Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When would you feel comfortable with patients who have a history of hormone-receptor positive breast cancer using hormonal IUDs (e.g. Mirena)?
While we typically recommend removing progesterone-secreting IUDs in patients with ER+ breast cancer, especially while receiving chemotherapy or adjuvant endocrine therapy, there is no data that I am aware of to support this recommendation, and we sometimes administer a systemic progestin (megestrol...
What is your approach to patients with SLE who develop a rash after hydroxychloroquine initiation?
First, I diagnose the type of rash. If it is a severe cutaneous reaction, e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), or if it is a more persistent type of reaction like a lichenoid reaction, I stop hydroxychlor...
How do you address social determinants of health that impact patients (e.g., housing instability, food insecurity) but for which there are no immediate resources available?
This is a complicated answer that will vary from state to state, county to county, and overall, it is not a straightforward answer. I do wish we had better systems in the U.S. for managing the social determinants of health (SDOH), and I don't have all of the answers here. Housing instability, food i...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
Do you routinely adjust your interpretation of SLUMS and/or MOCA tests in patients depending on their level of education?
I have routinely adjusted the MOCA score based on their educational level. If their educational level is less than 8th grade, I use MOCA Basic for assessment. Personally, I have not used SLUMS for assessment, so I cannot comment on that.
Do you routinely adjust your interpretation of SLUMS and/or MOCA tests in patients depending on their level of education?
I have routinely adjusted the MOCA score based on their educational level. If their educational level is less than 8th grade, I use MOCA Basic for assessment. Personally, I have not used SLUMS for assessment, so I cannot comment on that.
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
What strategies have you found helpful to manage SSRI associated night sweats?
Reduced dose to the lowest effective dose. Gabapentin can be used off-label for hyperhidrosis and vasomotor symptoms of menopause. I had one patient on an SSRI for GAD and found the gabapentin helpful enough for anxiety that he tapered off the SSRI. If it is just night sweats, you can do a nightly ...
In a woman with bipolar disorder with a menstrual component would lamotrigine itself worsen the condition given that it interacts with prescribed estrogen?
Very unlikely. Estrogen can cause a lowering of the Lamictal serum levels and not vice versa. So, if a patient on Lamictal is put on an estrogen product, there may be a need to increase the dose of Lamictal.
How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?
Great question and one that comes up all the time for me. As the patient has more signs of true infection, such as those you mention with fever, leukocytosis, and respiratory distress, I am much more likely to start antibiotics. If the patient just has chest radiograph findings of opacities and some...