Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What evaluation do you do in patients with hypertension and persistently elevated aldosterone/renin ratio (over 20) but without an elevated aldosterone level (under 10 ng/dL)?
Patients with proven primary aldosteronism (based on pathology and postop aldosterone levels) can have plasma aldosterone levels <10 ng/dL. Repeating the levels, especially after optimizing their medications, can improve the test's sensitivity. The key in such cases is a PRA level <1 ng/dL. In the a...
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...
What are your management strategies for patients with nephrolithiasis and hypercalciuria who have a severe sulfa drug allergy and are unable to tolerate thiazide diuretics?
This is a difficult situation. Assuming the nephrolithiasis is calcium-based, I think the patient has to lean more heavily on dietary control. Dietary sodium restriction will decrease hypercalciuria. A further increase in fluid consumption will dilute the urinary calcium concentration. We are fortun...
How do you approach using DMARDs for patients with CPP arthritis who have frequent flares?
As far as I know, none of these agents are proven to prevent CPPD flares. Colchicine for acute flares. If someone is aware of evidence that any of these other choices work, I would be glad to hear about them. I have a patient with Gittleman's syndrome who had severe CPPD with almost constant flares....
Have you seen rheumatoid nodules or RA-ILD in patients with seronegative RA?
By definition, rheumatoid nodules are considered to be a highly specific manifestation of RA. Regarding the first part of the question, one should never see true rheumatoid nodules in someone who does not have seronegative RA. Though there are sporadic case reports of finding these nodules in people...
How do you counsel patients and partners of patients with HPV+ cancers regarding the HPV vaccine?
The patient was likely exposed in their teens or twenties. The partner is likely too old to be vaccinated. Independent of the cancer, children should be vaccinated.
How do you approach the initiation and/or continuation of antiseizure medication in a patient who has experienced one lifetime seizure with a normal EEG and MRI with a comorbid health condition that is associated with an increased risk of epilepsy?
AAN Guideline (2015): Management of an Unprovoked First Seizure in AdultsAntiepileptic drug treatment after an unprovoked first seizure (Bao et al 2018)The 2015 AAN guidelines point to level B evidence that starting ASMs decreases the overall risk of recurrent seizure within 2 years. The Bao et al 2...
What is your preferred formulation of parenteral iron?
The question is not simple. The formulation I use the most is ferumoxytol because four insurance carriers allow a total dose infusion of 1020 mg in 20-30 minutes. This has been published twice (Auerbach et al., PMID 21922526 and Karki and Auerbach, PMID 31155744). Otherwise, it must be given as two ...
How do you approach the work up of pulmonary artery aneurysm in the absence of other clinical features of Behcet’s?
While Behçet’s disease (BD) is one of the most well-recognized causes of pulmonary artery aneurysms (PAA), it may not be the most common one globally. In scenarios where a careful history, exam, and vascular imaging don’t reveal other BD-compatible findings, other conditions can be more likely. It i...
Do you routinely obtain baseline vascular imaging (CTA, MRA, PET) in patients with suspected GCA, but negative temporal artery biopsy?
Vascular imaging is particularly helpful in patients with large vessel giant cell arteritis. This patient subset may present with persistent constitutional symptoms, refractory polymyalgia rheumatica, fever of unknown origin, or with vascular signs/symptoms (for example arm claudication). These pati...