Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What workup do you recommend on patients with suspected ischemic cranial nerve six palsy?
The conventional wisdom is that 90% of isolated ischemic (or "vasculopathic") 6th nerve palsies recover in 6 months or less. Diagnostic certainty of this etiology is increased if the patient is hypertensive, diabetic, or maybe has hyperlipidemia or tobacco use. The real problem for the non-ophthalmi...
How would you manage cognitive changes in a patient with memory impairment and significant brain atrophy with no diagnostic testing consistent with Alzheimer's disease?
It would depend on the clinical history, pattern of atrophy, and diagnostic biomarkers. If I had a patient with a typical clinical history of AD with progressive episodic memory loss substantiated by neuropsychological testing, IADL impairment, and hippocampal atrophy on imaging, I probably would no...
When do you screen for pulmonary hypertension in ILD patients?
Pulmonary hypertension (PH) is a frequent finding in patients with advanced interstitial lung disease (ILD) and its presence is associated with worse morbidity and mortality. The prevalence of PH will depend on the severity of ILD, ranging from around 10% at diagnosis and about 60% of patients with ...
When would you consider biopsy for an incidentally noted, PET negative, solid, solitary pulmonary nodule that is >8mm in size?
No, probably not. The whole point of a PET scan is to use it for its negative predictive value (which is very high for a nodule that is solid, and large enough). I'd like to know just how large it is because smaller nodules (e.g. just at or above the 8 mm size threshold we all perseverate on) can be...
What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?
A timely question, as we head to 2023! The only reason to use biosimilars is for the broad purpose of resource stewardship. There isn't a medical reason to prefer a biosimilar over a reference product (or vice versa), because if a product were found to have a significantly different therapeutic effe...
How do you recommend discussing family member genetic testing with a patient recently diagnosed with ADPKD?
Depends on the age of the family member (adult versus young adult versus under age 18). Depending on whether the "recently diagnosed" patient has had genetic testing, variant testing in the ADULT family member could be recommended in a straightforward manner through most testing companies. That pers...
How do you approach monitoring for lymphoproliferative disease in Sjogren's patients?
I have an increased index of suspicion for lymphoma, myeloma, and amyloid in Sjogren's. Increased age, longer disease duration, and greater disease activity increase the lymphoproliferative risk.Persistent unilateral parotid or other salivary gland enlargements, lymphadenopathy, vasculitis (purpura,...
Would you treat a patient aggressively for lupus nephritis if they have persistent proteinuria over 1 gram but cannot get a timely kidney biopsy?
It all depends. I would keep pushing for a biopsy and try to overcome the barriers ASAP. If it is the patient who is the barrier (not wanting the biopsy), I would educate them on how a biopsy ends up not even being due to SLE in some cases and immunosuppressant treatment therapy would be exposing t...
Is it safe to use quinacrine in SLE patients with a history of hydroxychloroquine-associated retinopathy?
To my knowledge, quinacrine, an anti-malarial, is not FDA-approved for use in the US. It may be obtained from compounding pharmacies but the FDA makes no assertions regarding either its safety or its efficacy. For lupus, it has been used primarily as adjunctive therapy for cutaneous disease, e.g. ad...
How do you utilize at-home seizure monitoring devices for your patients with epilepsy?
Absolutely! All video recordings are useful; home videos, cellphones, security cameras, etc.Benbadis, PMID 36891282