Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you evaluate a patient with an isolated high RBC count but with a normal hemoglobin and hematocrit?
My first question would be, how long has the elevated red cell count been present? I ask this because, in a study of 10,000 individuals, erythrocytosis was initially found in 88 but after a year only 11 still had this finding (Ruggeri et al., PMID 13679323). If therefore, the observation is recent, ...
Would you extend the duration of anticoagulation in patients with a provoked DVT, but evidence of residual clot at 3 months?
This is a really interesting discussion. I do tend to get Dopplers at the end of the anticoagulation treatment period, but only to assess the new baseline and to help decision-making in the future if they develop new symptoms and have another Doppler. I find this to be very helpful to understand if ...
What is your approach to tapering chronic steroids in patients who are at high risk of HPA suppression?
There are rare cases when the adrenal function never seems to recover. The ACTH recovery happens before cortisol so that it can be monitored as a marker. When I get a consult about tapering GCs in a patient on long-term therapy, I usually let the primary team (e.g., rheumatologist) cut back on predn...
What workup do you recommend for otherwise healthy migraine patients that develop dizziness with episodes?
The workup should exclude other potential causes of vertigo including CNS disorders, and Meniere's disease, with neurology examination, MRI brain, videonystagmography, or electronystagmography. An article also evaluated vestibular migraine versus migraine without vertigo and found in several studies...
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
How do you approach management for patient's with HIV on ART with persistent low level viremia but no new resistance mutations identified?
The US Department of Health and Human Services describes the different levels of virologic response related to ART[1]: Virologic suppression: A confirmed HIV RNA level below the lower level of detection of available assays. Virologic failure: The inability to achieve or maintain suppression of viral...
Is a history of provoked DVT a contraindication to starting testosterone replacement therapy in a middle aged man with symptomatic hypogonadism who is on anti-coagulation?
The data on testosterone replacement and thromboembolic disease is not so clear but there is likely a link and should be noted in patients at high risk (e.g smoking, prior event, erythrocytosis). It’s important to discuss the risk benefits with the patient but as long as they are on anticoagulation,...
Can anabolic agents be used in a patient with history of radioactive iodine treatment for hyperthyroidism?
This is an interesting question. When PTH was approved it had a black box warning for patients who had a history of radiation to the skeleton due to risk of potential osteosarcomas. The black box has been removed for the duration of use. Since we have another anabolic agent without that black box, I...
How would you approach the workup of unilateral chorea with a normal MRI?
I would first rule out Sydenham chorea by checking ASO titers, DNase B titers, ESR, and CRP, and performing an echocardiogram and EKG. I would also recommend an MR angiogram if not already done for Moya-Moya. Following that, I would check copper levels, ceruloplasmin, serum amino acids, serum lactat...
How do you manage dry eye syndrome due to lacrimal or meiobian gland dysfunction after external beam radiotherapy?
I have also found autologous serum (AS) or platelet-rich plasma (PRP) eye drops/tears to be extremely useful (provided by an ophthalmologist). Dry eye can also be exacerbated by graft vs. host disease, which I have anecdotally seen worsened within radiation fields and is characterized by a lasting m...