Office Logo c 2005

ClinetQ&A

•   Have an Anonymous Query for Dr. Nash - EMail to:  Appointment@lqent.com  •

  • "Throat/esophagus concerns. I am a 24 year old female. I have smoked hookah approximately 4 times a week for the last 5 years of my life. Last Wednesday, I was smoking for several consecutive hours while studying & my mouth and throat started hurting. I haven't smoked since. My mouth stopped hurting altogether, but my throat still feels like something is in it. A few people have said they noticed a change in my voice. My father asked if I was sick because I sound nasally "or something". Eating ice cream caused irritation."

    Anonymous Client

    The Electronic Cigarette / Hookah negative short-term effects are primarily respiratory effects.

    E-Cigs and their liquids contain nicotine - negative effects of nicotine are well known - Do not Smoke it !

    The Hookahs' are primarily water vapor and their flavorings are considered safe for consumption - But the effects of inhaling these substances is unknown and since these liquids can potentially contain contaminates your use of these devices can put you at an increased health risk. These devices and substances are largely unregulated by the FDA.

    If you are dripping the liquid directly onto the heating element additional multiform toxins can be created and inhaled with increased toxic negative effects.

    Your reaction above is a warning to stop using these devices. Your Upper and Lower airway is in Hypersensitivity and Damage mode. You should visit your local ENT for examination and treatment. Stop smoking these devices.

    Good Health

    Eric A. Nash, MD


  • "Drunk feeling For the past two weeks I have had a constant drunk feeling along with eyes unable to focus well and my left ear seems clogged but don't see any wax. I'm scared and don't know what to do"

    Anonymous Client

    It is best that you visit your Internist or Urgent care. Not all dizzy or vertigo symptoms one can experience have the ear as their primary source. Possible other reasons include dehydration, medications your taking, heart and blood pressure issues or illness.

    Visit your physician for a complete workup

    Good Health

    Eric A. Nash, MD


  • "Throat cancer, male smoker, 61 years and I do drink alcohol. Greetings. First it was cancer on the root of tongue. It spread to my lymph node which has been removed. Now I have a throat cancer, a big one. I am 1,75 meters high and have only 59 kilograms. My doctor don't recommend chemotherapy and since my whole mouth has been exposed to radiotherapy they don't recommend that either. I can't swallow not even my saliva. They are going to do total laryngectomy. How complicated and treateable it is and how much life could I get after this? Thank you for your time"

    Anonymous Client

    You have asked a fair question. To do you fair justice in answering your question - it cannot be done adequately in this forum. I recommend having a face to face with your diagnosing physicians and surgeons. Concerns of Life expectancy and Quality of life vs potential aggressive procedures should be honestly discussed and your decision for treatment, or not, fully considered and respected.

    Good Quality


    Eric A. Nash, MD


  • "I sniffle all the time I sniffle all the time constantly through the day. Should I be concerned? It's really annoying to people around me. Is there anything you can suggest?"

    Anonymous Client

    If your 'sniffles' are clear drainage - what you are most likely experiencing is something called Vasomotor Rhinitis.

    Vasomotor Rhinitis is a label applied to head and neck symptoms triggered primarily thru our nervous system. It includes symptoms that look and feel like an infection + head cold or severe + chronic allergies.

    These Vasomotor symptoms can be triggered by:
    Heat, Cold, Stress, The Wind, Your Favorite foods, Strong Emotions, Someones Breath, Bad Smells like Gasoline, Chemical used to clean, Colognes, And other things that you are Hypersensitive too.

    Of note: When our Mothers' told us to 'not go outside in the cold', for example with bare feet, or we would get 'sick'; we were not getting an infection from going outside necessarily but to the observer we had sniffles, nasal congestion, drainage, etc after the cold exposure. These symptoms mimic an actual head cold or Allergies but are actually a presentation of hypersensitivity and Vasomotor Rhinitis.

    A potential treatment for your 'sniffles' is use of a prescription neurological (cholinergic) blocker called Atrovent (generic: Ipatropium Bromide) nasal spray. Of Course, visit your local ENT for a complete examination and history for accurate diagnosis and treatment.

    Good Health

    Eric A. Nash, MD


  • "Ear problem I have numbness in my ear but no pain other than a head ache"

    Anonymous Client

    This is a challenging complaint to answer. A complete examination and history are needed to accurately 'Ferret' out the reason for this problem.

