Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you treat a young patient who presents with coronary vasculitis and aortitis with persistently positive MPO but no other features of AAV?
Once infectious causes such as syphilis have been excluded, the most common causes of the combination of aortitis and coronary vasculitis would be Takayasu arteritis and IgG4RD. However, AAV can cause both aortitis and coronary vasculitis (albeit infrequently). Therefore, if there are no features of...
For a patient who has T4 squamous cell esophageal carcinoma on imaging, and who has biopsy-confirmed disease in an involved local lymph node, are EUS or EGD still indicated to complete workup?
EGD will help better define the mucosal extent of the disease. EUS would not help much but if upper thoracic, bronchoscopy may help to rule out invasion.
What are your management strategies for patients with chronic kidney disease attributed to deferasirox use who require frequent blood products for a hematologic disorder?
It depends on the type and severity of the hematological disorder as well as the extent of CKD. Currently, two oral chelators; deferasirox and deferiprone, are available, in addition to deferoxamine, which can be administered SubQ or IV. These can be mixed and combined, and combination therapy may b...
How would you manage a young patient with HL who develops HF (EF < 30%) after 4 cycles of A+AVD who obtained a PET2 CR?
This is a tough case, and the management would depend on the extent of disease. Assuming that this is advanced stage HL, given the use of BV+AVD, I would be in favor of completing 6 cycles of therapy with a non-anthracycline-based regimen. You can consider consolidative radiation, but this would nee...
What is your preferred method for subclinical CAD screening prior to initiation of class IA antiarrhythmic drugs for atrial fibrillation?
This is a somewhat unique question in that I rarely use IA agents for atrial fibrillation. In my training and early practice, they were used but not so recently. I believe oral procainamide is not readily available, though the IV form is. Quinidine doesn't have a great efficacy adverse event ratio a...
Should patients who develop primary hyperparathyroidism after 5 years of Prolia treatment for osteoporosis be referred for parathyroidectomy?
There are other reasons to treat primary hyperparathyroidism surgically beyond osteoporosis, what is response to treat as far as BMD?
In which patients with nephrocalcinosis and an incomplete distal RTA would you consider further testing for medullary sponge kidney?
Yes, definitely. The better question is how to test. Since sponge kidney is an anatomical disorder of dilated collecting ducts in the renal papillae, it's best to look anatomically. These are 3-dimensional structures and are best seen with a 3-dimensional image. We no longer have intravenous pyelogr...
How would you approach a patient with new temporal headache, temporal artery tenderness and TA biopsy with mild thickening, but normal inflammatory markers?
Some more information is needed. Is this bilateral or unilateral and if the latter is there a potential other cause? Was this patient started on prednisone for presumed GCA prior to obtaining the temporal artery biopsy and if so how long before? When were the “inflammatory markers” measured relative...
In which patients with suspected IgA nephropathy and microalbuminuria would you recommend a kidney biopsy?
There are no guidelines to answer this question. This is my approach. In proteinuric patients, with intact kidney function, threshold proteinuria (UPCR) of 0.5 g/g, or UACR <300 mg/g would be an indication to biopsy. In diseases such as IgA Nephropathy, treatment is driven by the degree of proteinur...
What are the important aspects that you mention when consenting patients for hemodialysis?
I will answer this question a little differently than I think was the intent of the person asking the question. I find that many patients are resistant to starting dialysis at first. In my first conversation with them, I will make it clear to them that the problem is the kidney failure and not the d...