Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?
While TA ultrasound may have a role in the assessment of disease relapse, currently there is little evidence to understand its utility in this area. It is well known that the halo sign is steroid responsive and multiple studies have shown that the halo sign recedes within the first several weeks of ...
What is your approach to managing intradialytic cramping that recurs despite multiple dry weight adjustments in a patient with ESKD?
This is a great question and there is no easy answer. As always, try and make sure the patient is following fluid restriction in between treatments as having less fluid to remove during a session may reduce cramping. I also try gabapentin 100mg prior to treatment for cramping. If they treat early in...
What symptomatic management do you recommend in patients with post LP headaches?
In my clinical experience, the symptomatic/medical management of post lumbar puncture (LP) headache is challenging and of limited utility. In contrast, for the vast majority of cases, a large volume autologous epidural lumbar patch ("blood patch") is highly effective (and much appreciated by the pat...
Do you always perform temporal artery biopsy in patients with positive inflammatory markers and high clinical suspicion of GCA?
As with most clinical scenarios, the short answer is 'it depends'. If a patient has cranial symptoms, elevated inflammatory markers, and suspicion for GCA is high, I do refer for temporal artery biopsy to help confirm the diagnosis. This is in line with guidelines from the American College of Rheuma...
How to you treat pregnant women who develop Bell's Palsy?
Bell's palsy is definitely more common in pregnancy and in the immediate postpartum period. For the most part, treatment is identical to how you would treat a non-pregnant patient (which itself is controversial). Whichever treatment is used, it is important to consider initiating treatment within 3 ...
Do you recommend decreasing the loop diuretic dose when starting an SGLT2 inhibitor in a CKD patient given its natriuretic and osmotic diuretic effects?
The decision to continue or not a loop diuretic when starting an SGLT2 inhibitor should be individualized based on the patient's blood pressure/volume status.In general, if a patient's blood pressure/volume status is high, like in the setting of heart failure, SGLT2 inhibitors, and loop diuretics ar...
If a PET/CT scan is positive for mediastinal lymph node involvement, is a mediastinoscopy or EBUS still required for NSCLC staging?
The gold standard for mediastinal staging is still mediastinoscopy. You can have 15 to 20 percent false positive PET findings in mediastinum and for these patients surgery should not be excluded based on PET findings alone.
Is either ESR or CRP more sensitive or specific for the diagnosis of GCA?
I typically obtain both an ESR and a CRP in the workup of new onset or relapsing GCA. The CRP may be slightly more sensitive than the ESR based on Kermani et al., PMID 22119103 which demonstrated a sensitivity of 86.9% and 84.1% respectively for CRP and ESR, for a positive TAB. There is discordance ...
How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?
In my opinion, there is no one simple treatment for such headaches. We try slowing the infusion rate, premedicate with steroids, low dose Lasix, or premedicate with Nurtec. Usually, one of these methods helps minimize or eliminate the headaches.
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...