    The difficulty is that: where we perceive discomfort (pain, numbness, headache, fullness, paresthesias) to be in the Head and Neck is often not where the source (primary generator of the discomfort) is located.

    The Ear is innervated by 4 cranial nerves and cervical (neck) nerve branches. This means that discomfort for the Ear could actually be from the Ear itself (outer ear and inner ear) or perceptually referred to the ear from:
    1) Jaw joint
    2) Molar Teeth
    3) Posterior tongue
    4) Posterior Nose and Upper Throat
    5) Tonsils
    6) back of throat
    7) Soft Palate
    8) The Pharynx (throat)
    9) Voice Box
    10) Deep neck
    11) Posterior neck Musculature
    12) or of a Purely Neurological origin of varying causes

    In short, unless your Ear exam is abnormal, a complete Head and Neck examination and History is needed to 'Ferret' the source of your complaints and the eventual appropriate application of a treatment. Visit your local ENT for a completes examination; and your Internist.

    Good Health

    Eric A. Nash, MD


  • "Vocal cord partial paralysis happened during general anesthesia How long until very hoarse voice goes away?"

    Anonymous Client

    It is important to have your voice box looked at by your local ENT.

    Possible causes of this paresis / hoarseness you are describing may include compression of the (recurrent) laryngeal nerve by the intubation tube balloon cuff pressing posteriorly on your larynx just below the vocal cords or possibly the dislodging of one of the vocal muscle bony attachment (arytenoid bone) which can rarely occur during removal of an intubation breathing tube.

    A complete exam with your local ENT is recommended and should include laryngeal stroboscopy.

    Good Health

    Eric A. Nash, MD


  • "Hello I'm having a dry, uncomfortable throat for the past few months. I had it last year around this period as well, but it doesn't lasted longer than this period. I used lozenges such as methol and the pectin, and also being drinking lot of fluids but it's am still encountering the uncomfortable sensation in my throat. I went to the Doctor 10 days back and he prescribed a Zantac 150mg for me. But I'm still having the discomfort. It's there any way you can give me some suggestion to stop this feeling."

    Anonymous Client

    A throat and voice box examination with your local ENT is a first step in understanding your complaints, A common complaint with both post nasal drip and acid reflux is a sense of 'fullness' or 'tightness' or 'dryness' or 'foreign body sensation' in the throat. These symptoms are also referred to as pharyngospasms.

    For now until you are examined by your local ENT I would stop the lozenges and the pectin; and,
    In general:
    - increase frequency rather than absolute volume of water over the day is helpful; (sips of water every 15 minutes)
    - practicing reflux precautions - no intake of anything by mouth within 2 hours of going to bed and not laying flat in bed;
    - and using saline spray (not wash) in nose at least twice a day followed by gently blowing your nose into a tissue.

    Good Health

    Eric A. Nash, MD


  • "ear blood I thought my ear was full of wax. The Q tip came out with blood on it. There is no pain. Do I need to see a doctor?"

    Anonymous Client

    It would be best to see your local ENT. It is likely that the thin skin of the canal was abraded by the QTip. Microscopic exam and ear cleaning would be helpful for your ear as well as possible antibiotic ear drop treatment.

    Good Health

    Eric A. Nash, MD

  • "deep cough Every time i lay down I get a deep dry cough and cough up dark flem and it is persistent"

    Anonymous Client

    A Deep Productive cough as you are describing likely represents two possible scenarios:

    1) A thick mucous collection in passage ways of the lungs, moves, when you lay down on your side or back and begins to form a mucous plug inducing your cough or;

    2) When you lay down, an already inflamed larynx covered with mucous is additionally exposed to post nasal drip or pooled secretions from lower pharynx and these secretions escape into the wind pipe just below vocal cords - inducing a productive cough without necessarily having a lung source. These secretion can contain infectious bacteria or acidic contents from stomach.

    An examination of your larynx and history by your local ENT is necessary to accurately assign an appropriate diagnosis and treatment for your complaints

    Good Health

    Eric A. Nash, MD


  • "hearing voices I was wondering if there is any way a ear infection can cause someone to hear voices and hear things from a long distance away?"

