Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
How long do you continue surveillance with imaging and sputum cultures in a patient with NTM with no indications for treatment?
Since NTM lung disease typically develops over years, it is reasonable to monitor the patient with periodic HRCTs, even if the patient is relatively asymptomatic. I typically do this every 12 months in an otherwise stable patient. The reason for this is because we know that in up to 2/3 of patients,...
How do you manage osteoporosis in patients with anorexia nervosa (who often are young women < 40)?
There are several considerations when a diagnosis of osteoporosis is made in an anorexic female. 1. The bone mineral density study simply provides you with information for how much calcium per unit area is present in the bone. Based on this information a T score is provided. However, a T score of -2...
What is the minimum daily duration of supplemental oxygen therapy you recommend to patients with chronic hypoxic respiratory failure?
I think the REDOX trial has changed the landscape of long-term oxygen therapy, and I would now advise most patients to use oxygen a minimum of 15 hours/day. In patients with particularly severe hypoxemia, e.g., patients whose PO2 on room air is in the 30's, I would advise them to use oxygen for as c...
When do you consider lamotrigine in bipolar depression?
Lamotrigine can be initiated and maintained in bipolar II since hypomanic episodes would be unusual. As mentioned before, it is not for an acute situation but can be introduced anytime. Dosing though is recommended as no less than 200 mg and can be taken to above 400 mg. Please check levels 8 to 12....
Do you routinely start anticoagulation for a patient with newly diagnosed hepatocellular carcinoma presenting with a portal venous thrombosis?
No. Anti-coagulation is generally not indicated. Anti-coagulation is usually only indicated for acute PVT causing symptoms. This is more common with underlying thrombophilia. PVT is very common in cirrhosis and anti-coagulation is not required. PV thrombus from tumor similarly is common and anti-coa...
For how long would you treat a patient with dematiaceous fungi growing on a native heart valve discovered at the time of valve replacement?
The first step is to determine whether the positive culture may be a contaminant, as it very well could be. Every valve sent for culture should have also been sent for histopathological examination. In a patient with fungal endocarditis, one should expect to find evidence of acute inflammation and t...
How do you approach conversations regarding discontinuation of transfusions in patients with advanced hematologic malignancies who are otherwise appropriate for hospice?
While not an expert in leukemia care or MDS, the answer is nuanced (both in the care of patients and to hospice agencies). Some hospice programs will make exceptions to blood transfusions depending on how frequent - so it is always good to ask. From a clinical perspective, important to consider whet...
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...