Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is a reasonable length of time for systemic anticoagulation in patients presenting with MI in the setting of coronary artery aneurysm with large thrombus formation?
This is a great question. I would make the following points in reply: The present standard of care for antithrombotic therapy after a type 1 acute myocardial infarction, with coronary thrombosis, is dual antiplatelet therapy for one year (preferentially including a potent P2Y12 inhibitor). Current e...
Is GLP-1 therapy a viable treatment option for a patient with Type 2 Diabetes complicated by atherosclerotic heart disease and cholelithiasis?
The absolute risk difference between GLP1RAs and placebo was not remarkable (5 -27/10,000 per year for different conditions such as biliary disease, cholelithiasis, cholecystitis, cholecystectomy and biliary cancer). In addition, the risk of pancreatitis was not higher (RR 1.46 [0.59 to 3.61], P val...
How do you workup splenomegaly related to possible hematologic etiology in the absence of abnormal blood counts, adenopathy or severe constitutional symptoms?
The presence of splenomegaly is an important finding found either on physical exams or by imaging. As noted in the question, the initial work up includes physical exam looking for lymphadenopathy. In addition, laboratory evaluation, including absolute white count, and differential may help explain w...
Is there any evidence for amyloid/amyloidosis causing a spurious/false PSA reading?
This is an excellent question.Our group has been involved with amyloid/radiation effects in patients with Alzheimer’s disease Turn our initial run-up and through our most recent reviews, I have not seen any significant publications nor have I seen clinical situations that this addresses, although am...
Below what eGFR would you consider discontinuing lithium in a bipolar disorder patient with chronic kidney disease?
It seems nowadays we have other effective therapy besides lithium for the treatment of bipolar disorder. I tend to stop lithium as soon as I get a sense that there is a decline in kidney function as to avoid further damage. Of course, all of this depends on the specific situation and other possible ...
What is your approach for patients with a history of nephrolithiasis who are being evaluated for living kidney donation?
We have a protocol that guides us on the work-up in this situation. If they have a remote history of stones, then we do a Litholink and if they have a urinary milieu that is risky for stone disease they are counseled on fluid intake and dietary changes. If they have symptomatic stones, they are rule...
How often do you screen for cerebral aneurysms in patients with autosomal dominant polycystic kidney disease who do not have a family history of intracranial aneurysms or for whom the family history is unknown?
We recently wrote an editorial about this topic. Our conclusion was as follows: "considering the potential for morbidity and mortality in this unique population at risk for ICAs with possibly higher-than-average risk of rupture, we believe that presymptomatic screening for ICA in all individuals wit...
What is your approach to de-escalation of asthma inhaler therapy in the setting of negative bronchoprovocation testing when patients are averse to deprescribing?
I discuss the reason we are doing the bronchoprovacation test and what the results would mean. This makes it easier for patients to de-escalate therapy and seek an alternative diagnosis for their symptoms.
How do you treat benign fasciculation syndrome?
Reassurance. Just telling the patient that it isn’t ALS and it’s a benign and common condition will often suffice. If it doesn’t suffice: Address anxiety with psychotherapy, medications, or both. Reduce caffeine intake, and ensure the patient gets adequate sleep. If the first and second options don...
How do you approach medication management in biopsy-proven pulmonary sarcoidosis with disease stable for over 2 years on hydroxychloroquine and low dose prednisone?
Epidemiologic studies in sarcoidosis show that the majority of sarcoid cases are benign. Some patients can have disease remission, and therefore are able to come off of therapy. Most of this data is in pulmonary sarcoidosis and the data is less clear when there is other organ involvement. The diseas...