Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you follow LFTs in patients on tamoxifen as suggested in the prescribing guidelines?
I check LFTs about every 6-9 months for patients on tamoxifen. In my practice, most patients with an LFT abnormality will have a G1 AST or ALT abnormality when it is discovered. Therefore, this seems to be frequent enough. If LFTs are abnormal, then I hold tamoxifen, and LFTs usually improve or norm...
What 24 hr urine calcium cut off value do you use for recommending parathyroidectomy in patients with asymptomatic hyperparathyroidism?
I use 5.0 mg/kg as a cut point.
Should I treat a patient who doesn't know she has cancer?
Interesting opinions. Wonder if anyone has their own experience. I will bite. My grandfather was diagnosed with mesothelioma (he had worked in a salt plant laden with asbestos). He had 9 children in North America and was staying with them. They chose, as a family, not to tell him he had cancer. We a...
Despite low T scores (-2.5 or worse), what is the actual fracture risk in relatively younger patients (early 50s to mid 60s) with low BMD?
Good question. The first thing that I do is to accurately measure the height of my patient with a stadiometer. I then follow the height over time since it is the most sensitive indicator for silent spinal fractures occurring over time. I then evaluate them by measuring their vitamin D status, i.e., ...
Would you increase the hydroxychloroquine dose to more than 5 mg/kg/day in a compliant patient with active non-organ threatening lupus (skin+joints) if serum hydroxychloroquine is not at goal until you reach an acceptable concentration?
Absolutely! Thanks for asking as this should be the trend in dosing.However, let's call this "non-life threatening lupus" instead of "non-organ threatening".Cutaneous lupus is one of the top reasons for the poor quality of life in lupus patients (Klein et al., PMID 21397983), so remission is our goa...
How do you treat patients with comorbid Bipolar Disorder and ADHD?
I usually start with non-stimulant medications, guanfacine (or clonidine) being my first choice. I'll move to bupropion or amantadine after that. I've had good results with amantadine and not much luck with atomoxetine (I find more problems with nausea and high blood pressure than benefits with that...
How do you approach a patient with biochemical evidence of primary hyperparathyroidism, but normal parathyroid scan?
Negative sestamibi scans are not unusual in patients with primary hyperparathyroidism. Other imaging tests may be negative also. If the patient has biochemical evidence of the problem and has even mild complications referral to an experienced parathyroid surgeon would be warranted. Alternatively, ci...
How does one interpret an SPEP showing potentially obscured but non-quantifiable M-spike however an IFE showing monoclonal protein?
Not all patients with monoclonal gammopathies make a detectable paraprotein on SPEP, or, in some cases like IgA gammopathies, it may be 'hidden' in the beta-region of the SPEP, or the rare IgD and IgE gammopathies may be too low to detect on the SPEP. In addition, for the 15-20% of patients who have...
What is your fluid intake target for patients with nephrocalcinosis and no history of kidney stones?
Nephrocalcinosis represents calcification of the renal parenchyma as opposed to nephrolithiasis that represents classification in the urinary space. The two conditions occasionally coexist, such as a medullary sponge kidney, distal renal, tubular, acidosis or primary hyperparathyroidism. For patient...
How often do you pursue malignant transformation screening In patients with lymphomatoid papulosis or pityriasis lichenoides?
In the case of patients with lymphomatoid papulosis (LyP) or pityriasis lichenoides, regular follow-up and monitoring for signs of malignant transformation is important, given the potential (though generally low) risk of progression to lymphoma, especially cutaneous T-cell lymphoma. For LyP, follow-...