Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?
It is important to keep in mind that immunomodulator therapy is also frequently associated with gi toxicity (MMF, methotrexate, leflunomide, azathioprine, etc.). Given this, it is important to begin one therapy at a time in order to mitigate side effects and do understand which agent is responsible....
What cardiac surveillance would you do for an asymptomatic male patient with a remote history of mantle field radiation for Hodgkin's lymphoma?
I would follow the long-term follow-up guidelines from COG based on heart dose - Children's Oncology Group (survivorshipguidelines.org)
Do you prefer monitoring creatinine over cystatin C levels in patients with lymphoma and chronic kidney disease given the potential for cystatin C levels to be increased with certain malignancies?
My default is to monitor creatinine, not cystatin C, in all patients with malignancies except: if patients have had weight loss and down-trending creatinine, patients are at eGFR cutoffs for chemotherapy drug dosing, leading to concern for potential over/under-dosing, there is concern for pseudo-AKI...
Do you recommend stopping a SGLT2i indefinitely if a patient with chronic kidney disease and diabetes develops euglycemic diabetic ketoacidosis?
I would. In my opinion, the risk of ketoacidosis will outweigh the possible benefit from SGLTs.
Do you recommend dietary protein restriction in your patients with chronic kidney disease?
Not really. I let the serum BUN be the guide. If the serum BUN is very high and otherwise patient does not need dialysis then it may be helpful to decrease the protein intake. This is more often observed in inpatients (with some degree of AKI) than outpatients.
Can joint replacement surgery be performed in someone with active Paget’s disease elsewhere?
Joint replacement surgery can be done in patients with Paget's disease. There should be no problem particularly if the patient has been treated to suppress disease activity. The best treatment is a 5 mg intravenous infusion of Recast which can suppress disease activity for 5 years or more.
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.
How do you counsel newly diagnosed patients with ALS on dietary recommendations?
I counsel all my newly diagnosed ALS patients about the importance of weight maintenance. Weight loss is an established risk factor for accelerated ALS progression according to several studies (Janse van Mantgem et al., PMID 32576612 and Jawaid et al., PMID 20500116). Therefore, we always aim to mai...
Do you routinely perform genetic testing in patients presenting with pulmonary fibrosis who endorse a family history of fibrotic lung disease?
I receive this question frequently when I hear from other clinicians and I think it is a very thought-provoking question. We know that patients with pulmonary fibrosis (PF) commonly have first-degree relatives with interstitial lung disease (ILD). Some studies quote numbers as high as 20% so it is d...
How would you manage patients with exposed bone due to injured gingiva after recent chemoradiation?
Pentoxifylline and vitamin E