Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to the management of shrinking lung syndrome in SLE?
I agree with the approach laid out by Dr. @Dr. First Last. As with Dr. @Dr. First Last, we rarely see it, maybe once a year. The only thing I can add is whether the patient is overweight. I have a young man with lupus and shortness of breath who we evaluated and he has restrictive lung disease with ...
What do you do when a patient experiences multiple rounds of antidepressant-related tachyphylaxis?
Our clinic is having remarkable success with TMS for those patients.
How do you dose apixaban in patients with CrCl <30 mL/minute?
Patients with chronic kidney disease are challenging to treat with anticoagulation as they have an increased risk of both venous thromboembolism and bleeding. Treatment should be individualized after weighing the risks and benefits of anticoagulation as well as the indication for anticoagulation. Th...
How do you counsel patients with elevated Thyroglobulin Peroxidase antibody levels, diffuse thyroiditis features on ultrasound, non-specific symptoms of fatigue, but normal biochemical thyroid function labs?
Assuming this is a female patient and TSH and free T4 are both quite normal, the patient does have asymptomatic Hashimoto’s thyroiditis. The fatigue is unrelated to the thyroiditis. She will need periodic monitoring of TSH and thyroid supplementation only if the TSH is high on two measurements.Howev...
Would you escalate treatment for a clinically stable/asymptomatic lupus patient with persistent leukopenia/neutropenia, already on hydroxychloroquine?
The short answer is it depends on several variables most importantly, whether the patient has been experiencing recurrent infections. Additionally, the presence or absence of coincidental lymphocytopenia can be relevant. Worth mentioning that the most common hematologic manifestations in lupus are a...
What is your approach to the management of Bell's palsy that has not improved after six months?
My understanding is that 'Bell's palsy' means idiopathic facial palsy. Therefore, I usually evaluate for other causes, depending on the clinical scenario, before calling it Bell's palsy. We see a lot of Lyme disease in PA. Facial palsy may be the initial manifestation of neurosarcoidosis and may res...
Do you recommend any specific testing for patients with recurrent nephrolithiasis and suspected absorptive hypercalciuria?
I would consider genetic testing in this situation, although it would not alter my recommendations for diet and thiazide diuretic treatment. I would also look for primary hyperparathyroidism. Counterintuitively, parathyroid hormone increases absorption of urinary calcium; that’s why HPT patients are...
Are there instances when you recommend using sevelamer for patients with recurrent calcium phosphate nephrolithiasis?
Basically no. The main drivers of calcium phosphate stones are mildly alkaline urine and hypercalciuria. Primarily, I am looking for the causes of these conditions. Urine volume is always important. If urine phosphate is elevated, my first intervention in that regard is dietary. Stephen B. Erickson...
Is prophylactic anticoagulation indicated in patients with frequent ulcerative colitis flares?
Background: We know that inflammatory bowel disease (IBD) is a risk for incident and recurrent venous thromboembolism (VTE). What is not clearly established is whether the IBD needs to be 'active' in order for it to be a risk factor, e.g. would patients who have had proctocolectomy (and perhaps no e...
Do you consider stopping zonisamide in a female patient with epilepsy who becomes pregnant?
There is nothing specific to zonisamide in this matter and the same question applies to any ASM except basically VPA. Should we stop the ASM if the woman becomes pregnant? I have never understood this question. If it's considered possible to discontinue the ASM due to pregnancy, it suggests that she...