Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your typical workup for a patient with a spontaneous renal infarct?
Broadly speaking, in the setting of a renal infarct, consider a thromboembolic event (venous thrombosis with paradoxical embolism or an arterial source) or a local vascular event such as dissection. The latter can be easily missed because the appropriate imaging is generally not performed. Once a va...
What workup do you recommend for patients with stabbing headaches?
Stabbing headaches, also called icepick headaches or jabs & jolts, are severe pains in the head, often occurring spontaneously but sometimes caused by coughing or sneezing, lasting for seconds. They are so intense that they make the sufferer grab his or her head. They generally occur infrequently in...
What is your approach to a patient with normal LFTS and high titer auto-antibodies suggestive of autoimmune hepatitis?
Normal LFTs in the setting of high titer liver autoantibodies would still lead me to request a Hepatology consult, even in the setting of a previously defined autoimmune disease, i.e., SLE or Sjogrens. After Hepatology assessment, and if there is a documented rheumatologic autoimmune disease, most o...
Is there any experience of using sarilumab instead of tocilizumab for steroid sparing effect in GCA during national tocilizumab shortage?
This is certainly a very good question, but unfortunately, we don't have an answer. The sarilumab GCA and PMR trials were unfortunately terminated due to the pandemic. I've heard of anecdotal experiences of the use of sarilumab but haven't used it myself (not sure if insurances would approve). Both ...
How soon after completion of salvage RT to the prostate bed do you allow urethral dilation?
In my experience, anastomotic strictures do not resolve spontaneously or with treatment interruptions. In part, the answer to this question depends on how symptomatic the patient is and how close you are to the end of treatment. If the patient is totally obstructed or close to it, you're probably go...
In a patient with inflammatory orbital disease without a discrete mass to biopsy and recent bisphosphonate use, how much additional workup would you do if basic labs, urine studies, ANCA serologies, thyroid studies, chest imaging (to r/out sarcoid) are normal, before concluding that the process is likely secondary to bisphosphonate use?
Bisphosphonates are a known but rare cause of orbital inflammation. An intravenously administered bisphosphonate is far more likely to cause this compared to an oral drug. There is usually a close temporal association between taking the medication and developing the inflammation. The diagnosis is on...
How does one interpret persistently positive lambda light chains on serum immunofixation but without measurable serum monoclonal protein and a normal light chains and ratio?
I would probably also check a 24 hour urine protein electrophoresis with immunofixation to evaluate if any significant and measurable monoclonal proteinuria that would make me more worried about SMM, MGRS, or amyloidosis. Would check urine protein/creatinine ratio to evaluate protein excretion for t...
How do you decide on initiation of treatment with steroids or immunomodulatory therapy in patients with statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy?
In the setting of limited experience, in patients with statin induced necrotizing polymyositis (HMG-CoA reductase antibody mediated necrotizing myositis), the best approach is typically steroids (prednisone 20mg or so), IViG 2gm/kg every 4 weeks, and potentially CellCept at 2000 to 3000mg per day, w...
What are best practices for engaging with multidisciplinary colleagues to ensure patients with earlier stage NSCLC are being appropriately considered for novel adjuvant therapies?
Treatment of early stage or locally advanced stage NSCLC truly requires a cohesive multidisciplinary team and consistent messaging. Many, if not all, of these cases should be discussed prospectively at a multidisciplinary tumor board. It is also important to set expectations with patients up front a...
How do you approach the management of immunosuppression in patients with lupus nephritis that go on to dialysis?
It depends entirely on their disease status and profile. It is not unusual for patients to have decreased disease activity when they go on HD. If there is still clinical activity though, I maintain them on immune suppressives and prefer mycophenolate mofetil (a major anti-renal transplant rejection ...