Questions: "He seems depressed and was having trouble breathing. He has been in constant pain for months. Now he has shingles on his scalp face and eye. He takes pain killers every day and his Dr does not offer any type of pain management that I know of. I think he needs a new Dr. and then you would probably need to wait months to see a new Dr. I asked if he would just call the ambulance - and that way he could get right in ... and maybe they could tell him what to do. I want to set up some apts and go this week or next.”

Answer:  It is obviously hard to know what exactly is going on from this limited information. Please see the following remarks regarding the issues you brought up. The bottom line he needs to see a doctor today.

Breathing:

• Trouble breathing can mean a lot of different things and needs to be addressed by a qualified physician in person. The list of possibilities for shortness of breath goes on for volumes; however, I will address a few potential causes.
• Trouble breathing can represent an acute life threatening illness such as pneumonia or pulmonary embolism. Pneumonia usually has associated symptoms of fever (but not always) and pulmonary embolism usually presents with symptoms of acute chest pain (but not always). Sudden onset or worsening of symptoms needs to be addressed immediately in the ER.
• However, trouble breathing can be a chronic problem such as emphysema.
• Knowing his personal history of prior heart attack, one contributing factor that I would consider is congestive heart failure (this may not be the only cause; sometimes there are many causes for shortness of breath at the same time).
• Congestive heart failure happens when the heart is not strong enough to push the blood/fluid away from the lungs and therefore fluid backs up in the lungs. Congestive heart failure can be mild and treated with medications on an out-patient basis. However, congestive heart failure can also be severe with large pleural effusions which requires management in the hospital.
• Again, any shortness of breath needs to be addressed by a qualified physician; the range of potential possibilities is enormous and there is no way I can evaluate them over the internet. If symptoms are severe and or new he needs to go to the ER.

Depression:

• There are numerous causes of depression. The severity of depression also ranges significantly from mild to severe. As you know, severe depression can also be life threatening, which needs to be addressed in a hospital. 
• Seasonal affective disorder is a possible contributing factor that gets everyone down this time of year. In addition, being sick, especially with a chronic illness will depress almost anyone. Depression also runs in the family. Again, this needs to be addressed by a qualified physician in person. 

Shingles

• Shingles is a painful, blistering skin rash due to the varicella-zoster virus. This is the virus that causes chickenpox. After you have had chickenpox (most of us have), the virus goes dormant, living quietly in your nerves for most of your life. However it can wake up again in the form of shingles. It is not clear why this happens but it often occurs in times of severe stress or illness.
• Shingles often disappears on its own. It usually clears in 2 to 3 weeks and rarely recurs.
• Shingles can also be treated with antiviral medications such as acyclovir, famciclovir, and valacyclovir which can shorten the time of illness. The earlier you start the medications the better.
• Infection in-and-around the eye is an emergency because it can cause permanent blindness. If there is eye involvement, this needs to be addressed immediately in the hospital and treated with IV medications.
• Shingles is also very painful because it is an infection of the nerves. Pain can also be managed with various pain medications. Other medications such as prednisone may reduce swelling in some patients. Antihistamines such as Benadryl can help to reduce itching. Some have used nontraditional methods such as meditation and acupuncture. The list goes on but one of the most important things is to keep the area clean and dry to prevent a secondary infection. 

A different primary physician?

• Knowing the person you mentioned with the above illnesses (name left anonymous for the blog), I could imagine he may not have told his doctor all of what is going on. It is also possible that he may not have shared with you all that his doctor is doing for him.
• However, if he doesn’t like his current doctor, for whatever reason, he can get another doctor. The availability of doctors varies from place to place. However, it shouldn’t take months to get an appointment to see a new primary physician.
• Regarding finding a new physician; an ambulance driver would not know what primary physician to send him to.  This is not their training or role.
• In the short term, he needs to see someone about the shingles eye involvement and the shortness of breath today.
• In the long term, he needs to thoroughly address his many medical problems with a primary physician he is comfortable with. He might want to consider a university doctor.
• If I was looking for another doctor, I would first see who is on my insurance approved physician list. I would also ask around to see who is happy with their doctor and go from there. If you want to help out with this, you don’t have to be in his town. It can all happen over the phone and on the internet. I wouldn’t wait till your visit to do something about getting him a new doctor if you think it is important. I am sure that your other sister who is in his town would be happy to help out with information and transportation.

