Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What would be your next step in workup for a patient with IgG Kappa Monoclonal protein detected on SPEP and free lambda light chains found in the urine, with chronic diarrhea for 3 years and concern for GI amyloidosis?
This is a great question. I think the most important thing when it comes to the consideration of amyloidosis is thinking of it in the first place! For patients with MGUS (or myeloma) but with red flag symptoms of amyloidosis, it is important to work these up. The studies recommended may differ base...
How do you diagnose and manage patients with hypnagogic shooting headache?
Hypnagogic stabbing headache is not an entity. Hypnic headache is and so is stabbing headache. We diagnose both conditions based on the history. Hypnic headache resembles cluster headache, except that the headaches are bilateral. If they last (significantly) longer than 1-2 hours, the proper diagnos...
How do you approach management of a patient with lower extremity ulcers from livedoid vasculopathy with a history Sjogren’s and Factor V Leiden?
Assess for additional procoagulant risk factors (smoking, phospholipid Abs, estrogen, paraprotein), and mitigate.Maximize pain management and wound care.In Sjogren's with vasculopathy, pts have responded to hydroxychloroquine, aspirin, and pentoxifylline. When lesions resolve, have continue hydroxyc...
Would you recommend genetic polymorphic testing before the initiation of antiplatelet medication in patients with ICAD?
This is not a bad idea if a rapid test is available. If the patient has clopidogrel resistance, I would treat it with brilinta.
Is concomitant use of azathioprine and febuxostat safe from a bone marrow toxicity standpoint?
No- Logan et al., PMID 31885095.See evidence. If you must use both for outside reasons- start really low and slow and monitor very very closely!
How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?
I would be very cautious attributing ataxia to the presence of ACL (even if they were persistent). While an association between ataxia and apl has been described, the differential is extremely broad and should be carefully worked up in conjunction with a neurology team. Some of the more common cause...
What is your approach to pulmonary vasodilator therapy in patients with COPD and Severe Group 3 Pulmonary Hypertension?
I'd like to first acknowledge that there are no large randomized controlled trials specifically in patients with severe COPD-PH to guide practice. Before I consider PH-specific treatment, I like to exclude other causes of PH namely CTEPH, LHD, and CTD-PH which would influence treatment options. Seco...
Would you consider a primary prevention ICD in a patient with hypertrophic cardiomyopathy and non-sustained ventricular tachycardia, in the absence of any other high risk predictors for sudden cardiac death?
Nonsustained ventricular tachycardia in hypertrophic cardiomyopathy without major risk factors (IIa primary prevention risk factors in 2020 ACC AHA HCM guidelines – max wall thickness >3 cm, FH SCD, LVEF <50%, unexplained syncope, LV apical aneurysm) remains a minor risk factor in adults (IIb consid...
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Once troponins start to decrease, I start the steroid taper and follow troponin levels. If they rise, I slow the taper. I also get serial ECGs, esp if there were arrhythmia manifestations of myocarditis. Don't forget to assess for the need for PJP prophylaxis with Bactrim or pentamidine and PPI sinc...
What is your approach to rectal cancer staging in patients who cannot undergo an MRI?
Endoscopic ultrasound of the rectum in addition to CT scans with contrast, if any doubt, will do a PET/CT scan.