Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage anticoagulation in a patient with DVT from likely malignant mechanical obstruction?
This is a very difficult situation to manage. Would promptly initiate therapeutic anticoagulation as long as no increased risks for bleeding. The surgery to remove the uterine mass is likely urgent. I would confirm with gynecologic oncology (or the team planning on removing the mass) that it is not...
How do you approach a patient who develops a rest tremor after chemotherapy?
Like many questions in Neurology, this question can be simple or rather complex to answer. If the patient is felt to have a drug-induced tremor, withdrawal of the offending drug or drugs should be the first choice whenever possible. In the chemotherapy setting, a common scenario would be when a dopa...
How frequently do you recommend EKGs in pediatric patients on antipsychotics, especially in patients taking antipsychotics with more QTc risk?
AACAP recommends baseline EKGs only in patients with a family history of cardiac problems (sudden cardiac death in young/arrhythmia in close relatives), personal or family history of arrhythmia/other cardiac abnormalities, personal history or symptoms including syncopal attacks, and palpitations to ...
How do you monitor safety, effectiveness, and adherence to therapy when using sedative hypnotics in patients with insomnia?
Generally looking at the average sleep length and quality monthly as described by the patient; side effects are always a concern; if there is any possibility of modifying overall sleep hygiene–that would be the way to go; strength of the medicine should be the lowest possible; definitely avoiding or...
Do you prefer celecoxib over a nonselective NSAID in patients with chronic kidney disease?
There are many potential advantages of celecoxib, as a "selective" COX-2 inhibitor, over non-selective NSAIDs. Because of the lesser inhibition of platelet function, it has potential advantages in the peri-operative period, in patients with bleeding disorders or taking anti-thrombotic or anti-coagul...
Do you pursue a cardiac evaluation in all patients with an excised cutaneous myxoma?
I'm a dermatopathologist, not a clinician, but would note the following data points: Many things are called myxomas. Those associated with Carney complex, in which atrial myxomas also occur, are a specific variant, superficial angiomyxomas. They usually have inactivation of protein kinase regulator...
Is ABI (Ankle Brachial index) lower limb arterial doppler not recommended if patient already has arterial stents in the legs, and if so, what other imaging modality would you consider as first-line?
ABI is still helpful in follow-up of patients with arterial stents but only gives a sense of global perfusion to the distal limb and may not be helpful in patients with calcified non-compressible vessels, (e.g. CKD, diabetics), so a better assessment is arterial duplex that can visualize the entire ...
Is there a role for 24 hour urine stone risk profiles in your patients with known recurrent struvite kidney stones?
It depends. Pure struvite stones are not a metabolic abnormality; they are the consequence of a urease-producing urinary infection that splits urea to ammonium, raising the urine pH into the high 7-8 range, which in turn precipitates magnesium ammonium phosphate, otherwise known as struvite. Pure st...
Which steroid-sparing agent do you prefer to treat multi-organ Sweet's syndrome?
I have used methotrexate in combination with cyclosporine with some success but am most impressed with the effect of anakinra to control disease and allow discontinuation of corticosteroids. I would also recommend them in that order.
How do you approach management of adult patients with CVID and sarcoid-like syndrome?
Common variable immunodeficiency syndrome (CVID) is the most common primary immunodeficiency, and is of course, characterized by recurrent infections. This can lead to bronchiectasis due to structural damage from these recurrent infections. However, patients can also have non-infectious manifestatio...