Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your work-up for acquired keratoderma?
The differential diagnosis for acquired keratoderma is broad and includes categories such as inflammatory skin disorders (such as pityriasis rubra pilaris, cutaneous T cell lymphoma, etc), infections (syphilis, crusted scabies, HIV, etc), medications (tyrosine kinase inhibitors, etc), nutritional de...
When do you use levocarnitine in patients on Depakote therapy for seizures?
No, unless they have elevated ammonia or LFt levels related to VPA. Hope this helps!
Do you ever do surveillance MR imaging in patients with stable exam and history of cardioembolic stroke?
I typically do not do an MRI unless a patient is having symptoms.
What is your approach to using medications that can cause bone marrow suppression in SLE patients who have persistent leukopenia?
I am so glad someone asked this question. I have heard some peers state that they are reluctant to use immunosuppressants in this situation. However, I do not agree with this. The whole reason our systemic lupus (SLE) patients have leukopenias is due to their autoimmunity (but make sure drugs, infe...
How do you approach anticoagulation in the setting of HIT and thrombocytopenia?
This is a very relevant but rather broad question. On a day-to-day basis, the decision on whether one is dealing with HIT vs other causes of thrombocytopenia can be complex. Applying the 4Ts score is easier in retrospect, but in real life patient management, the score has the potential to change alm...
How slowly do you taper a dopamine agonist to prevent dopamine agonist withdrawal syndrome (DAWS)?
Just to add to the discussion above, there are some risk profiles you can consider as reported in Rabinak and Nirenberg, PMID 20065130. Those who developed DAWS had higher dopamine agonist dosage and higher overall levodopa equivalence daily dosage, prolonged exposure to agonists, and lower UPDRS mo...
How much weight would you place on a low titer Ku antibody in a patient with mild CPK elevation but no weakness on exam and no other features of CTD overlap syndrome?
Not much as we know autoantibodies can be false positive especially at low titre. I do not treat patients with just autoantibody without any clinical feature. If this patient has anti-Ku antibody with elevated CK, I would just monitor the patient regularly for development of new clinical symptoms/si...
How do you approach differentiating segmental arterial mediolysis from abdominal vasculitis?
This can be quite challenging. Patients with SAM tend not to have increased inflammatory markers to the degree that patients with abdominal vasculitis do. In addition, I rarely have found a SAM patient being systemically ill like we commonly do see patients with systemic vasculitis involving the abd...
How do you manage dyschezia and tenesmus following TNT with short course RT?
Specifically for the management of moderate to severe tenesmus and pelvic pain/cramping, I’ve found that combinations of steroids, bentyl, and gabapentin are very effective. Another consideration, if sequencing short course RT prior to chemotherapy, is to delay chemotherapy for 2-4 weeks after short...
Do you favor the use of Fick or thermodiluation to measure cardiac output in patients with interstitial lung disease with suspected pulmonary hypertension?
Unless the patient has a left to right shunt or a metabolic cart is used to calculate direct Fick, thermodilution cardiac output (TDCO) is the preferred method of cardiac output measurement in all patients with pulmonary hypertension. This is supported by current guidelines. It's important to take t...