Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
How do you instruct patients taking sucralfate?
I have been prescribing carafate for many years now and to this day I don't know if it helps patients or if compliance is possible. I would be curious to know what the experts think.
Which patient population would benefit most from cellulose and citric acid (Plenity) therapy for weight loss?
Theoretically, this could be a treatment option for patients who do not have insurance coverage for/cannot afford GLP-1RA, and who are not candidates for alternative therapy with phentermine, qsymia, or contrave (perhaps due to high blood pressure). However, the weight loss benefit of treatment with...
Would you consider dual antiplatelet therapy for stroke prevention for ICAD in patients with a history of SAH?
It depends on the strength of the indication for DAPT and the cause of SAH. It is important to keep things in perspective: the absolute risk reduction from DAPT for secondary stroke prevention in the POINT, CHANCE, and THALES trials was small (on the order of 1-3% absolute risk reduction) for minor ...
In patients with embolic stroke and a PFO, how often do you go beyond venous Doppler of the lower extremities to screen for DVT (e.g. MRV or CTV abdomen and pelvis)?
No other testing; treat with anticoagulants long term or until PFO fixed & no venous clots.
How do you manage patients with post spinal tap headaches?
There are two tracks of treatment to consider in these patients. The conservative path would be laying supine as much as possible or bed rest, aggressive hydration including intravenously, and caffeine consumption. This should be the first step and tried for 24 to 48 hours before considering procedu...
What is the normal range of spinal tap opening pressure?
Normal range is variable based upon supine versus sitting up, diurnal variations, etc., but the most important thing is what is considered "Low" and "High". For any patient, despite of age and BMI, supine opening pressure above 250 mm of water is considered high, and <6 mm of water is considered low...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
What antithrombotic regimen do you recommend prior to and in anticipation of CEA for patients with symptomatic carotid stenosis?
Dual antiplatelet therapy with aspirin and clopidogrel
Do you counsel patients against driving who presents with transient global amnesia?
No. A single episode of TGA is usually isolated and I would never consider driving precautions. No data suggests that an episode of TGA suggests an increased risk of LOC or seizures in the future. Additionally, I am not aware that TGA itself poses a driving risk.