Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What would be your next diagnostic test of choice for a patient with findings concerning for silent ischemia on noninvasive functional testing in the absence of chest pain?
There are a lot of unanswered questions just from the information given. Why was the test done in the first place if truly asymptomatic? If not having chest discomfort, were they having an anginal equivalent - such as a new complaint of shortness of breath with exertion not previously present? What ...
What topicals have you had success with treating body acne?
Agree with Jim Leyden that systemic therapy, especially isotretinoin, is far superior to topical therapy in treating truncal acne. However, in patients who refuse systemics, some of the newer topicals may be helpful. The newer retinoid formulations, trifarotene cream and tazarotene lotion, both have...
How do you approach DMARD therapy in a patient with lupus and recurrent pericarditis?
Both asymptomatic pericardial effusions and symptomatic pericarditis are common in systemic lupus erythematosus (SLE) patients. I will limit my answer to symptomatic pericarditis per the question.The first thing to be sure of is that the symptoms are truly due to pericarditis. The full differential ...
How do you approach a patient at intermediate ASCVD risk who has been referred to you because of an abnormal coronary CTA (obstructive lesion ~90%) but an excellent exercise capacity on treadmill without angina and a negative MPI?
Unless the reported lesion involves proximal LAD or LM (MPI can look normal if balanced ischemia), I would then treat medically (ISCHEMIA trial, ACC/AHA stable CAD guidelines).
Do you find 14.3.3 eta or vectra DA helpful in clinical practice?
These blood tests were developed to help diagnose and monitor rheumatoid arthritis.14-3-3 eta is an interesting protein that may have pro-inflammatory properties and could be helpful in diagnosing RA (Maksymowych et al., PMID 25128504), confirmed in a recent meta-analysis to have reasonable diagnost...
What treatment modalities have you had success with for treating sebaceous hyperplasia?
I have used light electrodesication with a blunt tip needle with good effective results without visible scarring for the vast majority of patients. I find that it is efficient and less expensive than laser modalities. The procedure is uncomfortable for my patients and typically I need to use topical...
Does the presence of diastolic dysfunction guide subsequent pharmacological, pacing and ablative therapies for atrial fibrillation?
For the majority of patients with atrial fibrillation, symptoms are generated by the elevated heart rates rather than the irregularity or the loss of the atrial contribution to ventricular filling. The exception to this is patients with heart failure with preserved ejection fraction (diastolic dysfu...
Besides treadmill, what other exercises may be considered for post-exercise ABIs, and are their diagnostic parameters identical to standard post-exercise ABIs?
2 minutes of Toe-raises has been demonstrated to be an acceptable alternative to exercise ABI's.
What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?
Elevated ACE, dihydroxy vitamin D, and soluble IL2r levels have been shown to correlate with disease activity, but it is important to keep in mind that the sensitivity and specificity are variable and they should never be used in isolation to diagnosis or assess disease activity in sarcoidosis. The ...
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...