Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In which clinical scenarios is relying on the urine protein-to-creatinine ratio as a measure of proteinuria unreliable, and interpretations should be made looking at urine protein and urine creatinine separately?
I typically only use spot UPCRs because (1) they are easy to obtain and thus trend (2) they account for BSA indirectly because it accounts for Cr excretion. The best role of urine protein measurements is really just to trend if your therapy is effective or to screen for disease. When looking at urin...
What is the best way to approach elevated liver enzymes in patients treated with combination TKI and immunotherapy?
We rely on clinical judgment in this case as both TKIs and immunotherapies can cause elevation of liver enzymes. Currently, the recommendations in case the attribution of the hepatitis is questionable is to hold both drugs and to check the liver enzymes daily; if it improves, then it is likely due t...
Can you use other iron formulations if a patient develops Stevens-Johnson Syndrome with ferumoxytol?
I have never seen it in tens of thousands of doses so it is difficult to answer. If this is actually real, it must be due to CHO component and not Fe (that would be awful). I would use another formulation and premedicate with steroid and H2 blocker before. Do not use antihistamine.
Should assessing for a MTHFR mutation be part of the thrombophilia evaluation in a patient presenting with a thrombus?
MTHFR mutation testing is of very little utility, given that the functional readout of MTHFR dysfunction is homocystinuria. The intake of the treatment of homocystinuria is folate, which is ubiquitous in the US diet. Thus, homocysteine levels would be adequate for testing, if such testing is indicat...
What is your differential for a patient presenting with multiple digits affected by flexor tenosynovitis, dupuytren's, and no evidence of peripheral inflammatory arthritis?
Other than idiopathic Dupuytren's and recreational or occupational flexor tenosynovitis, I would look for underlying thyroid disorders that can induce trigger finger with some palmar fascia and tendon thickening, and also diabetic cheiroarthropathy. There are several musculoskeletal complications se...
What indicators do you use to identify patients with CTD-ILD who do not have potential to improve from continued immunosuppressive therapy?
This is an interesting question. We need to clarify what this phrase means "who do not have potential to improve". It may be easier to identify patients who may benefit from therapy.ILD physicians work under the motto, 'stability is success'. Thus, improvement may mean 'did not deteriorate'. Minimal...
How do you approach treatment of vasculitis in a sickle cell disease patient?
Will highly depend on the vasculitis type and the acuity of the situation. For ANCA vasculitis, approaches based on rituximab and low glucocorticoid doses might be attractive (granted not severe disease, e.g. RPGN, DAH which should require pulse glucocorticoids). For large vessel vasculitis, a si...
How would you approach a patient with refractory polymyositis (elevated CK, weakness) despite MMF, IVIG, and moderate dose prednisone?
This is a tricky question as true "polymyositis" is exceedingly rare. In most cases, inflammatory myositis without a rash can be further categorized as an immune-mediated necrotizing myopathy, antisynthetase/overlap myositis, or IBM. So when faced with a refractory polymyositis, the first thing I wo...
Are there circumstances when you may consider imaging enthesitis in patients with psoriatic arthritis?
If you already know that there is "enthesitis", then there may not be a reason for imaging. However, there are a few circumstances to consider imaging entheses in a patient with psoriatic arthritis:1) When there is concomitant widespread pain syndrome and the enthesis is tender but not swollen on ph...
What is your approach to differentiating SLE flare in pregnancy vs pre-eclampsia?
Differentiating SLE flare in pregnancy from pre-eclampsia is challenging. This is particularly so because SLE patients have a higher risk of developing pre-eclampsia during pregnancy. There are no hard and fast rules, and often time as a provider, you are never 100% certain if a patient is having a ...