Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In which situations do you preferentially use an MCOT in lieu of a standard event monitor?
In most situations where the concern for "actionable" arrhythmias is low (e.g., isolated palpitations, mild lightheadedness, AF burden, PVC burden, known persistent AF for assessment of rate control, etc.), I typically would use an extended 7-14 day Holter mostly for symptom-arrhythmia correlation s...
What therapies do you routinely use to prevent mucus plug formation after endobronchial stent placement?
After airway stent placement, especially silicone stents and/or Y stents, I start my patients on albuterol neb BID; hypertonic saline neb BID, and NAC neb BID. If there are any issues with adherence, I use either albuterol + hypertonic saline or albuterol + NAC depending on patient preference. If th...
What is your approach to bridging anticoagulation in patients with history of recent HIT?
One should not re-expose patients with past HIT to heparins. Even with remote HIT, there is a high rate of serologic recurrence (eg, Warkentin and Anderson, PMID 27114458) and while the rate of overt HIT relapse may be low with proper precautions, I have seen and published a couple of fatal HIT recu...
Are the results of the BOREAS trial generalizable to non-white populations?
There is currently not enough data to conclude that the trial is generalizable to non-white population.
How would approach the management of a patient with significantly positive anticardiolopin and beta 2 glycoprotein antibodies in the absence of any clotting (including obstetric) history but with significant thrombocytopenia (but no other features of active connective tissue disease)?
I would first evaluate for other causes of thrombocytopenia (most of them can also result in positive APL antibodies): CTD, medications, liver disease, pregnancy, malignancy, splenomegaly, etc.I would not treat stable asymptomatic thrombocytopenia.If worsening/symptomatic, I would treat like any oth...
When do you consider genetic testing in patients with concern for hemiplegic migraine?
No, a good history will make the diagnosis for you!
How do you treat patients with hemiplegic migraine?
The is no agreed-upon treatment for hemiplegic migraine. I have often used NSAID’s acutely, occasionally triptans, and rarely steroids when nothing is working. The relatively new acute care gepants could be tried, but I have not done that as these patients are hard to find. I would consider adding a...
When do you consider use of ketamine in patients with migraine with aura?
Never. For the treatment of migraine, like for any other condition, we should rely on specific medications, that is, triptans or gepants for abortive treatment and gepants or CGRP antibodies for preventive treatment.
What is the differential for elevated T3 (with suppressed T4 and normal TSH) in a patient not taking any thyroid hormones?
This patient has a low to low normal TSH, with weight loss and fatigue so I would approach this as mild hyperthyroidism, or T3 thyrotoxicosis. Sertraline has been associated with abnormal TFTs, usually an elevated TSH and low T4, not with increased T3 levels. Assess the patient for any other sympto...
How long do you normally wait before considering any bronchoscopic procedure (EBUS-TBNA, Transbronchial biopsy) after an episode of acute PE in a patient needing these procedures?
This depends upon the indication for bronchoscopy and the risk stratification for an acute PE. Generally, anticoagulation can be stopped safely for a short period of time after 10 to 14 days of therapeutic coagulation in low-risk PE but for higher-risk patients or if the bronchoscopy is not urgent a...