    Anonymous Client

    From a pure ear perspective, the answer is yes. An ear infection in the middle ear that is severe can set off vascular and auto-immunologic changes within the inner ear (cochlea). These events can cause temporary or rarely permanent electro-physiological malfunction (hearing loss / death of individual cochlear cells).

    The ear is not just a microphone. The brain talks back to the ear in real time. The cochlea has nerve cells and muscle cells; there is a one to one mapping of the cochlear nerve and muscle cells to the auditory brain cortex. We have the ability to enhance ranges of frequencies in real time. This is why we can have a conversation with one person in a crowd of people or an orchestra conductor can hear the section that is not performing well down to the individual bad performer or a mother can pick out her baby in a room of crying children.

    The Cochlea can be poisoned by a severe infection leading to the 'Abnormal Auditory Perception' and 'Auditory Recruitment' hinted in the above question. Patients have described to me hearing echos, tinnitus and distant sounds perceived as voices, crowds or music. FYI: Tinnitus is a brain phenomenon; the sound (generated in the brain) is usually in the frequency range where our hearing is less. It is thought the Tinnitus is the brain to attempting to electro-physiologically reconnect to the cochlear damaged areas.

    You should visit your local ENT for Historical and Physical examination and Hearing testing.

    Good Health

    Eric A. Nash, MD


  • "lost voice i keep losing my voice. the sound goes up and down when i try to talk and my throat feels tight. any ideas why? i am not sick"

    Anonymous Client

    We generate our voice by the passage of air through our voice box (larynx). The vocal fold (cords) slide atop a gelatinous layer that separates it from the laryngeal vocal muscle (vocalis or thyroarytenoid muscle). Normally this system works well to project our voice; but

    Disturbances in:
    Neurologic Muscle Control (IE tremor, spasmodic dysphonia, weakness, paralysis, presbylarynx) or
    Disturbance in:
    Moisture content and Viscosity of gelatinous layer between vocal fold covering and the thyroarytenoid muscle (IE low estrogen levels in post menopausal women, testosterone / progesterone changes in men, geriatric age, dehydration, mucositis) or
    Disturbances in:
    Integrity of Vocal Fold covering (IE ulcer, infections, tumor growth, post nasal drip, acid reflux, asthma inhalers use, persistent cough, vocal abuse) or
    Disturbances in:
    Lung volume and breathing coordination

    can lead to noticeable changes in how we hear our own voices as not being our normal.

    In the question above a possible reason may be:
    1) Acid reflux - the sense of tightness is a frequent complaint of GERD sufferers due to pharyngosapsm.
    2) Neurological muscle control issue or a Psychological influence on your vocal projection.

    A visit to your local ENT doctor is best for direct laryngeal observation and complete historical evaluation.

    Good Health

    Eric A. Nash, MD


  • "sore or strep throat? I have had sore throat for the past 3 to 4 days with a cough that hurts. Its red and cant tell if my tonsils are looking like early signs of strep."

    Anonymous Client

    From this picture it appears that there is some inflammation and injection of the posterior oral pharynx as well as some exudate on the tonsils. Sore throats are largely bacterial but can also be viral.

    Visit with your local physician or urgent care. Potential treatments may include gargling with Chlorohexadine (prescription) mouth wash twice a day for 5 to 10 days and possibly the addition of antibiotics. The treatment will depend upon the extent of your symptoms at time of examination.

    Good Health

    Eric A. Nash, MD

  • "Can't breathe out of my nose while sleeping Every morning I wake up and my nose doesn't feel congested but almost swollen on the inside and I have to breathe out of my mouth. I have tried nose strips which helps a little This has been happening for about 2 years. Is there anything I can do? Why is this a problem now and wasn't before?"

    Anonymous Client

    Nasal congestion is caused by reduction in the openness of the nasal passage ways. This can occur mechanically from a combination of Turbinate hypertrophy and nasal Septal deviation. There are 3 sets of turbinates on each side of the nasal cavity. These provide warmth and moisture to the air we breathe in. The humidity and heat to air provided by the Turbinates allows for the efficient extraction of oxygen and off loading of CO2 in the lung alveoli This is called respiration and is vital to life. Our respiratory engine is most efficient with nasally delivered air due to its heat and moisture provided by the Turbinates. The Turbinates also provide some resistance to allow time for distal alveoli in the lungs to fill ( respire ).

