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Archive: Dr. Tom 120
Posted March 19, 2008

Readers: Read Dr. Tom’s Commentary on Spirometry to understand the importance of this diagnostic lung test.

 

 

Lost Health Insurance and Would Like Your Opinion
Q. How bad does this look Dr. Tom?  You said that x-rays won't show emphysema until its real bad.  What about CT' Scans? O2 pulse level 92 to 93 percent at 6000 feet at the Doctors office; 98 percent at 6000 feet on my personal oximeter and drops to 94 percent climbing a 800 foot hill. 02 97 to 98 percent at sea level.

PFT test
FVC 91 Pred
FEV1 93 Pred
FEV1FVC 81
FEF 25%-75% 98 Pred
FIFC 94 Pred

X-rays showed mild degree of non-specific interstitial disease.

CT scan impression:  Right-sided hilar lymphadenopathy with borderline bronchiectasis, and a small amount of infiltrate at the right apex.  This is tiny and it could be due to adjacent pressure from a large osteophyte on the rib.  In addition, there is a small likely subpleural node near the left apex.

The reason I am asking your opinion is because I have been complaining of shortness of breath for 7 years.  However, it is not shortness of breath in the usual sense of the word.  I do not huff and puff. . My worst sense of SOB is waking up at 5am on the dot every morning and basically never leaves until I take the medications I listed, and sometimes it takes two doses 4 hours apart before pain and SOB go away.

I suffer allot of back, shoulder, sternum pain.  When the pain is gone, the sense of not getting enough air is usually gone with it.  Inhalers don't help much.  However, when in allot of pain, I can take a Klonopin, a 20 milligram Baclofen and a Percocet, all prescribed for chronic pain and anxiety from having allot of chronic pain and feeling SOB.

As heart could be a potential issue, I will answer that I have had two ultrasounds and a stress test.  The treadmill was in normal. The chest pain does not increase with activity and neither does SOB.  It tends to go away if anything.

I am asking your opinion because these test were run in Arizona under the state provided health plan. The pulmonologist never saw the CT scan.  He did his own PFT and stated that it seemed perfectly good and handed me a sack full of Advair. I now live in California, have no Insurance and California has no low-income coverage unless you are disabled.

So I could use an answer to the CT and PFT, and the back, rib, sternum pain, and why when inhalers won't help. The combinations of muscle relaxers and painkillers will usually get rid of SOB along with the pain?

Other problem is, these kinds of drugs make me very fatigued at work and frequently unsafe to drive from dizziness.

A. Dear Dan, You ask so many questions that it is impossible to answer them all. In short, it does not look like you have much wrong objectively. My suggestion is to try to forget these symptoms and get on with your life. Dr. Tom

 

Shortness of Breath, Could it be Asthma?
Q. I have had shortness of breath for the last few months. It varies in intensity - never terrible - but enough that I am afraid to work out hard (my breathing gets worse when I do), and feel I have to "hold back" physically, even when it comes to working out around the house. I have always been active and fit, am 5" 8" 125 lbs, 45 years old, one child. Have always been healthy.

I also have pain upper left side of my back and cannot tell if it is muscular or in my lungs.

I went to a pulmonologist who prescribed prednisone 10 mg 2 x per day. I took 10 mg 1 x per day for 1 week, and it helped the breathing. In the last couple of days, the breathing has gotten worse - like it was before I sought help from the doc. I am now taking his recommended 10 mg 2 x per day.

What could this be? If it is (somewhat) helped by the prednisone, does that mean it is asthma? I never have "attacks," per se. What about the back pain?  I am confused!  Help

A. Dear Karen, This could be asthma. Your doctor should determine if you have airflow obstruction by using simple spirometry and if it is reversible with bronchodilators. I cannot relate the back pain to asthma. Dr. Tom

 

What is the Likelihood Malignancy of Nodules in  Non Smoker’s?
Q. My 36 year old girlfriend, a nonsmoker, very healthy has five nodules on her lungs. What is the likelihood they are malignant? Should she wait two weeks as the doctor has advised?

