Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage symptomatic iron deficiency in patients with PV on frequent phlebotomies?
While iron deficiency by itself is not harmful, if someone has symptomatic iron deficiency, you could consider them intolerant to phlebotomies, and start a cytoreductive agent. Then, over time they can replete their iron stores. In some patients who are very symptomatic from their iron deficiency, I...
How do you view the balance between opting for percutaneous coronary intervention and prioritizing optimal medical therapy as the initial treatment choice for patients with stable angina?
This is the holy grail of Cardiovascular practice on how to marry the prevalent scientific data to clinical practice. In my opinion, an astute history and in-depth analysis of patient symptoms (angina and ischemia with their varied clinical presentations) hold the key to individualized patient care....
Which images do you routinely request when ordering a HRCT chest?
The images I tend to request depends in part on the clinical scenario. In general, I find it helpful to obtain a traditional "ILD protocol" when I meet an ILD patient for the first time, especially when the diagnosis is unclear. This includes both prone and supine images with 1-1.5 mm cuts, in addit...
How do you counsel patients on the likelihood of resolution of their hypertension post adrenalectomy for primary hyperaldosteronism?
Primary hyperaldosteronism is a curable cause of hypertension. Removal of an Aldosterone producing adenoma results in correction of biochemical abnormalities in almost all patients. Hypertension also improves but not in all patients. Studies have shown that "cure" of hypertension occurs in about 27-...
For a patient with May-Thurner syndrome and DVT, would you recommend anticoagulation for 3-6 months or indefinitely?
This is a very good question, there is little data on this and there are only a few case series. One case series of 8 patients showed a 25% risk of recurrence in one year with May-Thurner syndrome but too small of a sample to really know what the risk is, plus this probably included a heterogenous m...
For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?
Agree with Dr. @Dr. First Last. In the clinical trials that led to rivaroxaban and apixaban approval, many patients had 2 days of injected anticoagulant first to arrive at successful outcomes leading to DOAC approval. I suggest IV heparin until hemodynamically normal (for PE), sq LMWH for a dose or ...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
What is your approach to managing Grover's Disease (Transient Acantholytic Dermatosis) that has failed topical steroids?
I'm a big fan of low-dose naltrexone for Grover's Disease (and Hailey-Hailey and Darier's Disease). It's a safe and effective treatment that I've seen work very well. The dose ranges between 1-5mg daily. It seems like 3mg is often the sweet spot. Patients sometimes report more trouble sleeping and/o...
Would you recommend starting an SGLT2 inhibitor in a proteinuric CKD patient with chronic asymptomatic bacteriuria?
In spite of the biological plausibility that SGLT2 inhibitors are associated with increased risk for UTI, population-based cohort studies, like the one of Dave et al in diabetic patients, did not show a higher risk of severe or minor UTI with SGLT2 inhibitor users and other antidiabetic drugs. The d...
How do you practically approach a tailored elimination diet in young patients with numerous food impactions and esophageal strictures who are intermittently compliant with PPI or topical steroids?
The first thing I would do is discuss with them the different approaches and efficacy of diet therapy. Currently an empiric elimination diet is the favored approach. Which empiric elimination diet is chosen is a discussion to have with each individual patient in a shared decision approach. The six f...