Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage elevated vWF and FVIII levels in a patient with a family history of coagulopathy?
Hard to be specific without more clinical details. I would not repeat levels. Although the higher the FVIII and VWF levels, the higher the risk of thrombosis, but there is no known specific cut-off. Currently, there is no role for empiric anticoagulation. As with all patients, DVT prophylaxis in hig...
How do you manage tacrolimus-related psychosis?
The mechanism of tacrolimus-related psychosis is unclear, but some papers have suggested that calcineurin (which is involved in the regulation of dopaminergic, glutamatergic, and GABAergic systems and implicated in psychotic disorders) may play a role (1). As a result, antipsychotics are often a mai...
What work up do you pursue for splinter hemorrhages in an otherwise healthy patient?
I would take a good history, ask for a thorough review of systems, review their medications, etc., and do a physical exam to rule out signs of a systemic illness. The workup (for endocarditis, etc.) can be directed by those findings, if present. Otherwise, the most common cause of splinter hemorrhag...
How would you manage superficial vein thrombosis that persists on imaging after treatment with full dose anticoagulation?
This is a challenging yet instructive real-life case in clinical decision-making, highlighting variations in practice that often diverge from existing evidence.Before answering let me make some assumptions: Duplex Ultrasound Findings: I assume that Duplex ultrasound did not reveal thrombus extension...
How do you manage polymorphic light eruption (PMLE)?
It depends on the severity and frequency of the case but typically: strict photoprotection with sunscreen, UPF clothing, etc., topical steroids bid starting the day before planned sun exposure and continuing for a week or two, intermittent prednisone course (best for my patients who flare the same ...
Do you take any different approaches for patients with end stage kidney disease who are about to be initiated on intermittent hemodialysis and have residual renal function?
The main consideration I have in these patients is making sure I do not try to remove extra fluid; if there is enough residual renal function to provide at least 1,000 ml/day of urine output, most likely this patient will not require net ultrafiltration, only dialysis. By paying attention to this on...
What is your approach to patients with chronic kidney disease who are found to have pelviectasis without hydronephrosis on renal ultrasound imaging?
Good question. I would involve urology early on. I would get more history as to other signs/symptoms of urinary obstruction (nocturia, BPH symptoms, history of retroperitoneal fibrosis). Then, consider a Lasix urogram.
At what stage of the neuropathy workup do you screen for B6 toxicity?
In my experience, vitamin B6 deficiency due to poor oral intake is very uncommon. However, toxicity may occur with supplementation typically more than 2 gm/day, although chronic use of 50 mg/d may also be a cause. Vitamin B6 is present in many supplements and toxicity may cause direct damage to the ...
How would you treat a patient with rectal cancer with a solitary lung metastasis, who now has no evidence of disease after total neoadjuvant therapy followed by rectal surgery and resection of the solitary metastasis?
Surveillance! Assuming this patient received “complete” total neoadjuvant therapy with at least 3-4 months of systemic therapy, preoperative radiotherapy to the pelvis and curative intent operations to the pelvis and lung with no evidence of residual disease on post-op imaging- this is the early out...
Do you warn patients about suicidal ideation when starting anti-seizure medications?
Yes. I always discuss with every patient the FDA's warning on increased risk for suicidal ideation and behavior when I start an antiseizure medication (ASM). Here are the reasons: Nowadays, patients go to the internet and review the adverse events of prescribed medications. In the case of ASMs, the...