Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you obtain spot urine protein or 24 hour urine protein quantification studies in pregnant patients who are found to have proteinuria on a standard urinalysis test?
If a patient has a positive dipstick for protein, I would do a 24-hour collection, just to get the most accurate answer to the question of whether there is truly abnormal proteinuria or not, and taking into account the physiologic protein increase that happens during pregnancy. I generally check a b...
How do you approach patients with RA and severe bronchiectasis with associated findings of UIP?
Usual Interstitial Pneumonia or UIP is among the most serious forms of RA-associated lung disease. Clinical studies have demonstrated that its prognosis is similar to idiopathic pulmonary fibrosis (IPF). UIP is extremely challenging to treat and we have learned from experience that our DMARDs and bi...
How do you approach patients with onychomycosis that does not respond to terbinafine and prolonged courses of fluconazole?
Terbinafine is usually effective in the treatment of the most common nail infections. Failure of treatment with terbinafine and fluconazole should make us consider bacterial co-infection or other non-dermatophyte organisms (i.e., aspergillus or non-C albicans). Fungal cultures are often falsely nega...
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.
What is your approach to postpartum screening and cardiovascular risk assessment in patients with a prior history of preeclampsia?
Hypertensive disorders during pregnancy, including preeclampsia and gestational hypertension, elevate a woman's long-term risk of cardiovascular disease. The American College of Cardiology (ACC) and the American Heart Association (AHA) now recognize preeclampsia as a risk-enhancing factor for heart ...
When do you consider immunosuppression in patients with Sjogren's neuropathy?
Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, ...
For patients with incidental findings of venous thromboembolism during workup of a treatable malignancy, how do you approach discontinuation after the treatment is complete?
Your approach to incidental thromboembolism found on the workup of malignancy should be similar to any evaluation of a thrombosis. It should be a structured approach with the following questions evaluated before deciding on long-term or short-term anticoagulation. First, one should determine the loc...
Which screening method for diabetes do you consider to be the most sensitive?
I don’t usually think about which screening method for diabetes is the most sensitive. I am more likely to consider which is most appropriate for my patient. I never order OGTT for non-pregnant patients. They are cumbersome and, compared to FPG and A1C, they don’t significantly change my recommenda...
What is your approach to correlating stenotic lesions on coronary angiography to magnitude of decline in LV systolic function or cardiomyopathy severity when deciding to intervene or medically manage stable ischemic heart disease as an outpatient?
I use a combination of EKG, ECHO, Stress test, and viability (nuclear or MRI) to correlate the stenotic lesion to ischemic/hibernating/infarcted myocardium. I would only intervene if there is a large amount of ischemic/hibernating myocardium in the area supplied by the stenotic artery. I also use FF...
What is your approach to a patient with incidental radiographic findings of sacroiliitis without clinical inflammatory back pain?
I agree. As mentioned, often, the radiology report going back to orthopedics, for example, may say "spondyloarthropathy" whereas, in fact, the radiologist is just describing osteoarthritis and/or spondylosis (the combination of OA and degenerative disc disease). Then, a rheumatology referral is init...