Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?
I would do my best to minimize immunosuppression. I would use IL-6 or Abatacept and possibly rituximab. Have done all to minimize DMARDs and have had success with all 3.
Do you continue to utilize ESR and CRP in patients on tocilizumab?
Yes, it is still worthwhile getting these tests. Anti-Il-6 therapy will reduce CRP and ESR values to very low levels, so when a result returns higher than expected, it may imply limited compliance with the drug. In some patients with very high CRP values at baseline, the CRP may take some time to re...
Do you treat secondary erythrocytosis caused by SGLT2 inhibitor?
I have seen this once, and stopped the SGLT2 inhibitor, and recommended they identify an alternative strategy to treat his DM. It seemed to help overall.
How do you work up a young patient with increasing ferritin and normal TSAT without infectious, inflammatory, or liver disorders?
This is a tough one. If the ferritin is increasing and the TSAT is normal and there is no evidence of hemochromatosis, the ONLY possible explanation is some underlying morbidity, inflammatory, rheumatologic, malignant, or infectious is present. In pediatrics, HLH (hemophagocytic lymphohistiocytosi...
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
How do you follow up a patient with esophageal adenocarcinoma who is not a surgical candidate after finishing chemoradiation?
I am assuming that this patient has adenocarcinoma and also had definitive dosing radiation (50.4 Gy +) and not neoadjuvant dosing as was used in the CROSS trial (41.4 Gy). If that is the case, you would use the same surveillance as you would after surgery which is H&P every 3-6 mo with labs and sca...
How would you approach an elderly patient with tibial plateau insufficiency fracture and normal DEXA?
Tibial plateau fractures are common among young individuals and often the result of trauma or injury. In the elderly, they can be related to injury but as well as poor bone strength and quality. In the aging population if DXA testing is normal and the fracture is not the result of major injury searc...
How should you work up calvarium or other osseous lesions when found during the initial staging of a patient with a new diagnosis of NSCLC otherwise non-metastatic?
In general, I try to "prove" metastatic disease to ensure appropriate staging. I have had several situations where a skull or other osseous lesion is suspicious on CT and have tried to assess by PET or NM bone scan - ultimately though, have referred for biopsy and have actually diagnosed several int...
How do you manage a diabetic patient with generalized myasthenia gravis post thymectomy previously treated with Imuran?
There is some additional information required to answer this question, specifically: a) did the patient have thymoma on pathological exam? and perhaps the most important b) What was the clinical status of the patient's MG prior to thymectomy (severity, MG ADL/QMG scores)? and c) Was azathioprine the...
Can APLS cause a false positive HIT ELISA?
Yes, that has been reported: Pauzner et al., PMID 19291166.