    As we mature through life our nasal and ear cartilages continue to grow. It takes only millimeters of change in the nasal airway openness to give us a sense of nasal congestion and plugging. It is possible that your nasal septum is contributing more to your nasal congestion complaints than earlier in your life due to its growth. It is also possible that you may have nasal polyps or a growth within your nose.

    I would recommend visiting an ENT for full examination. Potential treatments may include a combination of: Nasal Saline sprays, Nasal Antihistamine spray and Nasal Steroids Depending on your exam and response to medications; surgical reduction of the inferior Turbinates and or Septal surgery may be necessary and possibly Allergy testing.

    Good Health

    Eric A. Nash, MD

  • "Fungal Ear Infection I was diagnosed with a fungal ear infection and currently using oral antifungals and clotrimazole ear drops for almost for a month.but i am sometimes getting some pain in the ear,why is that? My SGPT level is at 59.Is it good to use the antifungals in the long term?"

    Anonymous Client

    The Best treatment for all ear infections is to have the ear cleaned by an ENT doctor first. When the debris is cleared from the skin of the ear canal, the medications applied are more effective. The blood supply to the ear canal is so minute that systemic orals (antibiotics and anti-fungals) are slow to non effective when used alone.

    Visit your local ENT for ear examination ( to rule out ear drum perforation) and cleaning. Use of topical anti-fungal POWDER along with cleaning of ear canal would be more effective for resolving a fungal infection. It is also possible that you may have a mixed infection of Bacterial and / or Fungal origin.

    Good Health

    Eric A. Nash, MD

  • "Heartbeat thumping in ear I hear thumping and my heart beat in my left ear what's wrong please help."

    Anonymous Client

    The more innocent reason for this symptom is that you have a clogged Eustachian Tube. This structure connects the middle ear to the back of the nose. There is a right and left Eustachian tube. As an air pocket or more likely a fluid pocket forms inside a clogged Eustachian tube, the low frequency body sounds, like blood flow, can be heard.

    A more concerning possibility is that potential vascular changes occurred where for example arterial enlargement is causing either the Eustachian tube to be compressed or alteration of blood flow in the ear (cochlea); allowing you to hear the heart beat in your ear.

    A Third possibility is that you are experiencing spasms of the muscles that are attached to the ear bones. When this happens you can experience a fast flutter thumping sound in the ear. This is called Tensor-Tympani Spasms.

    Visit your local Otolaryngologist to assess clinically your Head and Neck Health.

    Good Health

    Eric A. Nash, MD

  • "nose bleed Discomfort left ear and at time right nose bleed"

    Anonymous Client

    The Best approach for you is to visit with your local ENT for a complete Otolaryngologic examination.

    The Nose bleed and the ear discomfort may or may not be related. Problems in the back of nose where the Eustachian tube opening is located can possibly explain both of your complaints. For example infections or growths. It is also possible that the discomfort you feel in the ear is referred from somewhere else in the head and neck and your ear examine may be normal.

    A complete exam and diagnostic workup as necessary is needed.

    Good Health

    Eric A. Nash, MD

  • "I hear noise in my ears... In evenings I hear strange noise in my ears - shoul I be worried? What specialist I should contact?Thanks for help,M."

    Anonymous Client

    What you are experiencing is called Tinnitus. It is based in our brains and involves the hearing portion of the brain. There is a one to one neurophysiologic relationship the hearing cortex has with the ear (the Cochlea). Tinnitus occurs in the frequency ranges of where our ability to hear is the poorest. This is usually the higher frequencies. Typically Tinnitus is a benign but annoying condition. Having it is not an indicator of future disease. It is a marker of a level of current hearing functionality.

    Our minds cannot 'hear' this internally produced sound and hear a matching sound from the outside world that has the same character + loudness. Masking techniques take advantage of this fact to give sufferers of Tinnitus some relief. For example, if your Tinnitus disturbs your sleep: having a radio, TV or fan on in room where you sleep can 'Mask' your tinnitus and help you attain a more restful sleep. For those with severe Tinnitus all day long, a Hearing Aid can be helpful.

    Another approach for some relief of tinnitus is use of Vasodilators for ear circulation. Lipoflavanoids were studied decades ago to assist in relief for patients with Meniere's disease. Lipoflavanoids can be used with some success to relive Tinnitus. In my experience 50% of my patients with Tinnitus get relief by taking Lipoflavanoid twice a day everyday for 60 to 90 days. If there is no relief or change in tinnitus at 90 days, going longer than 90 days with this over the counter supplement does not seem to be helpful.

