Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you favor the use of Fick or thermodiluation to measure cardiac output in patients with interstitial lung disease with suspected pulmonary hypertension?
Unless the patient has a left to right shunt or a metabolic cart is used to calculate direct Fick, thermodilution cardiac output (TDCO) is the preferred method of cardiac output measurement in all patients with pulmonary hypertension. This is supported by current guidelines. It's important to take t...
Is an elevated CRP an expected finding in an otherwise healthy patient with hemoglobin S - alpha thalassemia?
If you Google "CRP levels in sickle cell disease", you will find a number of articles reporting that CRP levels are chronically elevated in many patients with SCD. This undoubtedly reflects the chronic inflammatory state that is part of the clinical milieu of SCD. Patients with Sickle - alpha thalas...
How would you treat systemic polyarteritis nodosa with orchitis, mononeuritis and glomerulonephritis in a person who is being treated for HiV with low level viremia?
Difficult situation but there is a clear need to make decisions and balance somewhat unquantifiable risks. It is always good to remember that polyarteritis nodosa is quite rare. One should ensure the diagnosis is confirmed with, preferably, both a positive biopsy of one of the affected areas and neg...
Do you recommend starting an antiplatelet for primary prophylaxis in post splenectomy thrombocytosis given there is some increased risk of venous thrombosis?
I do not recommend routinely initiating prophylactic antiplatelet therapy for post splenectomy thrombocytosis. First, in patients without a myeloproliferative neoplasm (MPN), the increase in platelet number post splenectomy is both delayed and mild, and there is no correlation between reactive throm...
How would you manage polymyalgia rheumatica refractory to prednisone, methotrexate and tocilizumab?
Interesting situation. With PMR, the first question I continue to ask myself is - do I have the right diagnosis? This disease is always rewarding to treat whether you get the thrill of starting steroids to be the hero or starting therapy and having to reassess. You report that there are no signs of ...
Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?
New onset hyperglycemia during ICPi therapy warrants careful review of potential risk factors for type 2 diabetes mellitus (T2DM) and close monitoring of symptoms and lab results to distinguish from the rare and typically more threatening checkpoint inhibitor-associated diabetes mellitus (CIADM). Ne...
What is your approach to the work up and management of interstitial lung abnormalities?
ILA are incidental radiological findings (non-dependent abnormalities affecting more than 5% of any lung zone) in asymptomatic patients. We first evaluate these patients for any potential causes of ILA (i.e. connective tissue diseases, aspiration, drug-related pulmonary toxicity, etc). If an underly...
What workup and initial treatment should be considered for suspected autoimmune myelofibrosis?
Autoimmune myelofibrosis is rare and most often described in association with SLE, either concomitantly or during the course of the disease, and usually with depression of one or more of the blood counts. It is a rare occurrence with the proviso that since myelofibrosis is a reactive and reversible ...
How would you approach a rising PR3 in a patient with limited GPA who is currently asymptomatic on methotrexate?
This is an important question because ANCA testing is frequently used in the monitoring of disease activity in AAV. Unfortunately, ANCA is a much better diagnostic test than a disease activity biomarker. Multiple studies have looked at the utility of ANCA in monitoring disease activity finding that ...
What is your approach in a patient who develops interstitial lung disease while on anti-TNF therapy?
I would stop the TNF antagonist and never use this class of drugs again in the patient. In fact, I generally stay away from TNF antagonists in RA patients with any sign of pre-existing lung disease. The experience of Nakashita et al., PMID 25125479 is highly informative and parallels my experience, ...