfere with your everyday life. If saline spray isnt providing relief, try a more sticky/thick spray, which maydo a better job of coating the nasal passages, Dr. Hopkins says. Some can be caused by nasal dryness, a cold, and/or a deviated septum. My daughter reported the same thing so I wondered if it was connected to Covid. In particular, the body does this by continually adjusting the activity of a protein in the blood called plasminogen, which promotes the breakup of blood clots, or thrombolysis.. Certain people are more prone to getting nosebleeds, including: Holding an icepack (or a bag of frozen peas wrapped in a tea towel) on the top of the nose may help reduce the blood flow. articles a month for anyone to read, even non-subscribers. Heres how to promote healing: Even if your bloody nose isnt the result of an injury, it can still be a red flag in some cases. Either sit down or stand with your head bent forward slightly. And no, you shouldnt tip your head back (more on that in a moment). In the patient group, the nasal symptoms mostly occurred in the same period as the alteration in smell and taste, or before the latter began. Nose bleeds are common and are generally not a cause for concern. Taking care of nosebleeds: For people taking blood thinners. So can telangiectasias (also known as spider veins), which are clusters of small, dilated blood vessels close to the surface of your skin, Dr. Voigt says. Opens in a new tab or window, Visit us on Facebook. Experts explain the barriers around getting itand when access might be expanded. When a nosebleed happens, Dr. Hopkins suggests doing the following: Use an over-the-counter, nasal-decongestant spray that contains oxymetazoline, such as Afrin. Long Covid is a term used to describe signs and symptoms that continue or develop after Covid-19, including ongoing symptoms of the virus and postCovid-19 syndrome over 12 weeks. All that blood can be scary for kids and adults alike. These mucin-producing cells are also in the respiratory epithelium of the nose. 2. The majority of nosebleeds are anterior, meaning the blood is coming from the front of your nose, Dr. Patel says, so squeezing that part of your nose shut should help quell the bleeding. Any information published on this website or by this brand is not intended as a substitute for medical advice, and you should not take any action before consulting with a healthcare professional. Pathological blood clotting in COVID-19 patients has been studied extensively, but recognizing and addressing the high bleeding risk in a subgroup of patients is equally important, says first author Yu (Ray) Zuo, MD, MSCS, a rheumatologist at Michigan Medicine. Just as important as knowing what to do is knowing what not to do, even though they may seem like good ideas. Here are the various reasons why your nose might suddenly do its best impression of The Shinings elevator scene. Learn more here. In most cases, the body itself will start to repair the blood vessels that are causing the nosebleed. with these terms and conditions. It may also make it harder to breathe if the blood clot is large. Nosebleeds are common but can be a cause for concern in some cases. Retrieved on March 04, 2023 from https://www.news-medical.net/news/20201123/Nasal-dryness-could-be-an-early-warning-sign-of-COVID-19.aspx. A person may wish to focus on trying to breathe through the mouth, and they should avoid applying too much pressure to the nose. An over-the-counter saline spraymayhelp keep nasal passageways moist. This will shrink the blood vessels, which should help to stop the bleeding, Dr. Patel explains. These are both very rare causes of nosebleeds, so this fancy medical speak may be more useful at trivia night than when determining why your nose is bleeding. One is hemophilia, which happens if you dont have enough clotting factor (a protein necessary for normal blood clotting), according to the U.S. National Library of Medicine. Instead, pinch your nostrils and wait for the bleeding to stop. Millions of Americans have been getting their COVID-19 shots, and while some people have pain, fatigue, or fever afterward, most side effects are mild. There are two categories of blood thinners, according to the U.S. National Library of Medicine: anticoagulants, like heparin or warfarin, which slow your bodys clot-making process, and antiplatelet drugs, like aspirin, which make it harder for platelets to clump together and form a clot to stop bleeding. Tabassom, A., & Cho, J. J. Opens in a new tab or window, Share on Twitter. (accessed March 04, 2023). Shaena Montanari is a contributing writer to Business Insider. Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. The authors note that one large, multicenter study reported an overall bleeding risk of 4.8% among hospitalized COVID-19 patients, which increased to 7.6% among critically ill patients. If not, you can get rhinitis medicamentosa, or extreme congestion. This site complies with the HONcode standard for trustworthy health information: verify here. In children, inflammation of veins and arteries triggered by excessive immune activation may cause an illness similar to Kawasaki disease, an inflammatory disorder. This video shows you how to treat a nosebleed. "This one seems obvious, but even using a tissue inside the nose can start a nosebleed for some people. Lean forward so that the head tilts just in front of the chest. Several types of trauma can cause a nosebleed, including . The septum is a thin wall of cartilage that separates the nostrils. Random nosebleeds are always a nuisance, except maybe if you want to be Carrie for Halloween and dont have time to buy fake blood. You can find out more about our use, change your default settings, and withdraw your consent at any time with effect for the future by visiting Cookies Settings, which can also be found in the footer of the