Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the clinical significance of positive anti-thyroid antibodies in a patient that is post-thyroidectomy?
Ordinarily, the persistence of anti thyroperoxidase antibodies (antiTPO) or antithyrogloblin (antiTG) antibodies is of no concern or clinical relevance. However, in the case of patients with differentiated thyroid cancer, in whom thyroglobulin (TG) testing is a cornerstone of follow up, persistent a...
How do you handle elevated blood calcium levels from lithium?
Lithium in the past would often show up as calcium on blood tests, leading to an artificially elevated level. I don’t know if the modern tests have fixed that. Usually, I will watch it if over time the calcium is only mildly elevated, or refer for further workup (such as parathyroid issues, bone iss...
How do the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
What is the maximum dose or treatment course of topical steroids that you generally recommend to avoid causing systemic adverse effects?
Topical steroids cause essentially no systemic AEs. Dosing is limited by local AEs.
What unique factors do you take into consideration for geriatric patients with a first lifetime episode depression?
Late-onset depression can also be the earliest symptom of dementia, particularly Alzheimer's, in some cases!
In light of recent measles outbreaks, have you adjusted your vaccination counseling or preventive strategies for adult immunocompromised patients?
Check measles antibody (once) in individuals working in public places, especially when working with kids.
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 ...