Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider exploratory surgery in a young patient with normocalcemic hyperparathyroidism that meets one or more criteria for parathyroidectomy but has no localized pathology on advanced neck imaging?
If the patient has any complications that could be caused by primary hyperparathyroidism surgery would be appropriate done by a highly experienced parathyroid surgeon. It is not uncommon for imaging to be negative in patients with relatively mild parathyroid problems.
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...
What treatments have you found to be most effective for granulomatous rosacea?
Isotretinoin 20mg/day
Do you recommend noninvasive testing or coronary angiography as the initial test for pre-kidney transplant evaluation of an asymptomatic patient older than 50 years of age with ESKD secondary to diabetic nephropathy and no known history of CAD?
There is no evidence that revascularization of asymptomatic patients reduces the risk of transplant. obviously patient should have all relevant risk factors treated. the problem with routine angiography is that inevitably any lesion found is treated with stenting which actually exposes the patient t...
Following cardiac MRI, what imaging modality would you consider to further evaluate mild aortic regurgitation (regurgitant fraction on cardiac MRI of 26%) and mild to moderate mitral regurgitation secondary to mild bi-leaflet mitral valve prolapse (RF 30%) with low-normal LVEF and incomplete RBBB?
Consider an exercise echo if the patient is asymptomatic and continue to follow with echo-Doppler.
How would you approach initiating belimumab in a patient with serologic evidence of prior hepatitis B infection?
The patient in question is a patient who has serologic evidence of resolved hepatitis B infection. Of note, testing for hepatitis B is not a formal recommendation before starting belimumab. However, it is also important to point out that testing positive for hepatitis B was an exclusion criterion in...
Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?
I do not think there is a "right" answer to this question. First, I would want more evidence of distal renal tubular acidosis than urine chemistries. Specifically, I would do a urinary acidification test. If positive for distal RTA, and there is no other suggestion in the history or physical examina...
What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?
PFTs are often obtained in patients with systemic sclerosis to evaluate for interstitial lung disease. Low DLCO on PFTs can signify an increased probability of PH, but it is by no means specific. Echocardiograms are readily available, offer additional information about possible causes of PH (e.g. LV...
Do you counsel your patients on the potential decreased effectiveness of oral contraceptives while on Sarilumab?
As someone who focuses on reproductive health, I personally don't counsel on this. From professional drugs interaction resource: "Plasma concentrations of drugs that are CYP450 substrates may decrease following the initiation of interleukin (IL) inhibitors, tumor necrosis factor (TNF) blockers, or i...
What are magic mouthwash alternatives that you would recommend?
Many of our patients will make their own DIY MMW per Phil's My Pharmacist (YouTube) instructions -- uses benzocaine/Cepacol lozenges -- they say it's much more effective than the compounded one from the pharmacy. It is also more economical.If the majority of bothersome mucositis is in the oral cavit...