Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?
Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.I am a big believer in considering combination therapy as initial th...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
How do you approach initial steroid dosing in patients with eosinophilic fasciitis?
I usually start with a high dose at 60 mg daily for a few weeks, then add DMARDs like MTX.
In a patient with sicca symptoms and SS-B antibodies only, can a minor salivary gland lip biopsy with lymphoid aggregates, but also scattered areas of acute neutrophilic inflammation be consistent with Sjogren's Disease?
I agree with @Dr. First Last and cannot speculate on the neutrophils.I'd also like to point out that a French study showed that only 1% of isolated anti-SSB patients had Sjogren's disease, SjD (Jardel et al., PMID 28931060); all others had other autoimmune diseases, neoplasia, infection, and solitar...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
When do you recommend neuropsychiatric testing in patients with post-concussive syndrome?
I typically ask the patient what scenarios they experience cognitive issues. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and concentration/focus. In the post-concussion patient, they typically have developed adjus...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
How do you decide when an older patient's weight loss warrants an extensive workup versus a more focused or watchful approach?
I always start with the standard cut off of 5% of normal body weight in 6-12 months. If this cut-off is met, then I probe about intentional or unintentional. Many older adults are not eating enough protein (they need more than the RDA recommendation) -- I encourage 1-1.3 (sometimes 1.5) g/kg protein...
How do you decide when an older patient's weight loss warrants an extensive workup versus a more focused or watchful approach?
I always start with the standard cut off of 5% of normal body weight in 6-12 months. If this cut-off is met, then I probe about intentional or unintentional. Many older adults are not eating enough protein (they need more than the RDA recommendation) -- I encourage 1-1.3 (sometimes 1.5) g/kg protein...