Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you decide when and how often to reach out to patients with serious mental illness who are disengaging from care due to psychosocial stressors?
Outreach is always determined on a case-by-case basis, so it's difficult to give a definitive answer on this. Important factors to consider are the person's functional status, potential risk for harm without care, their decision-making ability, and the intensity of stressors. Obviously, those who ar...
For patients with Hashimoto's thyroiditis, is there a commercially available blood test for detecting abnormalities in the type 1 deiodinase enzyme in order to identify patients who would potentially benefit from T4 and T3 combination therapy?
Most clinicians decide to use combination therapy based on a weak response to levothyroxine, with patients still complaining of symptoms related to hypothyroidism. The TSH should not be low before selecting dual replacement.
In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?
This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pi...
How long would you hold clomiphene before checking baseline morning testosterone levels to evaluate the need for testosterone replacement therapy initiation?
The clomiphene challenge is to initiate therapy in men with secondary hypogonadism and trial a 3-6 month course to see their symptomatic and serologic response. If gonadotrophs and testosterone normalize and the patient feels symptomatic relief and has done something to address the root cause (weigh...
Do you screen for cardiac disease in patients with dermatomyositis in the absence of symptoms?
I don't typically evaluate for cardiac disease in patients with dermatomyositis who are not symptomatic. There are subtypes of myositis patients where cardiac involvement is more common (such as those with antimitochondrial antibodies and anti-SRP antibodies), and there it may make sense to keep a c...
How do you approach the management of recurrent episcleritis in a patient with RA that is otherwise well-controlled?
The episclera lies on top of the sclera. The majority of patients with episcleritis do not have a systemic disease, although patients with rheumatoid arthritis are more prone to develop episcleritis. Episcleritis must be distinguished from scleritis, which is also associated with rheumatoid arthrit...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
In patients with post-MI LV thrombus which resolves after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
I think the key word here is akinesis (or dyskinesis); effectively, an immobile segment of myocardium gravitationally farthest south of the ‘northward’ flow of blood across the aortic valve. This effectively allows for stasis in an injured and immobile region... two of the three components of Vircho...