Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should patients with co-existing moderate-severe valvular disease (particularly AS and MS) and malignancy requiring radiation therapy undergo more frequent surveillance surface echocardiograms?
The answer is yes, for some patients with baseline moderate to severe valvular heart disease receiving radiation, with the heart in the radiation field (i.e. left breast, lung, esophageal cancers), they should have more frequent surveillance echocardiograms.The 2020 ACC/AHA valve guidelines recommen...
How long would you continue prednisone in an ESKD patient with a failed kidney transplant who develops mild graft pain when steroids are tapered?
Typically when a patient develops pain over a failed allograft, we would try a PO pred pulse and a taper back down to 5mg daily. If, when the prednisone is low-dose or off completely, the pain recurs, you need to assess the risk/benefit for the patient of maintaining them on low dose steroid versus ...
When prescribing hydroxychloroquine, how do you explain the mechanism of action and how this translates into clinical benefit for the patient?
1. Explaining the mechanism of action of hydroxychloroquine (HCQ) when RXing it to a patient:- Time is limited in clinical practice, and there are SO MANY positive benefits of HCQ that I do not explain the MOA except with the statement:"HCQ calms down the immune system without actually suppressing t...
For patients maintained on antiplatelet monotherapy post-DAPT following PCI, what is your recommendation for holding antiplatelet therapy prior to non-cardiac surgery?
As clopidogrel recently has gained traction as a preferred long-term monotherapy to aspirin but is generally not allowed to be administered for a week prior to surgery I have “bridged” with 81 mg aspirin.
For patients presenting with spontaneous coronary artery dissection, what other non-cardiac/vascular work-up can be considered to further risk stratify them as a predictor for any future cardiovascular events?
Our general practice has been to do a CTA head to pelvis to evaluate for FMD and/or aneurysmal disease.
In patient s/p definitive chemoRT for vulvar cancer with complete response, how do you manage a non-healing vulvar defect if biopsy is negative for residual disease?
Hard and takes time. Vitamin E with trental and quit smoking.
Does pregabalin contribute to esophagitis or gastroparesis?
Based on personal experience, no. Regarding gastroparesis, it appears that pregabalin is frequently used for the abdominal pain related to gastroparesis with acceptable results and without worsening of gastric motility: https://www.tandfonline.com/doi/full/10.2147/CEG.S362879
What is your approach to managing a patient with a history of tardive dyskinesia on a VMAT2 inhibitor, presenting with parkinsonism and found to have an abnormal DAT scan?
I have seen multiple experts use both VMAT2 inhibitors and levodopa simultaneously in these instances, though reluctantly so. It depends on the severity of TD and PD (which is obviously exacerbated by VMAT2 inhibitors) and which symptoms are most bothersome for the patient. Some options include: R...
Are there any indications to close a PFO during pregnancy if a woman had a cryptogenic stroke in her first trimester?
In general, PFO closure is a secondary prevention procedure for PFO-associated stroke. In a pregnant patient, our usual preference would be to treat her stroke, continue ASA therapy (or therapy recommended by neurology) and ensure air filters on IVs (and all other stroke prevention) throughout any h...
How do you manage severe intra-dialytic hypertension that is not responsive to dry weight challenge in an asymptomatic patient with ESKD?
If the patient is truly not hypertensive at the start of treatment but becomes hypertensive during treatment (need solid evidence of this), then the best option would be an ACE or an ARB. If the blood pressure is high throughout then would continue to challenge dry weight as long as patient is able ...