Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach differentiating infectious vs inflammatory tenosynovitis?
Infectious tenosynovitis is boggy and very tender. Inflammatory tenosynovitis is less tender.
What is your approach to determining if an SPEP abnormality is causal or coincidental in peripheral neuropathy work up?
Because the answer to this question is long and complex, I would refer to a nice recently published review of the topic in Continuum (AAN) which provides a detailed discussion and nice algorithms to investigate the monoclonal gammopathy and determine a possible relationship to the neuropathy (or lac...
What is the preferred timing for removal of a peritoneal dialysis catheter in a patient who has transitioned to hemodialysis?
I think that depends on the reason for the transfer to HD. If it is absolutely certain that the patient will not return to PD- for example, despite maximal prescription PD unequivocally cannot deliver sufficient solute clearance or provide sufficient UF- then the catheter may be removed immediately....
Is there utility in obtaining pericardial fluid autoimmune labs such as ANA or RF in patients with recurrent idiopathic pericardial effusions, but no other clinical or serologic evidence of rheumatic disease?
There seems not to be a consensus literature on this topic, so my answer is based on common sense rather than science. The first step is a detailed history (including family history) and physical examination looking for evidence of inflammatory joint disease with/without other findings that might fo...
When would it be reasonable to consider enhanced external counter-pulsation therapy in patients with refractory angina despite maximally tolerated anti-anginal therapy?
I would exhaust all options for coronary revascularization first.
Do you use anti-DFS70 Ab to help reduce the posttest probability of ANA-positive patients having a systemic autoimmune disease if other autoantibodies are negative?
I agree with Dr. Dixit that any lab test, especially an autoantibody test, has to be taken in context with the clinical features and other lab features. Our laboratory does not run this test as part of our serologic profiles. It may be reassuring to the clinician and patient that it is likely they d...
How do you diagnose and treat patients with cervicogenic headache?
I struggle with cervicogenic headaches. Conceptually, it is a secondary headache disorder with headache attributed to a disorder of the cervical spine and its component bony, disc, and/or soft tissue elements. The ICHD-3 criteria help make this causal attribution. If a headache begins in relation to...
Would you anticoagulate a patient with an asymptomatic gonadal vein thrombosis on CT scan, found on surveillance imaging for colorectal cancer?
This is an area for which there are very limited reports (case reports/series) and certainly no small or large prospective studies. My bias is to initiate anticoagulation. It would be very important to look for an underlying malignancy or other explanation for the thrombus.
What is your approach to checking IgG levels post vaccination to detect common variable immunodeficiency in patients with systemic lupus?
I recommend that this type of workup for primary immunodeficiency disorders be done as soon as a diagnosis of systemic lupus erythematosus (SLE) is made. In other words, order quantitative immunoglobulins (IgA, IgM, IgG) plus IgG subclasses during your initial workup.Reasons being: Some primary immu...
How do you approach the usage of hydroxychloroquine in patients with rheumatologic conditions and baseline cardiomyopathy or heart failure?
This is an excellent and difficult question that parallels the recent posted question about the use of hydroxychloroquine (HCQ) in someone with an abnormal visual field. There is no question that HCQ can cause cardiomyopathy. There is no question that HCQ can prolong the QT interval. Fortunately, ca...