Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
What should the LDL target be in patients with prediabetes and high lipoprotein (a) with family history of coronary artery disease?
I don’t think that using Lp(a) to guide treatment is quite ready for prime time yet. It’s an independent predictor of risk compared to the rest of the lipid panel, but as far as I am aware, we do not yet have data that treating people based on it makes a difference. What I may do in this scenario is...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What is your approach to screening a cancer survivor for iron overload, and what is your treatment of choice?
We check a ferritin level after completion of chemotherapy. If ferritin is >1000 ng/ml we recheck the level as it can be falsely elevated with inflammation/infection. If ferritin is >1000 we obtain an liver MRI with iron quantification. if Liver Iron Concentration (LIC) is > 5 mg/g dry weight we ini...
What is your approach to screening a cancer survivor for iron overload, and what is your treatment of choice?
We check a ferritin level after completion of chemotherapy. If ferritin is >1000 ng/ml we recheck the level as it can be falsely elevated with inflammation/infection. If ferritin is >1000 we obtain an liver MRI with iron quantification. if Liver Iron Concentration (LIC) is > 5 mg/g dry weight we ini...
How do you follow patients after SBRT for NSCLC?
When we started our lung SBRT practice almost 13 years ago, the follow up schedule was based on trying to measure the benefits and impact of the therapy in a fairly structured fashion so that we could develop expertise in understanding outcomes, radiographic changes, patient experience, and treatmen...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
I'm a pediatric oncologist who runs our childhood cancer survivorship program, so I generally don't take care of adults. We are a free-standing children's hospital, so we have no affiliation with an adult program. So, when I transition our pediatric oncology patients out of our program, I transition...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
I'm a pediatric oncologist who runs our childhood cancer survivorship program, so I generally don't take care of adults. We are a free-standing children's hospital, so we have no affiliation with an adult program. So, when I transition our pediatric oncology patients out of our program, I transition...
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher ...
How do you manage dry eye syndrome due to lacrimal or meiobian gland dysfunction after external beam radiotherapy?
I have also found autologous serum (AS) or platelet-rich plasma (PRP) eye drops/tears to be extremely useful (provided by an ophthalmologist). Dry eye can also be exacerbated by graft vs. host disease, which I have anecdotally seen worsened within radiation fields and is characterized by a lasting m...