Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you utilize soluble IL-2 receptor or ACE levels as serum biomarkers to monitor disease activity in pulmonary sarcoidosis?
I use ACE levels to monitor disease activity in patients who demonstrate elevated ACE levels at diagnosis of confirmed sarcoidosis and for which there is no other explanation for elevation of ACE. ACE normalizes with treatment and will increase again if/when the disease relapses. The literature indi...
How do you decide when to initiate medical workup (e.g., thyroid, B12, infection) in a geriatric patient experiencing new onset or worsening low mood?
It is important to distinguish between low mood, which can occur from a host of environmental stressors, and frank depression, and there are 3 ways to look at either in the older patient: Early onset depression in someone now older, and the patient feels the present one is exactly the same as previo...
How exhaustive (especially considering cost) should an immunological workup be for patients with extensive, recurrent, or deep seated Staph aureus infections without obvious immunocompromise (e.g. cancer, diabetes, steroids) or recurrent breaks in skin integrity?
Obviously, children with recurrent Staph aureus infections should be evaluated for both CGD (chronic granulomatous disease) and IgM deficiency. However, the majority of adults with recurrent SA infections do not have a known systemic immunodeficiency. We should keep in mind that Staph aureus is an a...
Would you stop denosumab in a patient with chronic kidney disease if they develop asymptomatic hypocalcemia after the injection?
No. Stopping denosumab leads to rebound bone resorption and loss of all gains. The hypocalcemia indicates insufficient calcium and/or calcitriol. Calcium intake should be 1,000-1,200 mg daily from food and/or supplements in divided doses with food.
How do you counsel patients on peritoneal dialysis regarding the safety of engaging in aerobic and resistance exercises, considering the risk of developing abdominal wall complications?
The effect of exercise on intra-abdominal pressure (IAP) while on PD was examined decades ago by Twardowski et al., PMID 3774076. They found that walking, jogging, or using an exercycle resulted in only modest increases in IAP, while jumping or straining (e.g. weight- lifting) resulted in more marke...
Is there a serum potassium level for when you would recommend discontinuing potassium citrate in a patient with recurrent nephrolithiasis, hypocitraturia, and hyperkalemia?
I take hyperkalemia seriously, as cardiac effects do not correlate closely with serum levels. If evaluation does not reveal a correctable cause, I would decrease potassium citrate dosage to keep serum potassium below 5.0. Stephen B. Erickson, MD
How would you approach surveillance imaging for men with early-stage, hormone receptor-positive breast cancer after unilateral mastectomy?
As always, appreciate others' input. If you're referring to systemic imaging, I do not obtain surveillance systemic imaging as part of surveillance for any patient with early-stage hormone-positive breast cancer (male or female) unless there are symptoms or initial labs that suggest possible metasta...
How would you approach surveillance imaging for men with early-stage, hormone receptor-positive breast cancer after unilateral mastectomy?
As always, appreciate others' input. If you're referring to systemic imaging, I do not obtain surveillance systemic imaging as part of surveillance for any patient with early-stage hormone-positive breast cancer (male or female) unless there are symptoms or initial labs that suggest possible metasta...
How do you approach the medical evaluation of new onset psychosis in elderly patients?
The medical evaluation of new-onset psychosis begins with a thorough history (medical, neurologic, and psychiatric history), including a history of the present illness, medications, as well as the use of alcohol and recreational drugs. Obtaining information from family or others who know the patient...
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...