Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Once troponins start to decrease, I start the steroid taper and follow troponin levels. If they rise, I slow the taper. I also get serial ECGs, esp if there were arrhythmia manifestations of myocarditis. Don't forget to assess for the need for PJP prophylaxis with Bactrim or pentamidine and PPI sinc...
What is your approach to rectal cancer staging in patients who cannot undergo an MRI?
Endoscopic ultrasound of the rectum in addition to CT scans with contrast, if any doubt, will do a PET/CT scan.
Do you typically get muscle MRI in patients with symptoms of myopathy?
Not routinely, but there are some scenarios where MRI is useful. Selection of muscle to biopsy in a chronic progressive myopathy. In the past, we used to select muscles based on the degree of weakness on the MRC scale and the EMG findings. One would avoid muscles with MRC strength of 3/5 or less or...
How do you approach the diagnostic workup for patients with suspected Fabry's disease?
Quite simple- if you suspect the disease in a male, you can measure alpha galactosidase enzyme activity in blood; if normal the diagnosis is unlikely, if abnormal you can confirm with GLA gene sequencing. If you suspect the disease in a female (manifesting carrier), you should directly sequence GLA ...
How do you counsel patients about the malignancy risk associated with azathioprine?
Malignancy with the use of AZA (Imuran) was documented many decades ago in a renal transplant population, not in rheumatoid patients. Are they equivalent? Overall I consider Imuran a pretty safe DMARD. In fact, it can be used in pregnant patients with lupus, with mothers and babies doing just fine.
Is there any role of sympathectomy in Raynaud’s disease?
Sympathectomy was once considered to be the treatment of last resort for severe, refractory Raynaud's. Though severe Raynaud's remains a challenging disorder to manage, nowadays, sympathectomy rarely if ever enters the therapeutic discussion. Though most patients with Raynaud's phenomenon observed a...
What is your approach to therapy for pulmonary sarcoidosis resistant to methotrexate?
The first question I ask myself in any situation dealing with "refractory" sarcoidosis is "Am I sure active inflammation from sarcoidosis is the cause of their symptoms?". Oftentimes, I will see patients referred for refractory disease who end up having other causes of their symptoms. If I am confid...
How do you approach evaluation of hypocomplementemia in a patient with arthralgias and a history of Hodgkin's lymphoma treated in the past?
There are both acquired disorders - more common - of the complement system and inherited disorders - less common - of the complement system. Although rheumatologists commonly deal with autoimmune/acquired disorders of the immune system, they should be aware that certain inherited deficiencies of the...
How do you approach differentiating infectious vs inflammatory tenosynovitis?
Infectious tenosynovitis is boggy and very tender. Inflammatory tenosynovitis is less tender.
What is your approach to determining if an SPEP abnormality is causal or coincidental in peripheral neuropathy work up?
Because the answer to this question is long and complex, I would refer to a nice recently published review of the topic in Continuum (AAN) which provides a detailed discussion and nice algorithms to investigate the monoclonal gammopathy and determine a possible relationship to the neuropathy (or lac...