Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.
What is your approach to postpartum screening and cardiovascular risk assessment in patients with a prior history of preeclampsia?
Hypertensive disorders during pregnancy, including preeclampsia and gestational hypertension, elevate a woman's long-term risk of cardiovascular disease. The American College of Cardiology (ACC) and the American Heart Association (AHA) now recognize preeclampsia as a risk-enhancing factor for heart ...
When do you consider immunosuppression in patients with Sjogren's neuropathy?
Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, ...
For patients with incidental findings of venous thromboembolism during workup of a treatable malignancy, how do you approach discontinuation after the treatment is complete?
Your approach to incidental thromboembolism found on the workup of malignancy should be similar to any evaluation of a thrombosis. It should be a structured approach with the following questions evaluated before deciding on long-term or short-term anticoagulation. First, one should determine the loc...
Which screening method for diabetes do you consider to be the most sensitive?
I don’t usually think about which screening method for diabetes is the most sensitive. I am more likely to consider which is most appropriate for my patient. I never order OGTT for non-pregnant patients. They are cumbersome and, compared to FPG and A1C, they don’t significantly change my recommenda...
What is your approach to correlating stenotic lesions on coronary angiography to magnitude of decline in LV systolic function or cardiomyopathy severity when deciding to intervene or medically manage stable ischemic heart disease as an outpatient?
I use a combination of EKG, ECHO, Stress test, and viability (nuclear or MRI) to correlate the stenotic lesion to ischemic/hibernating/infarcted myocardium. I would only intervene if there is a large amount of ischemic/hibernating myocardium in the area supplied by the stenotic artery. I also use FF...
What is your approach to a patient with incidental radiographic findings of sacroiliitis without clinical inflammatory back pain?
I agree. As mentioned, often, the radiology report going back to orthopedics, for example, may say "spondyloarthropathy" whereas, in fact, the radiologist is just describing osteoarthritis and/or spondylosis (the combination of OA and degenerative disc disease). Then, a rheumatology referral is init...
How long do you wait for a patient to be seizure-free before you clear them with regard to operating heavy machinery (i.e., for work)?
I would use the driving laws in the state where the patient resides as the guide for this. After all, if the patient can drive a car, it would be hard to tell them they can’t operate other heavy machinery. In my state, this would mean 6-12 months (we have a variable restriction on driving privileges...
What further work up do you recommend for patients with a chronic high anion gap metabolic acidosis with normal eGFR who have been ruled out for lactic acidosis, ketosis, toxic alcohols, and other usual culprits of high anion gap metabolic acidosis?
I take a good history for Tylenol for pyroglutamic acid, as that may not be a test you can do. If there is ANY GI history of a D-lactate level. Might as well get a salicylate level, it can be hidden in wintergreen oil and a few other things. Make sure it isn't pseudohypobicarbonatemia, seen with hy...
Do you advise Kegels/pelvic floor physical therapy to minimize urinary incontinence when irradiating the prostatic fossa?
I have not recommended Kegels/pelvic floor PT in asymptomatic patients, but if patients are symptomatic either before, during, or after RT, I will make this recommendation. My preference is to refer the patient to a Physical Therapist or pelvic rehab team with special expertise in this field, but if...