Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend parathyroid imaging testing for patients with recurrent nephrolithiasis who are incidentally found to have an elevated PTH but who do not have hypercalciuria, hypercalcemia, hypovitaminosis D, or chronic kidney disease?
Yes, but with caveats. The “yes” is because hyperparathyroidism is a surgically curable disease if done by an experienced parathyroid surgeon. The caveat is if previous stone analyses have not shown a substantial calcium phosphate component, the stone formation may be due to other causes and unaffec...
What are preferred sleep aids in elderly patients with dementia?
Melatonin 3-6 mg because of their loss of melatonin-secreting potency with age. Doxepin 10 mg because of the cost of 3 and 6 mg versions. If restless legs or limb movements during sleep, gabapentin or pregabalin. Pregabalin can be better tolerated with less next-day sedation (also can be an issue wi...
Do you recommend obtaining a DEXA scan for patients with recurrent nephrolithiasis and hypercalciuria of unknown etiology?
I think this is an important question. I agree with Dr. @Dr. First Last. In my practice, if the patient is female, especially peri- or postmenopausal, I generally recommend a DEXA scan. If bone density is borderline or low, I typically refer the patient to an endocrinologist in our Bone Clinic for c...
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
Do you hold anticoagulation prior to performing bronchoalveolar lavage?
Can do BAL on anticoagulation. Anticoagulation does not increase the risk of bleeding for BAL.
How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?
This is an important question. Currently there are several groups of patients that benefit from reduced dose glucocorticoids: The largest group are patients who are receiving avacopan for remission induction. The ADVOCATE trial demonstrated that avacopan can markedly reduce the dose of glucocorticoi...
How do you read a PFT with restrictive type spirometry but normal lung volumes?
Non-specific pattern. Initially, NEJM papers showed that these patients develop obstructive patterns in the long term but follow-up papers have shown that patients can stay in that pattern (non-specific) or develop restrictive or obstructive patterns.
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
For male patients who strongly prefer to stop anticoagulation for unprovoked VTE, are there any tools or labs that you would use to guide your decision making?
This is a challenging situation as one of the more useful tools to predict risk of recurrence after unprovoked VTE, the HERDOO2 rule, suggests that even with an otherwise "perfect" score, men have a high enough risk of recurrence to recommend ongoing anticoagulation. As such, and given the generally...
What is your approach to immunosuppression in patients with preserved kidney function who are found to have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy?
This is a difficult scenario. Would definitely try to get a biopsy at a Higher level of care perhaps by Interventional Nephrology. Would obtain a comprehensive laboratory workup including kidney function, serum albumin level, random and 24-hour urine collection for albuminuria and proteinuria, Hepat...