Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage a patient who presents with hair loss that began after they started a GLP-1 inhibitor?
If it fits with telogen effluvium, I recommend monitoring. Many patients will improve after this initial shedding and will not have long-term shedding or long-term thinning. If there is any underlying androgenetic alopecia or pattern hair loss, then starting treatment as you normally would is also r...
What is the minimum duration of weeks on anticoagulation in which you would consider performing a DCCV without the need for TEE, provided the patient is an excellent historian and otherwise reliable?
If this were a board question, I agree with the guideline-listed answers here - it's 3 weeks. The most recent 2023 ACC AHA hours Atrial Fibrillation Guidelines by Joglar et al., PMID 38033089 are consistent: In patients with AF duration of ≥48 hours, a 3-week duration of uninterrupted therapeutic an...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
How long do you continue IVIG for myositis patients in remission on that therapy?
Typical total duration of IVIG is about 1-2 years. If someone is in remission, I will decrease IVIG to 1 gm/kg monthly dose. If still in remission for 3 months, I decrease to 1 gm/kg every other month for 2 more cycles. If still in remission, you could either stop or do 1-2 doses every 3 months befo...
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?
Large volume paracentesis (LVP) can lead to complications such as post paracentesis circulatory dysfunction. In patients who have ongoing acute renal failure, patients with borderline low blood pressure, or in patients who have a history of hyponatremia, LVP should be limited to 5L.
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...