    Of note: Aspirin like medication for pain relief can also cause Tinnitus (ie: Aspirin, Motrin, Aleve, Naprosyn, Toradol, Vioxx, Celebrex). If you have taken these around the time that your Tinnitus had started, you should consult with prescribing physician to potentially change these.

    For more detail you should consult with your local ENT.

    Good Health

    Eric A. Nash, MD

  • "tongue throat ears I have a raised bump towards the back of my tongue and tongue swollen it is hard to swallow and have low grade fever"

    Anonymous Client

    Infection is the likely cause of your symptoms.

    The back of the tongue has large taste buds as compared to those on the front two thirds of the tongue. The tongue also has tonsilar tissue at its back called 'Lingual Tonsils'. These have a similar pattern of infection like that of common tonsillitis from the "Palatine Tonsils' although a lot less common. Those raised bumps could be inflamed taste buds or lingual tonsil inflammation.

    Rest and hydration are fist order along with increased oral hygiene. If no daily improvement within 10 days seek medical attention for likely antibacterial treatment along with prescription oral antiseptic gargles.

    Good Health

    Eric A. Nash, MD

  • "Persian Cough Persistent cough for years. Have seen Ent, allergist and pullmonary.post nasal drip, mucous... plus help?"

    Anonymous Client

    Persistent cough can have varying sources.

    You should discuss your medications with you prescribing Doc particularly the blood pressure medications; some of these types of medications can create a 'chronic cough' condition with their use.

    Another possibility is that some mild heart arrhythmia's can induce spontaneous coughing spells.

    You could also be experiencing bouts of ' walking pneumonia'. This can plague older individual for months on end leading to persistent coughing. The frequent organism here is 'mycoplasma'

    A more common reason for cough is Post Nasal Drip. This is most often caused by vasomotor rhinitis rather than allergies.

    You should seek evaluation with an Internist and ENT specialist.

    Good Health

    Eric A. Nash, MD

  • "upper left quadrant pulsating pain I had acute bronchitis an have been treated with meds. However I now have this pulsing upper left abdominal quadrant pain that is persistent an is always in the same spot?? There is no relief from it... could it be a muscle spasm from coughing,? It's been 5 days now"

    Anonymous Client

    The best action to take for you is get urgent evaluation. I would visit your nearest urgent care or immediate care facility.

    Possibilities include something as simple as muscle spasm and rib pain from coughing to something serious as injury to your internal organs.

    Good Health

    Eric A. Nash, MD

  • "sinusitis I can't seem to get better,"

    Anonymous Client

    A question I always ask myself as a physician is: if I prescribe a given treatment to address a clinical diagnosis and that treatment is not successful at modulating or eliminating the patients complaints, then either the diagnosis is incorrect or the treatment is inappropriate or both.

    As a patient who is honest about the symptoms (metrics) they experience and responses to treatment they receive can follow the logic I outlined above. It is possible that you do not have sinusitis. A further work up of your complaints (metrics) in isolation and then grouped together can lead to clear delineation of these complaints and their best treatment options. Consult with a physician whom you can step through your list of complaints and do the complete work-up to solve them.

    Good Health

    Eric A. Nash, MD

  • "sinus head ache My sinis hurting me everyday I cant seem to get rid of it what can I take for my sinuses"

    Anonymous Client

    Headaches can have many sources in the head and neck. For example: nasal congestion can trigger a headache or even a migraine; tension headaches from neck spasms can also masquerade as a 'sinus headache'.

    Evaluation of your headache will include a workup to exclude the sinuses as the primary generator of your head pain. Visit your local ENT for evaluation and treatment.

    Good Health

    Eric A. Nash, MD

  • "Not sleeping well I wake of about 3-4 times in the night. I go to the restroom about 3 times. I don't sleep very well. What should I do?"

    Anonymous Client

    You should consider visiting your internist. Possible reasons for symptoms are endocrine based. Blood test could reveal too high thyroid levels or possible poor insulin / glucose control.

    A visit to your internist for a complete history and blood work will get you on track to feeling and sleeping better.

