Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What type of surveillance plan should one use to follow a young person after orchiectomy for a >3cm pure mature teratoma of the testicle?
I presume hCG and AFP were normal as well as appropriate imaging studies, thus a clinical stage I pure teratoma. These patients have a 25% probability for relapse and should be on regular surveillance. We have published on this topic previously. We prefer studies ( serum hCG, AFP, abdominal CT scan ...
In which patients with non-proteinuric chronic kidney disease would you initiate a SGLT2i?
I agree with Dr. Wish. I do not use SGLT2i in non-proteinuric diseases for kidney protection indication. EMPA-Kidney study also did not show benefit for UACR <30 (HR 1.01, 0.66-1.55) among >1200 participants with UACR <30 in the trial. While the secondary analysis looking at mean annual change in eG...
What is your approach to working up diarrhea in an immunocompromised patient?
Tough question and very common in clinical and research management. The approach is going to mirror any new complaint and start with a history. Diarrhea means many things to many patients/clinical trial subjects, so characterizing duration, frequency in a day, nocturnal events (diarrhea that occurs ...
What topical therapies do you most commonly prescribe for rashes near the eyes?
This is a difficult question because the term "rashes" is extremely broad! I think that as in most of medicine, moving through the appropriate steps is critical. There can be a rush to move towards treatment, but remember, there is an order to medicine: History -> Physical -> Diagnosis -> Treatment ...
How do you define an adequate EBUS when staging NSCLC?
Important question. There is a high degree of variability in the diagnostic performance of EBUS based pretest probability of disease, physician experience and skill, quality control, and evaluation skills of the cytopathologist. Nice consensus guidelines from CHEST was published a few years back det...
Is there a role for hydroxychloroquine for secondary prevention in patients with APS without SLE?
There are no prospective trials to answer this question. In one cross-sectional study (Erkan et al., PMID 12154210) there was a suggestion of a protective effect of hydroxychloroquine. However, patients were also on aspirin and it may be difficult to sort out which of these agents had the protective...
Is there a preference between the different high-intensity statins for high-risk stroke patients?
Atorvastatin 80 mg daily (studied in secondary stroke prevention in SPARCL) and rosuvastatin 40 mg daily are maximal approved doses for the two potent statins. These have been compared head-to-head in coronary atherosclerosis in SATURN study. The study was an atherosclerosis progression/regression s...
Do you routinely check a TSH level in patients with recurrent kidney stones who have hypercalciuria of unknown cause?
No. Although hyperthyroidism is a reported cause of hypercalcemia and hypercalciuria, it must be very rare cause of nephrolithiasis. I suspect the patient would be obviously hyperthyroid on examination. Hyperparathyroidism is a much more common cause of kidney stones. In my practice, if the stone an...
What is your approach for an RA patient with lung cancer who is starting immunotherapy?
How to manage the patient depends on how well controlled their RA is at the start of therapy and what kind of medication regimen they are on for their RA. If they are on csDMARDs and are stable we usually continue the csDMARDs with immunotherapy unless there is an objection with the oncologist (or i...
What is your approach to recurrent uric acid stone formers who have a persistently acidic urine pH and are unable to tolerate potassium citrate?
I use sodium bicarbonate. I teach the patient how to titrate the dose using pH dipsticks to get the urine pH >6.0. Although sodium may increase urine calcium excretion, in uric acid stone formers, this is not an issue. Long experience with sodium bicarbonate tells us it does not raise blood pressure...