Question: "They found a pulmonary nodule on a CT scan, what does this mean?"

Answer: This is a very common question/issue. What a pulmonary nodule means to you depends on a lot of factors.

What does a pulmonary nodule look like?

• A pulmonary nodule is basically a small focus of tissue in the lung. It is usually round but can often be oval, irregular, or speculated. Sometimes is can be calcified or have fat density.
• By definition a nodule is less than 3cm in size. If the lesion is greater than 3cm, it may be the exact same tissue etiology, but it is now called a mass.

What could it mean?

• Fat density in a nodule is considered benign.
• If calcifications are seen within a pulmonary nodule it is almost always benign as well.
• Calcifications are associated with prior or chronic inflammation/infection. In this scenario, the nodule is the tissue that is left over after your immune system has taken care of the problem. It is kind of like a scar.
• These “scars” do not always calcify and a non-calcified nodule can be more difficult to evaluate. None the less, a noncalcified-nodule can still represent the benign residue of a prior infection, but it is hard to tell for sure. So that is usually the major question; is the nodule cancer or not?

So how can you tell if it is cancer?

• The good news is that the vast majority of lung nodules are benign.
• The bad news is, if the nodule is not calcified or does not have fat, it can be difficult to impossible to tell on one CT scan if a nodule is cancer or not.
• Because cancers grow and scars generally do not, a follow-up scan can help. Scans at different times provide a reference point to evaluate if it increases in size over time. Some types of cancers grow very slow and therefore a long follow-up may be necessary to feel comfortable that the nodule is benign.
• Other factors play a role in the likelihood that a nodule is a cancer or not. The chances that a nodule is malignant increases with nodule size. Some other common factors that increase the likelihood that a nodule could be cancer is; patient age, history of other cancers, smoking history and history of other carcinogen exposure.

How often do you re-scan with CT and for how long?

• This is a major issue that is debated by many.
• In the last decade several articles have been published in major peer reviewed medical journals to try to establish a safe and rational approach to the management of this common issue. Most recently, in 2005 a consensus guideline was created and adopted by the major medical society on chest imaging (the Fleischner Society). Their follow-up algorithm is very helpful but remains general and many other individual factors will dictate management. The article is online:
• http://radiology.rsna.org/content/237/2/395.full

November 2005 Radiology, 237, 395-400.
• As you can see from this guideline, nodules less than 4mm are considered benign in low risk patients.
• I believe this is the size of the nodule you have on the CT scan (reference to the person asking the question).  However, a 4 mm nodule is not considered benign in high risk patients.
• The type of cancer you are dealing with (desmoid fibroma) is not known to metastasize to the lungs and therefore it is questionable if you should even be in the high risk patient category.
• These guidelines have been used by many, but not by all. For example, at MGH, they have a slight modification to the Fleischner Society recommendations based on their own experience.

This algorithm was used when I was at MGH. However, things in medicine often change with medical advances and it is possible that it has been updated since.

Question: "I have a question about by mammogram. Since I went to a new facility for my last mammo, they did not have comparison films from my previous, they think that my mammo is abn… do you know where I can have copies made?"

Answer: Get your prior mammograms sent to the new place.

• It is very important for a radiologist to have prior mammograms when reading current mammograms. It is one of the most important things needed to accurately read a mammogram.
• At least a 2 year old prior mammogram is best.

Explanation:

• There are many large textbooks on mammography, and the details of interpretation are way beyond the scope of this entry.
• Overall, reading mammograms is difficult because there is a wide range of what normal looks like. In addition, there is overlap between what disease and normal looks like.
• Looking at a mammogram reminds me of looking at the sky; there are all kinds of different possible patterns.  Because mammograms often look amorphous, one of the most powerful tools a mammographer has when reading a mammogram is the prior exam to see if there is a change.
• For example, on initial review a pattern in the breasts may look concerning.  However, if it is found to be stable for many years it may be deemed as benign. This is because cancers grow over time and stability would unusual for a cancer.  Old biopsy changes often cause breast distortion that can look concerning. However, biopsy changes should be stable or resolve over time. A cancer will grow. 
• On the other hand, a subtle asymmetry on a mammogram could be a cancer that will only be noticed if you see there was nothing there on the prior exam.

What do you need to do?