site. Use an over-the-counter, nasal-decongestant spray that contains oxymetazoline, such as Afrin. All rights reserved. Several types of trauma can cause a nosebleed, including: Trauma to the nose can burst the small blood vessels that line the inside of it, causing blood to leak out. your nosebleed lasts longer than 10 to 15 minutes the bleeding seems excessive you're swallowing a large amount of blood that makes you vomit the bleeding started after a blow to your head you're feeling weak or dizzy you're having difficulty breathing Causes of a nosebleed The inside of the nose is delicate and nosebleeds happen when it's damaged. This is another common reason behind nosebleeds, Riddhi Patel, M.D., an otolaryngologist at Northwestern Medicine Central DuPage Hospital in Winfield, Illinois, tells SELF. Here's what you need to know. At Mount Sinai, we have experience handling these cases of epistaxis. On a related note, if you have cold symptoms that dont go away after 10 days or that start to get better then come back with a vengeance, your cold may have progressed into a sinus infection, which happens when the cavities around your nasal passages get swollen. "Nasal dryness could be an early warning sign of COVID-19". Cookies collect information about your preferences and your devices and are used to make the site work as you expect it to, to understand how you interact with the site, and to show advertisements that are targeted to your interests. There are various bleeding disorders out there that could lead to intense nosebleeds, Dr. Voigt says. A new study published by an international team of researchers on the preprint medRxiv* server in November 2020 details the nasal symptoms that are associated with anosmia and ageusia (loss of smell and taste) in coronavirus disease 2019 (COVID-19), including the early warning signs of infection. Otherwise, nosebleeds have zero benefits and many drawbacks, including stained clothing and feeling nervous that something is wrong with your health. We avoid using tertiary references. How to Have a Sick Day When You Cant Actually Call Off Work. In some cases, nosebleeds can be caused by genes passed down in families. Allergies and colds can cause swelling of the lining of the nose and can cause bleeding. "Recurring nosebleeds and those that do not stop easily after several minutes applying pressure warrant medical evaluation," says Getz. The entry of the virus into the respiratory nasal epithelium, especially the goblet cells, may cause a sudden disruption of the mucus barrier, which in turn causes the epithelium to dry out. This Drug-Resistant Stomach Bug Can Cause Gnarly SymptomsHeres What to Look Out For, The Myth That French Women Dont Get Fat Is Both Wrong and Harmful, This Simple Morning Habit Can Help You Sleep Way Better at Night. Why nosebleeds start and how to stop them, Nicole Leigh Aaronson, MD, MBA, CPE, FACS, FAAP, When to see a doctor if a child has a nosebleed, insufflation, one example of which is snorting a substance or a drug into the nose. Signs and . 1. A new loss of smell or taste without a stuffy nose is a common early symptom of COVID-19. Picking or scratching at the inside of your nose is an easy way to wind up with a bleeding cut. As their names suggest, the former activates plasminogen and therefore promotes thrombolysis, while the latter has the opposite effect. I did not loose the sense of smell and taste. Nosebleeds, also known as epistaxis, are common issues that usually resolve on their own or are easily treated in a medical environment. This can burst blood vessels in the nose and lead to a nosebleed. The body performs this balancing act by changing the levels of two other proteins circulating in the bloodstream, known as tissue plasminogen activator (TPA) and plasminogen activator inhibitor-1. This often helps stop bleeding. Picking sometimesscratches the plexus and triggers a nosebleed, Dr. Hopkins says. weight loss or poor appetite. Some people dont even realize they have a deviated septum because the curvature is so slight, but others are aware because its tough to breathe properly. They found very high levels of both proteins in the blood of these patients. Additionally, the Platelet Disorder Support Association (PDSA), a nonprofit patient support group, noted that the risk of getting ITP or vaccine-induced thrombocytopenia "is less than 1 in 100,000." 6. My husband and I both had altered smell and taste . 7. LowFev=Low grade fever; DryCgh=Dry cough; RespDf=Respiratory difficulties; SrThrt=Sore throat; NslCng=Nasal congestion; HedAch=Headache; Fatigu=Fatigue; Diarrh=Diarrhea; Anosmi=Anosmia; Ageusi=Ageusia; Smdstr=Some disturbances; NasDry=Nasal Dryness; NasFl=Nasal Flush. All rights reserved. A new study published by an international team of researchers on the preprint medRxiv * server in November 2020 details the nasal symptoms that are associated with anosmia and ageusia (loss of . I am dealing with this now and it is so annoying. Heart failure: Could a low sodium diet sometimes do more harm than good? This will prevent blood from running down the throat. They can occur from birth or as a result of sustaining an injury to the nose. Advertising on our site helps support our mission. Early in the pandemic, research began to show that the blood of critically ill patients with COVID-19 is unusually sticky or prone to clotting, with potentially fatal consequences including deep vein thrombosis, stroke, and heart attack. If one of these conditions is the cause of the nosebleed, people can follow the same three steps as above to help stop it. Cleveland Clinic is a non-profit academic medical center. We link primary sources including studies, scientific references, and statistics within each article and also list them in the resources section at the bottom of our articles. This helps the blood clot. For example, a Blood