Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should we begin using bromocriptine for CVD management during pregnancy per ESC guidelines in patients with peripartum cardiomyopathy?
The use of bromocriptine for managing cardiovascular disease during pregnancy, particularly in the context of peripartum cardiomyopathy (PPCM), is a topic of growing interest and debate.Before answering this question, I want to make a few points: PPCM is thought to involve a combination of factors i...
Would you evaluate for thrombophilia in patients with incidental splenic infarcts in the setting of known cirrhosis, portal hypertension, and splenomegaly?
When approaching splenic infarction, one question is to attempt to discern if the infarction is due to venous thrombosis (e.g., in the splenic vein) and subsequent congestion or due to arterial thrombosis (e.g. in the splenic artery), which is much more common. Talking with an expert diagnostic radi...
How do you counsel and manage joint pain after isotretinoin treatment?
Firstly, if one starts with 0.5mg/kg joint symptoms rarely happen. My approach is to temporarily stop isotretinoin until symptoms pass and then start at half the previous dose and treat until clear. The ineffective dose was never found. We know now the critical factor in relapse is age-no matter wha...
Would you switch azathioprine to a different immunosuppressant if a controlled patient with SLE develops melanoma and/or non-melanoma skin cancer?
This is a difficult question with no definitive research-proven answer. Clearly, most of our drugs do enhance the chance of melanoma and nonmelanoma skin cancer. If one does a literature search the only one of our drugs that has not been reported to increase the chance for relapse of melanoma is Tac...
How do you counsel patients interested in estrogen containing oral contraceptives who have migraine with aura?
Outside of patients whose attacks are suggestive of hemiplegic migraine, I do not typically avoid the use of estrogen-containing OCPs. While it is my understanding that a number of international organizations and many neurologists (as well as Ob/Gyn) recommend their avoidance, there are several revi...
What approach to antipsychotics do you take with patients with primary thought disorder who are now geriatric?
The primary goal is to manage psychotic symptoms effectively while minimizing adverse effects, particularly those that may exacerbate cognitive impairment. Older adults may experience altered pharmacokinetics and pharmacodynamics, which can affect the efficacy and safety of antipsychotic medication...
Do you use any alternative or non-FDA-approved treatments for smoking cessation?
For a non-medication, non-nicotine option, NADA auricular acupuncture has had some evidence-based success in tobacco cessation. It can also be somewhat helpful for anxiety and insomnia. The results are not always mind-blowing, but the risks are also not high so, in general, the outcome tends to be w...
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
How do you manage and adjust Parkinson’s medication if a patient has worsening orthostatic hypotension while being treated with carbidopa/levodopa?
Levodopa is such an important pillar of Parkinson's therapy that it is often necessary to continue this drug despite the worsening of orthostatic intolerance.This is a step-wise approach (i.e., don't go to step 4 if you haven't addressed step 2): Ensure that the patient is getting symptomatic benefi...