• You need to get your prior mammograms sent from the older facility, to the place where you just had the mammogram.
• You can get copies at the place you had the mammogram, but film mammograms usually don’t copy well. The original is best.  However, if you had a digital mammogram done, then a CD copy is just as good.
• Once you have your old mammos sent to the place of your recent mammogram, the facility radiologist should reinterpreted your mammogram at no additional cost and provide you with an updated final report.

(image credit from Society of Breast Imaging, sbi-online.org)

Can you tell if this is abnormal or not?

It is really hard to say. 

A comparison would definitely help.

Question: " I was told I have radiculopathy. What is this?"

Answer:

• The name is derived from Latin and Greek
• In Latin, radicula refers to root.  In medicine, radiculo- refers to a spinal nerve root.  
• In Greek, pathos refers to suffering. In medicine, -pathy at the end of a word is a general way of saying there is disease there.
• Therefore, radiculopathy is disease of the spinal nerve root. 

Background anatomy (Spine, Disc, Nerves):
I have some great anatomy pictures from my anatomy textbooks. However, I apparently have to get copyright permission to post the images. I’ll draw something if my description doesn’t do the trick.

-Spine (bone):

• In the lower back (lumbar spine) the five bones are labeled L1, L2, L3, L4, and L5.
• The “L” is short for Lumbar, and the following number is the vertebra (from top to bottom).
• The 5 bones stack up like toy wooden blocks.
• There is a disc between each vertebra (this is often the cause of the problems).
• The spinal nerves pass through a narrow apace between each vertebral body.  This space is known as the neural foramina.

-Anatomy (disc):

• There is a disc between each vertebra which acts like a shock absorber and allows for some movement. This disc space is a type of joint.
• The disc itself is looks a bit like a ¼ inch section of a tree branch. However, this cut branch of soft wood has a round sphere of jelly in the center.
• The outside of the disc, (the part with the wood-like looking rings), is called the annulus fibrosis.
• The central jelly part of a disc is called the nucleus pulposus.
• In total; the disk with two adjacent vertebral bodies is like a jelly donut between two blocks of bone (vertebra).

-Anatomy (Neurologic):

• The best way to think of the spinal cord is a bundle of electrical wires.  These wires connect your brain to the rest of your body and then and back again to your brain.
• The spinal cord carries many different types of wires in a space called the central canal.  The central canal is a tube in the middle of your back surrounded by bone.
• The wires that branch off the spinal cord are called a spinal nerves which innervate (connect to) both muscles and skin.
• A pair of spinal nerves branch off from the spinal cord and travels outward between each vertebra through the space known as the neural foramina. 
• The nerves are labeled in the same way the vertebral bodies are labeled; L1... through L5. 

-Anatomy (Neurologic more specific):

• Each pair of nerves has a specific job(s) and takes care of a specific area(s).
• When something happens to a specific spinal nerve, you will have symptoms/disability in the territory that that nerve innervates.  This can cause the symptoms of radiculopathy.
• Specific maps of spinal nerve-skin intervention are called dermatomes. For example, a map of the area that the L4 spinal nerve innervates is of an area of skin from the back to your leg and knee, down to your foot.
• Specific muscles are also controlled by spinal nerves and when injured there can be associated decreased leg strength and atrophy.

There are several causes of radiculopathy but most of them are either the result of an injured disc, bone (or both).

Disc causes:

• When a disc gets worn out many things can happen.
• Sometimes the disc will just bulge out like a beer belly.
• In another scenario, a tear forms in the annulus fibrosis.  This creates an opening for the jelly like center nucleus pulposus to squeezes out through the tear. Commonly this is called this a “ruptured disc.” This process is similar to jelly doughnut being squeezed with the jelly squirting out of one side. This jelly nucleus pulposus is thick and can squish whatever is in its way.
• If there is adequate room for the adjacent nerves, and if the rupture is small, then symptoms may be minor. However, when the disc material pins a spinal nerve or the spinal cord against bone, the symptoms can be severe.

