Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to evaluating a patient with known rheumatologic disease and elevated free kappa:lambda ratio, but no evidence of monoclonal immunoglobulins?
The information given is a bit sketchy. But assuming a bone marrow biopsy has been done and there is no evidence of malignancy, I would adopt a watch-and-wait approach. If no bone marrow has been done, I would keep an eye on the appropriate blood tests and in collaboration with a hematologist do a b...
For a patient with a lung tumor that is radiographically consistent with early-stage NSCLC but pathology with characteristics overlapping with upper GI origin, what additional diagnostic procedures would you consider before treating?
In the absence of imaging findings in a patient with a risk profile consistent with early-stage NSCLC, I would probably just move forward with definitive management as NSCLC with either surgical resection or SBRT as appropriate. The only other thing I would consider is to make sure they are up to da...
Do you recommend obtaining a vasculitis work up for all patients seen for chronic kidney disease who are without a kidney biopsy?
I don't. There is a false positivity rate with ANCA testing which can complicate management, especially if the patient has diseases such as inflammatory bowel disease or rheumatoid arthritis. I would only check ANCA levels if the patient has hematuria, worsening renal function, or some other issue t...
How common are nasal telangiectasia in patients with systemic sclerosis?
Telangiectasias, particularly “matted’’ ones are often seen in patients with Systemic sclerosis (SSc), both limited and diffuse cutaneous. They can also be seen in patients with MCTD, UCTD with SSc features, Lupus or Dermatomyositis (often periungual). In SSc, they are most commonly on the face and ...
When is it safe for a rectal biopsy in a patient with prior prostate radiation?
A biopsy of rectal tissue that has been radiated will have a higher risk of developing non-healing wounds and ulcers. Part of the reason that biopsies are discouraged as well as radiation proctitis is a clinical diagnosis and that biopsies of proctitis are certainly not needed to confirm this. Recta...
Is a significant rise in cortisol post cosyntropin stimulation sufficient to rule out adrenal insufficiency in patients with low albumin?
We use the absolute cortisol (or free cortisol) values rather than the degree of the rise in cortisol as an indicator of normal adrenal function during the ACTH Stimulation Test. Is this question related to the critically ill patients?
How would you work up an elevated copper level without cytopenias in a patient with history of bariatric surgery not on supplements or using copper utensils?
Would make sure they are not on supplements as these are often recommended post bariatric surgery. Otherwise, not sure of a connection with bariatric surgery. Would check ceruloplasmin level to rule out Wilson's disease. A low copper level is more likely and can cause leucopenia and sideroblastic an...
How do you manage recurrent hemodialysis filter clotting in an in-center ESKD patient with heparin-induced thrombocytopenia?
I have actually not faced this situation recently. something that may be tried though: flush the lines more frequently with saline, giving patients dose of eliquis orally prior to treatment, other anticoagulant?
Do you recommend targeting a higher Kt/V in an ESKD patient on hemodialysis with pruritis and a Kt/V of 1.4?
I do not. I believe there is not good evidence to suggest more dialysis will help with ckd pruritis and in general slightly higher kt/v usually does not correlate well with actual clinical findings. A better study to be done would be to see if more frequent dialysis will help treat ckd pruritis.
Does your goal rate of correction in patients with chronic hypoosmolar hyponatremia differ based on the degree of hypoosmolarity?
Certainly the lower the PNa is, any increase in PNa will have a greater effect on serum osmolality, so yes the lower the PNa the more careful I am. I would suggest never to be complacent, but for instance if the PNa was 105 I would make sure not to increase it by more than 6 in 24 hours, but if it w...