Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How long do you continue antibiotics after cholecystostomy tube placement for acute cholecystitis?
The solution to questions regarding treatment duration invariably falls under the category of "it depends." For individuals with severe illnesses, particularly those with bacteremia, an extended treatment period ranging from 7-14 days might be needed. Conversely, for patients who show significant im...
How do you adjust the management of epilepsy in patients who are planning to fast?
Great question! During Ramadan, Muslims fast from dawn to sunset. They can take their medications before dawn and after sunset. In most cases, they can continue their current bid regimen without having to change to extended-release. Remind them of the importance of maintaining a good sleep schedule ...
Is there a need to bridge a patient with a history of Factor V Leiden on systemic anticoagulation such as a DOAC prior to elective low-rise procedures such as colonoscopy?
The prevalence of Factor V Leiden heterozygous is around 3-5%. Although it does increase the relative risk of thrombosis, the absolute risk is still low; this does not warrant any additional intervention even in patients undergoing major surgery. Colonoscopy is a low-risk procedure anyway. Excellent...
Are there instances when you would recommend against pursuing adrenal vein sampling in a patient with primary hyperaldosteronism and normal adrenal imaging?
Yes, it is not uncommon for patients to choose not to pursue an adrenalectomy. I do not get the adrenal vein sampling (AVS) until I've had a discussion about the risk/benefits of adrenalectomy. Sometimes, I'll have them visit the surgeon before attempting an AVS to get a full picture of the surgery ...
How would you approach management of nodular scleritis in the setting of suspected GCA?
Scleritis is probably a rare but real association with GCA. The rarity is such that I would not ignore alternative causes of scleritis. For example, ANCA-associated vasculitis could mimic GCA and syphilis has also been reported as a masquerade. Scleritis is usually divided into 5 forms: nodular, dif...
Can giant cell arteritis present with a partial cranial neuropathy?
Giant cell arteritis (although giant cells on temporal artery biopsy are not a sine qua non) most typically presents to the neuro-ophthalmologist with ischemic optic neuropathy (usually anterior and sometimes posterior).Ophthalmoplegia is uncommon in GCA but has been attributed to oculomotor and abd...
What is your approach to assessing traumatic exposure in children?
Ask explicitly with a child, adolescent, or adult: “Have you ever been hurt or abused by adults or other people, physically or sexually?” (Be prepared to elaborate). What we are getting at to some degree here is PTSD-like events. Sadly, people frequently experience death, tornadoes, car accidents, ...
Do you recommend adding Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who are on potassium citrate but continue to have hypocitraturia?
As an inventor of Moonstone Stone Stopper, I do have a conflict of interest. Having disclosed that, I will say that it is a good way to supplement citrate. Many of my patients use BOTH K citrate and Moonstone depending on whether they have bathroom access, are traveling, or the like. Many take the t...
Is there any role for prophylactic bronchial artery embolization in immunocompromised patients with invasive pulmonary aspergillosis?
Bronchial artery embolization is NOT without complications. Although the bleeding risk is very high in invasive pulmonary aspergillosis, empirical embolization is not well supported either by data or clinical practice. It probably should be a case-by-case decision.
Would you consider using Evenity in an elderly patient with rate controlled atrial fibrillation without history of MI or CVA?
The cardiovascular safety profile of Evenity is complex and has been reviewed in several publications. The concern is myocardial infarction and stroke. In general, if there is a history of an MI or stroke I would personally avoid Evenity. Although I do not have access to the safety dataset, I am una...