Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients with a curable breast cancer that there is no indication for additional surveillance imaging after treatment other than continuing annual mammograms?
This is certainly a difficult question to address. I acknowledge and validate the patient’s fears first. When breast cancer patients complete their primary therapy (often after they are stable on hormonal therapy or complete a year of Herceptin), and we begin talking about seeing them every 3 month...
For patients who have undergone ablation for atrial fibrillation with elevated bleeding risk, what is your risk/benefit approach when deciding to continue oral anticoagulation long-term?
I would generally determine the continuation of anticoagulation based on the patient's ChADSVASC score rather than the perceived success of ablation as many will have a burden of subclinical PAF despite ablation. So, if they are at high risk for stroke/systemic embolism, based on ChADSVASC, I would ...
How would you manage distal DVT in first trimester of pregnancy?
This is an excellent question. Essentially, this is an individual with an acute, provoked distal DVT in the setting of pregnancy. ASH 2018 guidelines for management of VTE in pregnancy recommends antithrombotic therapy with LMWH for individuals with acute VTE (Bates et al., PMID 30482767). While the...
What percentage of patients with non-sustained focal atrial tachycardia detected on an outpatient Holter develop paroxysmal atrial fibrillation, and how should we identify and treat patients at the highest risk of progressing to PAF?
I agree with most of the points by Dr. @Dr. First Last. I'll go through my train of thought from monitoring to what the %age is (PAT progressing to PAF) to afib management/reasons we care. Apologies for the length of response:1) The right monitoring technology should balance what you are looking for...
How do you approach COVID-19 vaccination in those with a prior history of glomerular disease?
It is well documented that patients with kidney disease are at increased risk for morbidity and mortality from SARS-CoV2 infection including increased rates of hospitalization, AKI and death. Those with preexisting glomerular disease (GD) have demonstrated impaired GFR recovery following AKI in the ...
How do you determine osteoporosis treatment response when patients have discrepant DEXA scan results during monitoring (eg improved BMD of the hip and spine but worsening BMD of the femoral neck)?
This is not all that uncommon. The first thing I do is ask if they have fractured since we started the therapy. If not, I relax a little. This is a nice scenario for using bone turnover markers as part of initial work up. If PINP goes up by >10 I am happy that an anabolic drug is working... more you...
At what ferritin threshold would a patient with anemia of inflammation or malignancy no longer benefit from iron supplementation for functional iron deficiency?
There is no level. I have given IV iron to people with low TSATs and ferritins in the thousands. 200 isn't even close to too high.
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
Is there safety data regarding the use of hormonal IUDs in patients with atypical ductal hyperplasia and other high risk, non-malignant breast lesions?
In searching the literature, I find nothing specifically about progestin-based IUDs and women at increased risk of breast cancer. Some studies, however, have found that hormonal birth control methods, including intrauterine devices (IUDs) containing progestin, may slightly increase the risk of breas...
How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?
Risk analysis is at the heart of all therapies that we prescribe for our patients. Patients on long-term daily NSAIDS are at higher risk for GI symptoms, bleeding, and perforations. These risks can be between 2-4%/per year, and vary based on risk factors such as age, general health, cigarettes, prop...