Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How common are nasal telangiectasia in patients with systemic sclerosis?
Telangiectasias, particularly “matted’’ ones are often seen in patients with Systemic sclerosis (SSc), both limited and diffuse cutaneous. They can also be seen in patients with MCTD, UCTD with SSc features, Lupus or Dermatomyositis (often periungual). In SSc, they are most commonly on the face and ...
When is it safe for a rectal biopsy in a patient with prior prostate radiation?
A biopsy of rectal tissue that has been radiated will have a higher risk of developing non-healing wounds and ulcers. Part of the reason that biopsies are discouraged as well as radiation proctitis is a clinical diagnosis and that biopsies of proctitis are certainly not needed to confirm this. Recta...
Is a significant rise in cortisol post cosyntropin stimulation sufficient to rule out adrenal insufficiency in patients with low albumin?
We use the absolute cortisol (or free cortisol) values rather than the degree of the rise in cortisol as an indicator of normal adrenal function during the ACTH Stimulation Test. Is this question related to the critically ill patients?
How would you work up an elevated copper level without cytopenias in a patient with history of bariatric surgery not on supplements or using copper utensils?
Would make sure they are not on supplements as these are often recommended post bariatric surgery. Otherwise, not sure of a connection with bariatric surgery. Would check ceruloplasmin level to rule out Wilson's disease. A low copper level is more likely and can cause leucopenia and sideroblastic an...
How do you manage recurrent hemodialysis filter clotting in an in-center ESKD patient with heparin-induced thrombocytopenia?
I have actually not faced this situation recently. something that may be tried though: flush the lines more frequently with saline, giving patients dose of eliquis orally prior to treatment, other anticoagulant?
Do you recommend targeting a higher Kt/V in an ESKD patient on hemodialysis with pruritis and a Kt/V of 1.4?
I do not. I believe there is not good evidence to suggest more dialysis will help with ckd pruritis and in general slightly higher kt/v usually does not correlate well with actual clinical findings. A better study to be done would be to see if more frequent dialysis will help treat ckd pruritis.
Does your goal rate of correction in patients with chronic hypoosmolar hyponatremia differ based on the degree of hypoosmolarity?
Certainly the lower the PNa is, any increase in PNa will have a greater effect on serum osmolality, so yes the lower the PNa the more careful I am. I would suggest never to be complacent, but for instance if the PNa was 105 I would make sure not to increase it by more than 6 in 24 hours, but if it w...
Do you recommend continuing peritoneal dialysis in an ESKD patient on peritoneal dialysis who is diagnosed with encapsulating peritoneal sclerosis since abdominal symptoms may worsen when peritoneal dialysis is stopped?
It is generally accepted that after a diagnosis of encapsulating peritoneal sclerosis (EPS), most patients are transitioned off peritoneal dialysis (PD) and switched to hemodialysis as patients with EPS often have chronic abdominal pain and will often have difficulty with dialysis adequacy and ultra...
How would you approach a patient with elevated CPK in the 500-1000 range with no weakness on exam or myositis on MRI but with positive HMGCoA ab?
No treatment but follow closely for weakness and muscle enzyme further elevation. If CK starts to go up and doubles and triples, or weakness start, then start treatment as soon as possible.
In a patient with a history of HIT, how would you reintroduce Heparin?
When patients with even remote histories of HIT are re-exposed to heparin, there is a very high risk of heparin-PF4 antibody seroconversion (Warkentin and Anderson, PMID 27114458). I have seen two patients who suffered a fatal relapse of HIT (e.g., case one in Kodityal et al., PMID 12890149). Bivali...