Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you consider attributing isolated psychosis to an acute ischemic stroke?
Though relatively rare, systematic reviews have found post-stroke psychosis to occur in just under 5% of patients. When considering attributing psychosis to an acute stroke, there are several things it can be helpful to consider: Differential diagnosis: Making sure to rule out more common etio...
How long would you anticoagulate for PE developed after air travel in a woman on an estrogen-containing vaginal ring for contraception?
This patient has two transient (“provoking”) factors that may have contributed to her pulmonary embolism (PE): the use of estrogen-containing contraception and, presumably, a recent long-haul air travel. Traditionally, it has been assumed that, after three months of treatment for the initial venous ...
Given the cardioprotective and renoprotective effects of SGLT2 inhibitors, should we consider administering to patients with well controlled type 1 diabetes despite the risk of DKA?
The key word in this question is "consider". GIven the lack of published clinical trials to assess efficacy (CV and CKD hard outcomes) versus safety (DKA) in this population, an answer at this time would be a qualified yes, with the qualifications being a well-motivated patient who adheres to self-g...
How do you counsel patients regarding using stimulants for attention-deficit/hyperactivity disorder during pregnancy?
There is limited research evaluating the course of ADHD across pregnancy and postpartum. The individual woman’s severity of illness and impairment inform treatment decisions across pregnancy. As with the treatment of all disorders during pregnancy, the risks and benefits of medications need to be ca...
Do you treat patients with culture positive mycobacterium abscessus if they are asymptomatic and do not have progression on imaging?
If by "symptomatic," the assumption is that patients have a productive cough, malaise, fatigue, and weight loss, they should be treated per protocol. We usually proceed with "shared decision making" discussing the nuances of untreated versus treated scenarios.
How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?
This is a challenging scenario that we often see in clinical practice with our current multiplex assays. A great reference is the following ACR abstract: Clinical Significance of RNP Antibodies in Diagnosis of Systemic Autoimmune Rheumatic Disease When Detected By Multiplex Immunoassay. As demonstra...
When is a paraneoplastic panel indicated when working up patients with neuromuscular conditions?
How would you interpret a positive dsDNA in a patient with a negative ANA performed via indirect immunofluorescence?
Another important consideration is the methodology by which the anti-dsDNA antibody was assessed. Most commercial labs use EIA, which is sensitive but not as specific as Farr or Crithidia assays. Many positive EIA results are negative when checked by these more specific methodologies.
How do you approach a negative ANA and positive dsDNA in patients with arthralgia, hair loss, or other UCTD features?
This could easily be a person with early (evolving) ANA-negative SLE (depending on the dsDNA titer) or early UCTD. If the dsDNA titer is low my concerns are somewhat diminished. I certainly would not assign a diagnosis of SLE given the information provided, with special reference to the person's anx...
Are there instances when you obtain an abdominal X-ray over an ultrasound or CT scan for kidney stone surveillance in a patient with recurrent calcium based nephrolithiasis?
I agree with Dr. @Dr. First Last. I see no use for an abd Xray. I, generally, go to US, which has no radiation and is good at localizing stones and can identify relatively small stones as well as give a good sense of stone burden. Occasionally, a CT may be required.