Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach for cancer screening for elderly onset RA?
For elderly onset RA, I would ensure that they had had all age-appropriate preventive malignancy screening with mammography, colonoscopy, PSA, and PAP smear, and in smokers or history of significant tobacco use, I would order low-dose CT screening for lung cancer. In those individuals with constitut...
How do you clinically distinguish between group I and group III PH in patients with CTD-ILD?
The distinction between pulmonary hypertension (PH) of the group 1 (pulmonary arterial hypertension (PAH)) and group 3 (pulmonary hypertension (PH) due to lung disease and/or hypoxia) is essential since the management is different. In group 1 PH we stratify the risk and treat with a variety of PAH-s...
Do you give additional pneumococcal vaccines after a dose of PCV20 in patients with asplenia?
Assuming the patient otherwise does not have immunocompromising conditions other than asplenia, following age-appropriate vaccine schedules is appropriate. A dose of PCV20 appears to provide adequate protection. However, ongoing surveillance studies will be important to answer this question, and vac...
What is your approach to a patient who has a cardiac PET scan suggestive of sarcoid but no other supporting evidence of a diagnosis of sarcoid?
The diagnosis of cardiac sarcoidosis (CS) can be challenging, as non-necrotizing granulomatous inflammation is frequently patchy, and as a result, may not be present on endomyocardial biopsy even in the setting of active cardiac disease. Many institutions, including ours, attempt to avoid endomyocar...
Would you add cholecalciferol or ergocalciferol to calcitriol therapy in patients with post operative hypoparathyroidism who have low 25 OH vitamin D levels?
Yes, if a person with hypoparathyroidism has a low 25(OH) D level, on calcitriol, I would do several things; first, figure out why it is low; and second, check a serum calcium and phosphorus level. If the calcium is low and the phosphorus is elevated, I would try using cholecalciferol 1000 IU daily ...
Do you add a separate dose of losartan for patients with heart disease and proteinuric kidney disease who are on maximal doses of sacubitril/valsartan but continue to experience proteinuria?
There is data in studies of proteinuric kidney disease to suggest that combining an ACEi and an ARB confers a little additional benefit in proteinuria management but confers a significant risk of hyperkalemia. I would presume the same risk/benefit ratio when using 2ARBs and I would not opt for that ...
How do you counsel patients who report a history of a lidocaine allergy?
Actual lidocaine allergy is vanishingly rare. I usually ask if this report is based on an episode at the dentist, which it very frequently is, and then I follow by asking if their "allergy" consisted of rapid heart rate, chest tightness, and an oftentimes intense feeling of anxiety. This report is l...
Is active smoking a contraindication to starting menopausal hormone therapy (HRT) in a post-menopausal woman with severe vasomotor symptoms and no other cardiovascular risk factors?
Not much prescription or guidance during fellowship and now learning.
What is your perioperative approach to holding and restarting hydroxyurea in patients with essential thrombocythemia?
I would like to rephrase the question since as written, the assumption is that hydroxyurea is a preferred therapy for ET, when any careful reading of the literature will show that there is no proven rationale for using chemotherapy of any sort routinely in ET. There is no association between the pla...
When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?
This is a very good question often debated by thoracic radiation oncologists with their thoracic surgery colleagues and can get complicated. The best way to look at it, in my opinion, is to understand the sensitivity and specificity of FDG PET/CT to detect true mediastinal nodal disease. For example...