Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach longitudinal melanonychia of one fingernail in a pediatric patient?
Unless the history and/or appearance are terribly concerning, I will generally measure, photograph, and follow up in 3 months for a re-check. Unless it has grown or changed dramatically during that time frame, I will usually just monitor clinically until it is stable.
How frequently and when should lipoprotein A levels be monitored?
Lp(a) levels are fairly stable throughout a person's life, which is why the Europeans recommend checking Lp(a) in everyone at least once. Some conditions can increase the level like CKD and hypothyroidism; it’s also an acute phase reactant. Menopause can increase it as well, so one might want to rec...
In SIADH due to malignancy, do you prefer to use free water restriction or salt tablets?
Fluid restriction is usually the first line measure in chronic SIADH. Salt tablets only work at high doses, as SIADH is a water, not a salt problem, and you improve sodium only minimally. Tolvaptan is a very powerful drug, but, as per the package insert, must be started in an inpatient setting. Addi...
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
Is there utility in monitoring IgE levels in patients with IgG4-RD?
Serum IgE levels are associated with disease extent/severity and risk of relapse in patients with IgG4-RD. In some patients (although this is not true for all patients), IgE decreases following treatment and increases with disease flares. However, some patients who have extreme IgE elevations at bas...
Do you stop tolvaptan below a certain eGFR in a patient with autosomal dominant polycystic kidney disease?
In general, the practical guidelines support continuing tolvaptan until dialysis or transplant (Chebib and Torres, PMID 33705818). There are situations where I will discontinue sooner, either due to apparent lack of benefit, due to precipitous, unexpectedly rapid decline or accelerated decline, or, ...
Given that there are a fair number of myocarditis cases without a troponin elevation, how do you clinically approach the diagnosis of myocarditis?
If clinical suspicion for myocarditis is not based on elevated troponin there needs to be some objective evidence for it. These would be CRP/sed rate/cardiac MR/biopsy. Unlikely to pursue the last step if the first three are all normal.
Would you consider using finerenone for proteinuric CKD associated with type 1 diabetes mellitus?
Yes, although T1DM is off-label for finerenone and there may be issues regarding its approval by prescription drug plans. I would start with an ACEi/ARB for proteinuria in a T1DM patient, then add spironolactone. If the patient develops breast problems on spironolactone, I would switch to eplerenone...
How would you approach a patient with axial spondyloarthritis who develops new-onset proteinuria?
I would approach the workup for proteinuria based on the differential diagnosis with leading etiologies including, acute illness, diabetes, nephrotic syndrome (minimal change disease, FSGS, membranous neuropathy), drug-induced proteinuria, vasculitis, and of course IgA neuropathy. Standard studies i...
Do you use vitamin B6 to help with Keppra irritability?
I am an adult epileptologist and do not routinely prescribe pyridoxine for neuropsychiatric adverse effects of levetiracetam. I do see this done a lot more in the pediatric population, where there is more data than is available in the adult population (though still not of very high quality). Anecdot...