Anatomic cause (bone):

• The spinal cord is protected from outside injury by the surrounding vertebra-bone.
• The nerve roots leave the central canal of the vertebra through openings called neural foramen.
• A possible outcome of the degenerative repair process is large bony callus formation which narrows the neural foramen and central canal. This is callus formation process is similar to a callus that may form on your foot in response to repetitive use. However, in the case of degenerative disc disease, the callus is made of bone.
• This bulky bony callus can get in the way and narrow the central canal and/or neural foramen.
• This callus generally grows relatively slowly and is not thought to be the cause of acute pain.
• However, a nerve within a critically narrowed space will be venerable to the presence of anything extra in that compromised area.  In this scenario, even the smallest disc bulge can completely narrow an already compromised opening.
• When the nerve gets pinched, you feel pain it in the area where that nerve was programmed to work.
• As discussed above, this can result in pain in a specific dermatome band and/or weakness of a muscle supplied by that nerve.

Diagnosis:

• Physical exam and symptoms often point to the problem.
• Anatomy and function are intimately related. The 3D imaging capability of MRI and CT can provide exquisite detail of the anatomic problem.
• As a result, imaging with MRI and CT can both confirm the cause of symptoms and quantify the extent of disease.  There is usually a direct correlation between the severity of the visible anatomic problem and symptoms. Imaging not only diagnoses the cause of symptoms, but also directs the type of treatment; the need for surgery or conservative therapy.

Question: “Every time I leave my doctor I have all of these questions. He talks so fast and I feel like I am being pushed out the door. What can I do?”

Answer: Unfortunately, this problem is becoming more and more common (details below).

Why it happens:

• There are many reasons why this happens and detailing all of the issues would take many volumes. However, for the most part it comes down to economics.
• Health insurance companies and the government (Medicare/Medicaid) continue to cut reimbursements and malpractice insurance premiums are always increasing.
• As a result, doctors are taking an economic hit on both ends; less money coming in and more money going out. As with any business, this squeeze means less money to keep the lights on, pay employees, etc.
• The problem has gotten so bad that some doctors have found that it is more economical not to work.
• The other alternative for a physician is to work more efficiently. That means a physician needs to see more patients in a shorter amount of time to get the same or less reimbursement.

What can you do?

• Learn more about the problem and become politically active… Ok, so no one seems to have time for that.

What can you do to help yourself?

• Knowing that your doctor only has a limited amount of time to see you, make the best of it. Be efficient yourself. Be clear about all of your concerns and problems.

How can I be more efficient?

• Be ready to answer questions about the what, where, why and when of your problem/illness. What makes it better or worse?
• Everyone does a better job at remembering things in a relaxed environment. Therefore, make a written list of your symptoms at home and bring it with you. Keep a medical diary of symptoms if it is an ongoing problem. In addition, the more time you prepare before your visit, the more accurate and complete you will be.
• More accurate patient information = more accurate medical diagnosis.
• Don’t rush in the doctor’s office, just be prepared.

“I never seem to get all my questions answered”

• Being more efficient/prepared will leave more time for you to ask questions at the end of your doctor’s visit.
• However, if you are like me, you often leave a situation such as this and think, ‘Ahh, I forgot to ask about XYZ.’ The solution is simple, bring a list of your questions with you and go through them one by one.
• Do some research beforehand so you can make the most of the time you have with your physician-medical expert. However, be warned, the internet is filled with all kinds of misinformation. Therefore, doing this type of research before your visit will give you an opportunity to have things confirmed/clarified by your physician.

I strongly believe that patient care should be a team approach between physician and patient. The older model of a passive patient with a dictatorial physician telling the patient what to do is becoming less viable, and was probably not the best approach to begin with. Do your part, be organized and educate yourself. Understanding a problem will lessen the fear/anxiety of uncertainty and will allow yourself to make more intelligent-informed decisions.

Question/Statement: "I saw the internist yesterday. She has ordered an ultrasound of the thyroid just for good measure..."

The "just for good measure" part kind of concerns me.

• In general, there should be a good reason to order any test. Just ordering a test or an exam without a significant indication can get you down the wrong path and can lead to additional tests or unnecessary complications.

Every test has it’s +/-

• No test is perfect and therefore it can’t be interpreted in a vacuum.
• Every test has different degrees of sensitivity and specificity.
• Sensitivity refers to how good a test is at finding something subtle.
• Specificity refers to how much you can rely on a positive result being real.

So what’s the problem?

