Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you add voclosporin to mycophenolate for refractory proteinuria in a patient with low EF?
There are two major potential concerns in a lupus nephritis patient with systolic dysfunction and a left ventricular ejection fraction (LVEF) of only 30%: QTc prolongation potential worsening leading to acute cardiac death Exacerbation of hypertension leading to worse LVEF and CHF However, with prop...
How do you manage patients with suspected cholangiocarcinoma that presents with biliary obstruction but has repeated negative brushings/biopsies?
This is often encountered in patients with PSC. Patients present with jaundice and biliary stricture, rising CA 19-9, and repeat ERCP with brushing/biopsies have shown no evidence of malignancy (often showed abnormal cells). Brushings have high specificity if positive (99%) but very poor sensitivity...
When would you consider CT aortic valve calcium score over TEE to further delineate the severity of LFLG aortic stenosis?
If the concern is for classical low flow low gradient severe AS (LVEF < 50%, AVA < 1 cm2 by echocardiogram with peak velocity < 4 m/s or mean gradient < 40 mmHg coupled with low stroke volume index, < 35 ml/m2), would recommend dobutamine stress echocardiography to distinguish between pseudo severe ...
How would you approach immunomodulatory treatment for systemic lupus associated protein losing enteropathy (PLE) in a patient whose clinical course has been complicated by significant infection?
Lupus protein-losing enteropathy (LPLE) is a rare manifestation of systemic lupus erythematosus (SLE). Therefore, the medical evidence for the "best treatment" of LPLE is only based on anecdotal reports, case series, and retrospective reviews.Although the easy way out would be to say that a SQ or IV...
How would you approach treating a patient with Rheumatoid arthritis/Psoriatic arthritis and alcoholic cirrhosis?
The liver plays a central role in the clearance of nearly all small molecule (e.g. non-biologic) drugs. Thus, cirrhosis perturbs the clearance of these agents. Moreover, there generally is a potential deleterious effect on hepatocyte health, making these drugs unattractive from a safety perspective....
What are your top takeaways from CHEST 2023?
There were so many great presentations: My top 3 were the following. Pulmonary Hypertension: Expert Didactics and DiscussionThe Pulmonary Hypertension: Expert Didactics and Discussion course was a half-day discussion on pulmonary hypertension evaluation and management. This was a master class that ...
How do you interpret a low VWF activity/antigen ratio, when both activity and antigen levels are above 50%?
This discrepancy is most likely caused by heterozygosity for a VWF variant that either causes VWD type 2M, with defective binding to GPIbalpha, or interferes with the binding of ristocetin, assuming that the activity represents ristocetin cofactor activity. The presence of a bleeding history suggest...
Is there an indication for adrenalectomy in patients with subclinical Cushing syndrome and adrenal nodule?
The short answer is "Yes". The indications for surgery depend on a number of factors, including the number of comorbidities and their severity and the degree of the HPA axis abnormality (1 mg DST and baseline ACTH/DHEAS level). We tend to be more aggressive with surgery in younger patients, although...
What further work-up (if any) should be considered in patients with pituitary microadenoma and stigmata of Cushing's disease but low ACTH and repeatedly normal plasma, urinary, and salivary cortisol levels?
I would obtain history of alcohol intake, depression and anxiety, and will assess the pituitary adrenal axis by overnight dexamethasone suppression test.
Is it possible to have undetectable cortisol levels in secondary adrenal insufficiency?
Yes, you can certainly have undetectable cortisol in central AI. Low IGF-1 and low-normal FT4 would suggest hypopituitarism. Do you have a testosterone level? I would perform a GH stimulation test. An abnormal test would confirm pituitary pathology. Before this, however, I would carefully investigat...