Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the management of a patient with symptomatic iron deficiency anemia who is intolerant of iron?
Oral iron will not work. I would bet my last dollar there was no anaphylaxis but rather an imprudently treated minor infusion reaction which is the cause of ostensible “anaphylaxis” over 99% of the time. You can’t verify that it was real because I can assure you: It was not. They did not do a trypt...
Do you routinely refer young patients with iron deficiency anemia for GI evaluation?
The answer is no, I do not. However, if after iron repletion deficiency persists, then I do. But as for pregnancy, unless there has been a precipitous and proven drop, I would definitely not do a GI workup during pregnancy.
Do you routinely refer young patients with iron deficiency anemia for GI evaluation?
The answer is no, I do not. However, if after iron repletion deficiency persists, then I do. But as for pregnancy, unless there has been a precipitous and proven drop, I would definitely not do a GI workup during pregnancy.
How would you manage symptomatic iron deficiency in patients with PV on frequent phlebotomies?
While iron deficiency by itself is not harmful, if someone has symptomatic iron deficiency, you could consider them intolerant to phlebotomies, and start a cytoreductive agent. Then, over time they can replete their iron stores. In some patients who are very symptomatic from their iron deficiency, I...
How do you view the balance between opting for percutaneous coronary intervention and prioritizing optimal medical therapy as the initial treatment choice for patients with stable angina?
This is the holy grail of Cardiovascular practice on how to marry the prevalent scientific data to clinical practice. In my opinion, an astute history and in-depth analysis of patient symptoms (angina and ischemia with their varied clinical presentations) hold the key to individualized patient care....
Which images do you routinely request when ordering a HRCT chest?
The images I tend to request depends in part on the clinical scenario. In general, I find it helpful to obtain a traditional "ILD protocol" when I meet an ILD patient for the first time, especially when the diagnosis is unclear. This includes both prone and supine images with 1-1.5 mm cuts, in addit...
How do you counsel patients on the likelihood of resolution of their hypertension post adrenalectomy for primary hyperaldosteronism?
Primary hyperaldosteronism is a curable cause of hypertension. Removal of an Aldosterone producing adenoma results in correction of biochemical abnormalities in almost all patients. Hypertension also improves but not in all patients. Studies have shown that "cure" of hypertension occurs in about 27-...
Do you prefer formal testing to establish a diagnosis of SIBO/IMO over empiric treatment?
Great practical question. I prefer formal testing for several reasons: Even though postprandial bloating and distention along with change in bowel habits are the hallmarks of SIBO/IMO, they are non-specific and can be caused by myriad of other organic causes. A normal breath test would direct the a...
For a patient with May-Thurner syndrome and DVT, would you recommend anticoagulation for 3-6 months or indefinitely?
This is a very good question, there is little data on this and there are only a few case series. One case series of 8 patients showed a 25% risk of recurrence in one year with May-Thurner syndrome but too small of a sample to really know what the risk is, plus this probably included a heterogenous m...
For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?
Agree with Dr. @Dr. First Last. In the clinical trials that led to rivaroxaban and apixaban approval, many patients had 2 days of injected anticoagulant first to arrive at successful outcomes leading to DOAC approval. I suggest IV heparin until hemodynamically normal (for PE), sq LMWH for a dose or ...