    Good Health

    Eric A. Nash, MD

  • "Painful lump? Hello, I'm 16. I have a pea sized lump behind ear lobe and it's painful. Inner ear hurts like an ear infection and it's swollen and my jaw hurts. On that side when I move it. My Grandma had nasopharyngeal cancer and also had a painful lump there that grew in size over time. Is it possible that I have the same thing?"

    Anonymous Client

    You should visit an ENT for a thorough Head and Neck exam. This lump could represent an extension of a severe outer ear infection or the pain you feel in the ear could be referred to the ear from the lump as its growth or inflammation activates the Greater Auricular nerve. Your Doc may consider antibiotics and or ear drops depending on exam. If treatment fails, fine needle aspiration of 'lump' or its removal may be considered as diagnostic and therapeutic.

    Good Health

    Eric A. Nash, MD

  • "Deviated nasal septum I am suffering from deviated nasal septum. But no symptoms , no problem. Only cosmetic problems. Should i go for a surgery or not???"

    Anonymous Client

    A deviated septum without any accompanying obstructed breathing symptoms does not need repair. However, for cosmetic reasons like crooked dorsum or top of nose or unusual protrusions of septum or nasal alar; cosmetic corrective surgery for the nose can be worthwhile if desired.

    Good Health

    Eric A. Nash, MD

  • "Excess mucus in mornings I have never been diagnosed with asthma, but over the last few months, I wake up sometimes with shortness of breath and a lot of mucus/phlegm backed up in my nose and throat. Are there any over the counter medications you could recommend to control this or could there be more to this problem?"

    Anonymous Client

    The heavy mucous in throat and nose and shortness of breath may not necessarily be related. The most easiest way to control this is to increase the frequency of your water intake, I recommend doing sips of water or tea every 15 minutes over the day. The more hydrated you are the less likely over night dryness and mucositis will occur.

    Since you are on Prilosec - I assume that you likely have Acid Reflux. GERD can sometimes make a person experience what i call 'pharyngospasms'. A state caused by hypersensitivity and irritation in throat from post nasal drip and / or acid reflux that can give you a sense of strain & strangle in your throat. I recommend continuing your prilosec and following reflux precautions - that is nothing to eat or drink within 2 hours of going to bed ( no water, no mints, no snacks, no pills) and keeping the head and shoulder above the stomach while sleeping. Five to Ten degrees or 1 to 2 pillows is all you need. Good Health.

    Good Health

    Eric A. Nash, MD

  • "Is there anything I can do about tonsil stones? I have a fear of swallowing them."

    Anonymous Client

    Tonsil stones are the concretions of food particles and saliva formed within the fronds and folds on the Tonsil surface. Tonsil stones formations are difficult to eradicate short of removing the Tonsils. I would suggest use of consistent oral hygiene - that is rinsing your mouth out with water after any meal; this includes gum, soft drinks and candy. Additionally, use of mouthwash after brushing teeth twice a day.

    Good Health

    Eric A. Nash, MD

  • "Why is my ear ringing? Every once and a while my ear will ring (usually right but can be both) and will stop after about 15 seconds. What is this? Could it be bad?"

    Anonymous Client

    Tinnitus is a brain phenomenon. It occurs in response to failings involving the cochlea - the hearing organ. If cochlea is sensitized due to medications, ear infections or exhaustion and there is an acute change in ear tube pressure a brief moment of Tinnitus can be brought on. Ear pressure changes can occur with a cough, a strain or a sneeze.

    Good Health

    Eric A. Nash, MD

  • "I had rhinoplasty done year ago. I cant really breath. I have to use afrin. It seems like islways have cold Breathing problems"

    Anonymous Client

    The source of your nasal congestion are likely the Inferior Nasal Turbintes. Secondly, there could be increased narrowing over time of the superior portion of interior nasal vault post nasal surgery. The purpose of the nasal turbinate is to add warmth and moisture to the air we breath. We are most efficient at repairing when we breath air thru our noses that arrive at the lungs with right amount of moisture and warmth.

    So to relieve your congestion and achieve comfortable breathing, you should consider a visit to an ENT and discuss treatment with 1 a saline nasal mist 2 nasal steroid spray 3 nasal antihistamine spray; all three to be used twice a day concurrently. If this fails consider operative treatment for the inferior turbinates.

    Good Health

    Eric A. Nash, MD