Advances review published in March 2022 found that risk factors for developing ITP after getting a COVID-19 vaccination was associated with lower platelet counts, being of a younger age, and the current ITP treatment. Repeat until it stops bleeding completely. Nosebleeds are caused when the tiny blood vessels on the inside of your nose start to bleed. This helpskeep your nasal plexus from drying out. Something is wrong with your nasal septum. Step 1: Sit up straight. During this time, the air is colder and dryer, he explains, and many people use heating systems in their homes. Is the ketogenic diet right for autoimmune conditions? Most nosebleeds are not a cause for concern, and it is usually possible to treat them at home by applying, Medical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. If you suspect this is your issue, Dr. Voigt recommends getting a humidifier. They also note that another protein, known as urokinase, also activates plasminogen and could therefore also play a vital function in blood clotting in COVID-19. There are different types of thrombocytopenia with different causes. Can You Drink Alcohol After Getting the COVID-19 Vaccine? Gently pinch the soft parts either side of the nose together with two fingers to stop blood leaking out. Here's Who Should (and Shouldn't) Get It, What Your Sex Has To Do With COVID-19 Vaccine Side Effects. Can poor sleep impact your weight loss goals? It is also necessary to see a doctor if the nosebleed occurs with other symptoms, including: Nosebleeds occur when the blood vessels in the nose burst, which allows blood to leak out. In that case, a doctor can likely fix the issue with surgery. Another is idiopathic thrombocytopenia purpura (ITP), which happens when you dont have enough platelets to help your blood clot properly. Best food forward: Are algae the future of sustainable nutrition? How Viagra became a new 'tool' for young men, Ankylosing Spondylitis Pain: Fact or Fiction. A rare condition called hereditary hemorrhagic telangiectasia (HHT) affects the blood vessels. Nosebleeds occur when blood vessels inside of your nose . They measured levels of TPA and plasminogen activator inhibitor-1 in the blood of 118 patients hospitalized with COVID-19 as well as 30 healthy controls. Additionally, over half of the patient group said they felt as if a strong nasal wash had been administered, while only one member of the control group reported this sensation, making the patient group risk 32-fold higher for this symptom. Sometimes blowing a nose too hard or aggressive suctioning of the nose can cause bleeding. . Can poor sleep impact your weight loss goals? Internal bleeding or hemorrhaging is bleeding that occurs inside the body when a blood vessel is damaged. No matter the cause, if you have a nosebleed, youre probably wondering how to stop it ASAP. In this interview, AZoM speaks to Rohan Thakur, the President of Life Science Mass Spectrometry at Bruker, about what the opportunities of the market are and how Bruker is planning on rising to the challenge. You can get a hole in your septum, which then has a raw edge thats very prone to bleeding, Dr. Voigt says. Physical trauma is one of the most common causes of a nosebleed. The singer has faced relentless comments about changes in her appearance for years. The blood clot may come out when removing tissues from the nose, but it can stay there for longer. Normally, our blood maintains a delicate balance between its tendency to form clots and its tendency to break them down. Can You Donate Blood After Getting the COVID-19 Vaccine? What are some of the best ways to clear phlegm with COVID-19? Trauma is a common cause of nosebleeds, but they can also occur in people who have allergies or sinusitis. (2017). A humidifier can also help. But the evidence to show it works is not very strong. But try and stay calm as best you can. The PDSA also said that there was a lower risk of developing ITP with Pfizer and Moderna vaccines. This may signal that they should be included in early diagnosis protocols for COVID-19, such as early monitoring and adjusted social isolation measures to prevent transmission. Feeling panicked over a nosebleed? And now, we wait. Can diet help improve depression symptoms? They conclude that the administration of anticoagulant treatments should therefore be selective and cautious to minimize this bleeding risk. Take the following steps to put an end to a nosebleed. 2004-2023 Healthline Media UK Ltd, Brighton, UK, a Red Ventures Company. Sellick says nosebleeds definitely are not a main symptom of COVID-19, but adds "we're at the time of year where people get nosebleeds anyway, due to allergies and being in air conditioning." 8/5/21 Is a Nosebleed a Sign of COVID-19? Visit our coronavirus hub for the most recent information on the COVID-19 pandemic. I am off quarantine and still having these symptoms. MNT is the registered trade mark of Healthline Media. At the end of my Covid period with very mild symptoms, but I have seen blood (especially in my morning shower) when blowing my nose as well. Some people need medical help to stop frequent nosebleeds. Next review due: 22 January 2024, a child under 2 years old has a nosebleed, you're taking a blood-thinning medicine, such as, you have a condition that means your blood cannot clot properly, such as haemophilia, your nosebleed lasts longer than 10 to 15 minutes, you're swallowing a large amount of blood that makes you vomit, the bleeding started after a blow to your head, the inside of your nose being too dry (maybe because of a change in air temperature), conditions that affect the blood vessels or how the blood clots, children (they usually grow out of them by 11), sit down and lean forward, with your head tilted forward, pinch your nose just above your nostrils for 10 to 15 minutes, do any heavy lifting or strenuous exercise.