A. Dear Tray, The likelihood of a malignancy is almost negligible, particularly if she has no family history of lung cancer. I would wait three months and repeat the scans to see if any of the nodules have grown. Dr. Tom

 

Worried about Sister
Q. Hi.  My sister (44) recently had a chest x-ray.  She did smoke for approx 8 yrs in her 20's.  Also, she had a very severe case of pneumonia at the age of 15, and severe case of the flu (respiratory) hit her pretty hard approx. 7 yrs ago.  The following is what her x-ray read:

Frontal and lateral views of the chest were performed.  Both lungs are well aerated.  There is subsegmental atelectasis in the left lung base.  Scarring is also suggested in the lower left lateral thorax.  There is slight hyperinflation of the lungs present with increased AP diameter of the chest suggesting a degree of chronic obstructive pulmonary disease.  There is no dense focal consolidation, pleural effusion or pneumothorax identified.  The heart and mediastinum appear normal.  Arthritic changes are present in the thoracic spine.

She is scared to death.  What does this all mean?  She did a PFT at her Dr's office and it read 81%.  Please break this down for us as to what it is she's facing.

Thanks so much!

A. Dear Cheryl, My service does not include an analysis of all that is on an x-ray or CT report. This is because I cannot see if I agree with the report. Your report is complex, with lots of minor things, probably signifying nothing much wrong with the lungs. If concerned, you should see a pulmonologist. Dr. Tom

 

What does Chest X-Ray Mean?
Q. Suspicious infiltrates, right upper lung,. take apicolordotic view. What does it mean?

A. Dear Marissa, It means the radiologist does not know what is wrong if anything and recommends more chest x-rays. Why won't your doctor tell you this simple thing? Dr. Tom

 

Does this Report Sound Like I have Idiopathic Pulmonary Fibrosis (IPF)?
Q. On 03-14-07 thoracic spine w/contrast showed "dependent congestion present at lung bases". On  02-27-08 abdominal CT with dye taken for abdominal pain-results bladder and kidney infection but also mentioned on report IMPRESSION: "Bibasilar dependent atelectasis is noted". Am I wrong in thinking this points to my have IPF?

A. Dear Sandy, No, this does not point to IPF. Dr. Tom

 

Venticular Plueral Shunt and Multi Drug Resistant Staph Infection
Q. My husband recently had a ventricular pleural shunt placed after a multi drug resistant staph infection on his old shunt.  This time his shunt has caused a small pleural effusion, and 4 mm ground glass nodule.

He is short of breath and has chest pain. Is there any thing we can do to decrease the pleural infusion.  My husband had been an Olympic class runner before his shunt infection and is use to running every day.

A. Dear Sue, Where is the shunt and what is its purpose. Why can't your doctor answer your question, he knows far more facts that I do about your husband. Dr. Tom

 

Is a Localized Wheeze a Symptom of Lung Cancer
Q.  Dear Dr. Tom, Thank you. I am very worried that I now have lung cancer. Can't sleep. Can't eat. Can't function.

I had slight cough that went away but left me with wheeze 4 weeks later. A weird wheeze. It is heard only if I exhale a certain way on exhalation.

My primary doctor ordered a chest x-ray and findings were: the lung volumes are slightly increased. There is minimal streaky bibasilar scarring without evidence of focal infiltrates or pleural effusions. Mild left upper lobe scarring is seen. There are minimal degenerative changes of the thoracic spine. Impression: Pulmonary hyperventilation with minimal bibasilar scarring. No radiographic evidence of acute cardiopulmonary disease.

So I went to a good pulmonary specialist and he did not hear the wheeze but ordered pulmonary function tests because I started smoking at 17 and gave it up at 41 about 15 cigarettes a day. During that time I gave up smoking for about 4 years total intermittently between pregnancies.

I went in again to see the pulmonary doctor today because I really could produce the wheeze, which he heard in the right upper lung. I have a peak air monitor and my reading is 625 which he thought was quite good even with the wheeze. I guess my question is do you think I have a good chance of having lung cancer? He ordered a CT Scan for this Wednesday. He is concerned about a tumor because it is a localized wheeze.

I am 55, no history of lung cancer in family but am worried sick.

I feel great, no shortness of breath, no coughing, good appetite, perfect weight, always busy with my 15 year old son and my married daughter. Never tired.