• A positive test result has more meaning if the disease was suspected to begin with. However, if the same test came back positive on someone healthy, then you got to ask yourself, is it a real result or a false positive?
• A better question would be, why order a test that is not indicated, because then you will not know what to do if the result comes back positive.
• Or worse, if you ignored everything else about the healthy patient except the positive test result, you might inappropriately treat them for something they don’t have.

Thyroid ultrasound:

• Unfortunately, thyroid ultrasound is one of those tests that is rather nonspecific. A thyroid ultrasound is nonspecific because you often can't tell what lesions are begin (good) or malignant (bad) just by the ultrasound appearance. Don’t get me wrong, I am not saying that thyroid ultrasound it a bad test. This is just one type of tool that works well for a particular job. You dont use a hammer when you need a screwdriver (unless you are going to make a mess of things).  Thyroid ultrasound, needs to be used appropriately to be relevant.
• So be warned, most people have abnormal looking thyroids on ultrasound. However, a few years back a bunch of doctors got together and created a consensus guideline to help sort out who should get a biopsy.
• Depending on what things look like on ultrasound, a biopsy may be recommended. This happens quite a bit.
• I use to do ultrasound guided thyroid biopsies all the time. Ill fill you in more if it comes to that.

Question/Statement: “My internist stated that the 'gold standard' for sarcoidosis is a bronchosomething or other--a biopsy.”

Answer: Although I am sure your internist has good intentions, the statement is not true. (see below).

Gold Standard Definition:

• In medicine, a 'gold standard test' is the diagnostic test that is regarded as definitive in determining whether an individual has a particular disease process. To meet this definition, the test must have the ability to definitively determine the presence or absence of a disease. The ‘gold standard’ is the single test that other tests are compared to.
• Of note, the term ‘gold standard’ is being replaced by ‘criterion standard test’ to mean the same thing. However, for the sake of the specific question/statement above, I will continue to use the older term.

Reasons for the answer:

• The definition of ‘gold standard’ refers to a single superior test. As you know, you can only have one best of anything. Therefore, stating that there is more than one gold standard for any disease (bronchoscopy or biopsy) is not compatible with the definition. For you Highlander (1986) fans out there, “There can be only one.”
• Secondly, there is no gold standard for Sarcoidosis. The definition of ‘gold standard’ requires that the test can definitively determine the presence or absence of a disease on its own. There are no tests for sarcoidosis that meets this criteria.
• Some people will inappropriately use the term ‘gold standard” to refer to the perceived best test. However, I would defer from this distorted definition because it is misleading. Following this erroneous rational gives a test more credit than it deserves and can lead to inaccurate conclusions.

Why is there no gold standard for Sarcoidosis?

• There is no single test to date that can definitively diagnose the disease. This is not too surprising given that the etiology remains unidentified. Even pathology samples, which are considered by many to be the best diagnostic option, are fraught with error.

Then how do you diagnose Sarcoidosis?

• Because there is no one single definitive test for sarcoidosis, the diagnosis is achieved via a combination of clinical, radiographic and histological findings.  Not every patient suspected of having sarcoidosis will need undergo risky invasive procedures. When noninvasive data is convincing enough, the diagnosis can be achieved. Obviously, this is not always the case and therefore more invasive procedures may be necessary to realize the diagnosis. I would recommend non invasive options first.

Here are a few references I found on a quick search (in regard to the specific question in red above):

“There is no “gold standard” of diagnosis but only support for the diagnosis”
http://www.baylorhealth.edu/proceedings/14_1/14_1_pierce.html

“There currently exists no gold standard to confirm the diagnosis of sarcoidosis.”
http://jem.rupress.org/cgi/content/full/203/2/359

“Owing to the absence of a diagnostic gold standard, sarcoidosis is a diagnosis of exclusion”
http://jada.ada.org/cgi/content/full/137/1/54

No single test can be relied on for a correct diagnosis of sarcoidosis.
http://www.medhelp.org/lib/sarcoid.htm

Sarcoidosis remains a diagnosis based on exclusion... A “gold standard” test to identify which patients require treatment when noncritical organs are involved would be useful.
http://www.nhlbi.nih.gov/meetings/workshops/sarcoid-wkgp.htm

Although there is no single gold standard test…
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891789/

As there is no definitive “gold standard” for the diagnosis, sarcoidosis is essentially a diagnosis of exclusion.
http://medind.nic.in/jac/t04/i1/jact04i1p12.pdf