Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For patients maintained on antiplatelet monotherapy post-DAPT following PCI, what is your recommendation for holding antiplatelet therapy prior to non-cardiac surgery?
As clopidogrel recently has gained traction as a preferred long-term monotherapy to aspirin but is generally not allowed to be administered for a week prior to surgery I have “bridged” with 81 mg aspirin.
For patients presenting with spontaneous coronary artery dissection, what other non-cardiac/vascular work-up can be considered to further risk stratify them as a predictor for any future cardiovascular events?
Our general practice has been to do a CTA head to pelvis to evaluate for FMD and/or aneurysmal disease.
In patient s/p definitive chemoRT for vulvar cancer with complete response, how do you manage a non-healing vulvar defect if biopsy is negative for residual disease?
Hard and takes time. Vitamin E with trental and quit smoking.
Does pregabalin contribute to esophagitis or gastroparesis?
Based on personal experience, no. Regarding gastroparesis, it appears that pregabalin is frequently used for the abdominal pain related to gastroparesis with acceptable results and without worsening of gastric motility: https://www.tandfonline.com/doi/full/10.2147/CEG.S362879
What is your approach to managing a patient with a history of tardive dyskinesia on a VMAT2 inhibitor, presenting with parkinsonism and found to have an abnormal DAT scan?
I have seen multiple experts use both VMAT2 inhibitors and levodopa simultaneously in these instances, though reluctantly so. It depends on the severity of TD and PD (which is obviously exacerbated by VMAT2 inhibitors) and which symptoms are most bothersome for the patient. Some options include: R...
Are there any indications to close a PFO during pregnancy if a woman had a cryptogenic stroke in her first trimester?
In general, PFO closure is a secondary prevention procedure for PFO-associated stroke. In a pregnant patient, our usual preference would be to treat her stroke, continue ASA therapy (or therapy recommended by neurology) and ensure air filters on IVs (and all other stroke prevention) throughout any h...
How do you manage severe intra-dialytic hypertension that is not responsive to dry weight challenge in an asymptomatic patient with ESKD?
If the patient is truly not hypertensive at the start of treatment but becomes hypertensive during treatment (need solid evidence of this), then the best option would be an ACE or an ARB. If the blood pressure is high throughout then would continue to challenge dry weight as long as patient is able ...
What is your approach to evaluating a patient with known rheumatologic disease and elevated free kappa:lambda ratio, but no evidence of monoclonal immunoglobulins?
The information given is a bit sketchy. But assuming a bone marrow biopsy has been done and there is no evidence of malignancy, I would adopt a watch-and-wait approach. If no bone marrow has been done, I would keep an eye on the appropriate blood tests and in collaboration with a hematologist do a b...
For a patient with a lung tumor that is radiographically consistent with early-stage NSCLC but pathology with characteristics overlapping with upper GI origin, what additional diagnostic procedures would you consider before treating?
In the absence of imaging findings in a patient with a risk profile consistent with early-stage NSCLC, I would probably just move forward with definitive management as NSCLC with either surgical resection or SBRT as appropriate. The only other thing I would consider is to make sure they are up to da...
Do you recommend obtaining a vasculitis work up for all patients seen for chronic kidney disease who are without a kidney biopsy?
I don't. There is a false positivity rate with ANCA testing which can complicate management, especially if the patient has diseases such as inflammatory bowel disease or rheumatoid arthritis. I would only check ANCA levels if the patient has hematuria, worsening renal function, or some other issue t...