Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden >20 percent?
In my younger days I've managed high-burden PVCs with minimal to no symptoms with a spectrum of strategies, including ablation (I've had a case of LVS PVC/VT ablation with late resolution akin to Candemir et al., PMID 30822513), BB, flecainide (case of resolved PVCs after medication holiday), and ob...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...
What work-up and treatment do you recommend for exertional headaches?
Primary Exercise Headache Diagnostic Criteria per ICHD-3: At least two headache episodes fulfill criteria B and C Brought on by and occurring only during or after strenuous physical exercise Lasting <48 hours Not better accounted for by another ICHD-3 diagnosis Caveats: Migraine headache worsened o...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...
What is your approach to the diagnosis of acute kidney injury suspected secondary to renal infarction from thromboembolic disease?
Renal infarction should be suspected in a patient with acute flank/abdominal pain, hematuria, and elevated LDH with normal AST and ALT, especially in the setting of atrial fibrillation, left ventricular thrombus, dilated cardiomyopathy, prosthetic heart valve, renal artery injury/dissection or hyper...
How do you typically manage a patient with a single positive blood culture from two sets growing Candida species in a stable patient without prosthetic devices or material?
Candidemia is defined as the presence of Candida species in the blood, and even a single positive blood culture specimen is considered significant and warrants treatment as candidemia. Initial management should include: Initiating antifungal therapy with an echinochandin (micafungin, capsofungin, o...