Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What work up do you recommend in post bariatric surgery patients who are slowly gaining back the weight despite no changes in diet?
Depending on which surgical procedure they had and how long ago they had it, patients may need evaluation by their surgeon. Meanwhile, I approach these patients similarly to patients who have not had surgery. I look for reasons for their weight gain such as change in diet (even if patient denies it ...
What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?
There have been a number of lupus biopsy and treatment questions here lately. The management of lupus nephritis is VERY difficult with innumerable permutations of past and present, biopsy nuances, symptoms, and treatment histories. The answer to this question depends on more than "subtle changes in...
How would you manage an elderly patient with mild pancytopenia who refuses bone marrow biopsy and whose flow cytometry is suggestive of CMML/MDS?
It depends on the actual age of the patient - 70s, 80s versus 90s. If 80s or 90s and not transfusion dependent - suggest observation as likely low-risk disease. Alternatively, if there is a need to start hypomethylating agents then would send peripheral blood for NGS and cytogenetics especially if h...
For patients with central hypothyroidism and a clear etiology (such as recent head irradiation), do you recommend brain imaging prior to starting thyroid hormone replacement therapy?
Levothyroxine does not cause tumor growth, and therefore you do not need to image before starting therapy. However, in general, it takes a long time for central hypothyroidism to develop after radiation, therefore in the presence of an early reduction in FT4 you must consider the possibility of the ...
How do you approach treatment of patients with brachioradial pruritus?
In my experience, I have been asked to treat this condition twice so far, and the results were not great. As I consider it a neuropathic syndrome, I usually start with alpha-2-delta calcium ligands like gabapentin or pregabalin, and I may also try antidepressants like TCA or duloxetine. Some dermato...
How do you counsel patients with postmedian sternotomy plexopathy?
Brachial plexopathy after median sternotomy is not very common. Its frequency varies in different studies but it's most likely between 0.5-5%. The most likely mechanism is traction of the anterior rami of the C8>T1 roots, often associated with a fracture or upward displacement of the first rib. A re...
In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?
Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been ...
Which brand/preparation of levothyroxine do you recommend to treat hypothyroid patients with alpha-gal allergy?
Alpha-gal syndrome is a type of food allergy to meats. None of the generic or brand-name thyroid medication tablets contain meat. In general, in patients with food intolerances, I recommend Tirosint capsules which contain only levothyroxine and glycerol BUT the capsule is made of gelatin derived fro...
Would you treat a sputum culture positive for Aspergillus niger despite an atypical CT chest and a negative serum galactomannan in an immunosuppressed patient who is too high risk for bronchoscopy?
What is your treatment approach for a young female who has an idiopathic small right elbow effusion with synovial thickening that has resulted in limitation in her range of motion?
I might aspirate the joint, send for gram staining, cell count, culture, and crystals, check serology to rule out autoimmune like RA or lupus, tick-born disease, and X-ray the joint. If all is negative, consider a short course of steroids, even synovectomy.