Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For patients with significant side effects to a cholinesterase inhibitor, do you try another medication in the class or avoid it altogether?
Firstly, I titrate up the medication so that if there is a side effect, I can retreat to my last tolerated dose. If the side effect is dizziness or faintness, then I will stop trying to escalate the dose. If the side effect is vivid dreaming, then one might try to take the medication in the morning....
When do you recommend driving tests in patients who have memory loss?
I recommend a driving test when: there is any concern by the family, the clinical dementia rating is greater than 0.5, there are visuospatial defects on cognitive testing, there are problems with Trails A or B, and also whenever I cannot be sure.
Do you use acetylcholinesterase inhibitors in patients with cognitive changes in the setting of cerebral amyloid angiopathy?
Many patients with CAA also have cognitive deficits. If so, I use cholinesterase inhibitors, usually donepezil. I would not prescribe these agents if the patient has only microbleeds and no cognitive impairment.
When do you recommend lumbar puncture in patients with concern for memory loss?
Rapidly progressive memory loss/dementia- because you obviously want to exclude diagnoses like CJD, infectious/autoimmune/paraneoplastic encephalitis, lymphoma or other malignancy, etc. When you need to know the patient's "brain amyloid status". E.g. a) Patients with amnestic MCI and atypical cour...
What topical or oral treatments do you recommend for patients with recurrent MRSA infections?
In my experience, the best way to evaluate recurrent MRSA infections is to check the nasal cultures of the patient and caregivers. Sometimes cutaneous carriage of the organism also needs to be checked and treated. Good hygiene with regular hand washing or alcohol sanitizers is essential. Treatment w...
How do you approach management of patients with active RA and recurrent non-severe C.diff?
I think the question here is why the patient is experiencing recurrent C.diff. Is it true recurrence or it never fully clears? Any IgA deficiency? CVID? I would do an immune deficiency work up- complements, immunoglobulines and flowcytometry, response to pneumococcal vaccine. In parallel to the wo...
When do you recommend testing for APOL1 variants in patients with proteinuric chronic kidney disease?
As yet, despite APOL1 being a clear risk factor for kidney disease and ESKD, there are no clear guidelines to assist in decision-making regarding genetic testing. This is mainly due to the fact that there are (as yet) no specific drugs for APOL1-mediated kidney disease. There is an RCT for inaxaplin...
Would you anticoagulate a patient with splenic infarctions in the setting of CMV viremia?
Based on my general knowledge/experience, I would consider CMV viremia as temporary, short-lived risk factor for a thrombotic event on a part of other inflammatory conditions, and outside of other indications for anticoagulation (e.g., atrial fibrillation, etc), my inclination would be to conclude ...
How frequently do you check CK in patients with Becker's muscular dystrophy?
I do NOT check CK regularly in Becker or other muscular dystrophies after the initial diagnosis. The question is why should we check it regularly when there is no disease-modifying treatment currently FDA approved for the vast majority of muscular dystrophies, and there is no correlation of the leve...
How often do you check carnitine levels in your patients with end stage kidney disease on hemodialysis?
About 10 years ago I used to check carnitine levels in ESRD patients with intradialytic hypotension commonly. If low then I would treat with levocarnitine. At some point I gave up on the practice not because it was not working but because it was hard to determine if it was working or not. I am aware...