Do you think this is cancer and if so how severe? The chest x-ray showed no cancer but the pulmonary doctor said that my wheeze is coming from an area that would not be picked up on a regular x-ray. That is why he has ordered the CT scan. I still have the pulmonary function tests to do as well but he liked the peak flow meter reading of 625. Do you think I have longer than six months to live? Do you think this localized wheeze is due to a tumor? I'm only 55 and I don't want to die. My kids need me. I haven't touched a cigarette in 14 and a half years and I feel great but so worried about this strange wheeze only when I breathe a certain way on exhalation.

Thank you,
Betsy Jorgensen

A. Dear Betsy, The best way for your pulmonologist to evaluate a localized wheeze is to place a scope into your lungs and look at the area, where the wheeze is located. He should know this, so ask him about it. I agree that a small tumor within an air passage is a possibility. Dr. Tom

 

Moved and have Three Bouts of the Flu
Q. I have moderate COPD.  I think my lung capacity is 54%.  Sorry I don't have more precise numbers.

I am currently on Advair twice a day, and I use albuterol as needed.  I moved to Albany, NY this year and have had 3 bouts with flu since I have been here.  Each time I have gotten lung infections and flare-ups and have been treated with steroids.

Now I am starting to have steroid psychosis with steroid use, which I really hate.  Basically I have been ill all winter.  One of my caregivers remarked that it was odd I had moved to this climate because it is so cold.  My question is what is a good climate for COPD, and is this a bad climate?  What would be better?

A. Dear Ginger, In general, a low altitude, warm and fairly dry climate is best for patients with advanced chronic lung diseases. Areas, such as the coast of Mexico. Moving will not solve all your problems, however.  Dr. Tom

 

Treated for Non-Hodgkins Lymphoma and Now Have a 9 mm Lung Nodule
Q. I had routine CAT Scan results today.  Was diagnosed and treated 2 years ago for non-Hodgkins lymphoma. Have been followed every three months since that time with CAT and PET Scans when appropriate.

Dr. has been monitoring a small nodule in my right neck that has neither grown, or reduced in size in 2 years.

Today he tells me that a 9mm nodule in now present on my upper right lung.  He is telling me that we will wait for three months, repeat the CAT scan and if the CAT scan shows it is still there we will do a PET scan the following week and go from there.  Is this reasonable?  I have no other symptoms and the oncologist is one of the best in our area.

I appreciate your advice.

A. Dear Elizabeth, In my opinion a new 9mm lesion requires identification now. A PET Scan will suggest malignancy, if it is possible. The definitive thing to do is a biopsy, which I recommend, in view of your history of non Hodgkin's lymphoma. Dr. Tom

 

Doctor Said I have the Lungs of an Eighty Year Old
Q. I had bronchitis recently and a chest x-ray. The report came back with advanced COPD diagnosis. It said it showed hyperinflated lungs and flattened hemidiaphragms. My doctor put me on Advair.

What does "advanced" mean? I'm kind of freaked out now. Should I see specialist. My doctor didn't say to but she also said I have the lungs of an 80 year old even though I'm only 48. I've also been a smoker for 35 years and am now trying to quit. Any info you can give me would be helpful.

Thanks, J Larose

A. Dear J., A chest x-ray cannot estimate lung function and cannot be used to classify the stage of emphysema. You need spirometry to measure your airflow and air volume.

There is a lot that can be done to slow or even reverse the course of emphysema, even in advanced stages of disease. You should not accept that your disease is advanced until it is properly evaluated by a pulmonologist. Dr. Tom

 

Is it Safe to Take All These Medications?
Q. I'm taking Advair, albuterol, Spiriva, and using albuterol solution/machine, and now Flovent just this pass week.  Tell me is this a little much or am I safe using all these medicine?

A. Dear Jeanice, These drugs are safe when used together. Advair contains the same drug as Flovent, but together, the dose is still not excessive. Consider the expense, however. Dr. Tom

 

Could Neuropathy be the Cause of Deterioration?
Q. I have a low (83-88%) O2 saturation at rest, even while on oxygen. Talking or intentional breathing raises O2 level up to 97%. Male patient (age 62) had 2-bypasses in 2000 + 2 stints in past 2 years…No heart damage, have mild COP, and smoked 40 years before bypass surgery. Sleep apnea diagnosis but BIPAP and CPAP even with oxygen ineffective.

