Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In extremely obese patients with spontaneous DVT/PE who have been anticoagulated for > 6 months, do you feel comfortable reducing the DOAC to prophylactic dose or do you prefer continuing full dose indefinite anticoagulation?
According to the ISTH guidelines (Martin et al., PMID 34259389) in patients with a BMI >40 kg/m2 or weighing >120 kg, it is suggested to use the standard doses of apixaban or rivaroxaban for VTE treatment and prevention regardless of BMI and BW. The ISTH did not discuss dose reduction after 6 months...
What lifestyle modifications do you recommend for patients with hidradenitis suppurativa?
It's important to approach this carefully since many patients have been told many myths that cause shame and stigma. I usually don't bring up smoking cessation or weight loss during the first visit. It's better to build a good relationship and trust, then address those. I always recommend patients g...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
How long does it take the hypothalamic-pituitary-gonadal axis to recover from secondary amenorrhea in the setting early onset and chronic use of oral combined contraceptive pills?
About 6 months after cessation of OCs.
Do you recommend the use of automated insulin delivery systems (such as Control IQ with Tandem insulin pumps) for managing gestational diabetes?
Currently, none of the current FDA-approved AID systems have algorithms set to achieve pregnancy-specific glucose goals. So using the manual mode with overnight target 90 along with appropriate bolus settings to keep PPG at goal is the most efficient.
Do you recommend using vitamin D analogs for patients with CKD and a high PTH but a normal 25-hydroxy vitamin D level?
The answer is that it depends on how high the PTH level is. KDIGO guidelines originally recommended targeting PTH between 65 and 130 for patients with non-dialysis CKD by using nutritional vitamin D if the 25-OH vitamin D level is low and using active vitamin D if the 25-OH vitamin D level is normal...
Below what ejection fraction would you avoid referral for AV access creation in a patient with advanced CKD and heart failure with reduced ejection fraction?
I would not refer a patient with advanced CKD and heart failure with an ejection fraction less than 30-35% for a hemodialysis vascular access for fear of worsening the heart failure. In addition, in my experience, if an arteriovenous fistula is placed in such a patient, it usually does not mature du...
Do you recommend genetic testing for patients incidentally found to have nephrocalcinosis on imaging?
In general, yes, but it’s usually not my first step if my family history is negative for nephrocalcinosis. These patients typically have unusually alkaline urine and often pass calcium phosphate stones. I rule out primary hyperparathyroidism and incomplete distal RTA. I look for medications that can...
How do you counsel patients with elevated factor VIII levels for their thrombosis risk?
I don't check the factor VIII level as part of a thrombosis workup because the result rarely if ever affects my management of these patients. I would explain to the patient that factor VIII levels are a function of several variables, including age, vascular health (and hence blood pressure, smoking,...