Condition deteriorating. Could a form of neuropathy be the cause?  If so, how do you test for this?

A. Dear Les, This is not due to neuropathy. There are special neurological tests, such as nerve and muscle stimulation that are used to establish a diagnosis of neuropathy. Dr. Tom

 

Abnormal Degenerate Cells in Sputum
Q. What does it mean when a sputum test comes back with an abnormal degenerate cells showing?

A. Dear Linda, It suggest the presence of cells that can be precancer, or early stage cancer. A follow up with a pulmonologist is appropriate. Dr. Tom

 

Does Asthma Show Up on a Chest X-Ray
Q. My daughter has gotten bronchitis & sinus infections early on. Finally she was diagnosed to have asthma, allergic rhinitus, sinusitus, frequent bronchitis, and allergies. But when I took her for chest x-rays the x-rays came back clear. But her primary doctor now has diagnosed her with asthma, etc as well as other doctor.

My question is, would that be normal for her chest x-rays to come back clear? She has mild to moderate asthma.

Her father will not give her the preventative medications because he doesn’t think she has asthma because of the chest x-ray! But I still have to take her to the doc. about every other month if not sooner, it is almost always the same symptoms.

A. Dear Michelle, A chest x-ray does not diagnose asthma. Your husband is wrong. Dr. Tom

 

Does Position of Needle Insertion Effect ABG Results?
Q. I work in a hospital as a respiratory therapist. Under normal conditions we draw the ABGs. But there are times when a physician or nurse draws one. As a therapist I know to insert the needle into the artery aim up the arm into the flow. We have been noticing physicians and nurses drawing them with the needle aiming toward the patient's hand. My question is could drawing in this manner be damaging to the patient in any way? If you can answer this one I would appreciate because I cannot find the answer anywhere. Thank you.

A. Dear Sharon, I do not know exactly what you mean by the needle aimed toward the hand. Any artery can be used for arterial blood. Most commonly it is the radial or brachial artery that is used. In no case do you aim the needle toward the hand! Dr. Tom

 

I Have Been Coughing and Wheezing for Many Months
Q. Dear Dr. Tom, I am 40 years old and about 6-7 months ago I started coughing and wheezing.  My Dr. has done an echo and PFT tests, both came back normal. Last week I had an x-ray and she told me I had inflammation or obstruction in my middle right lobe. Now she has given me a Z pack and an antacid for reflux.  I also have an inhaler.

I have never been diagnosed for asthma I do have hypertension.  I was taken off of it for a while to see if that was causing cough.

Now we are back to a wait and see.  I am very anxious and worry about the x-ray.  I am still coughing and wheezing even after the antibiotic.  What now?

A. Dear Dawna, If the issue is inflammation of the middle lobe, it needs to be addressed. If this is the cause of the cough, treatment of the underlying cause of the inflammation should stop the cough. Dr. Tom

 

Pain and Lung Cancer
Q. I am worried about having a lung tumor in my upper lungs - have had shoulder pain radiating down arm into my pinky and ring finger for four months now - getting worse. 

Have been to Dr. three times and had regular x-ray of neck/spine/shoulder which showed bone spurs and arthritis and MRI of head and neck - Dr. just said head was pulled back and things were tight in there?  Chest x-ray showed no nodules.  The pain will not go away and my Dr. said lung cancer did not cause shoulder pain, but I've read otherwise.  What should I do?

A. Dear Doris, Discuss the possibility of what is called medically, a Pancost tumor. This may not be seen my chest x-ray, but can be by CT. You are wise to pursue an answer for this pain. Dr. Tom

 

Follow-up Recommendations for Atelectasis
Q. I recently had an MRI and the findings included the following statement: "LUNG BASES-A small linear strand of atelectasis is demonstrated at each lung base."  My doctor said nothing to worry about. What follow-up would you suggest; if any?

A. Dear Jack, No follow-up is generally done for such minimal findings, when they are in both lungs. Ask your doctor what he feels is appropriate for you. Dr. Tom

 

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