Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to helping parents manage sleep disturbances in patients with autism spectrum disorder?
At our center, we start with sleep hygiene education, using tools such as the Autism Speaks sleep toolkit which has a printable PDF that is free for parental and clinical use. We also try to do therapy on sleep hygiene and our therapists will often try to find out what factors may exist in the home ...
What is your approach to evaluating amiodarone induced interstitial pneumonitis?
There are no definitive histopathological or radiological findings of amiodarone toxicity. For example, foamy lipid laden macrophages are reported but this reflects exposure, not injury, and these findings are present without interstitial lung disease related to amiodarone. High HUs have been report...
Do you refer all patients with a Beighton score over 5 to genetics for further assessment?
Our genetics clinic does not accept these patients for genetic testing anymore because they are inundated with such requests from patients with plain benign joint hypermobility syndrome. They reject these requests for genetic testing. They accept doing genetic testing only for patients with vascular...
Would you switch a patient with glucocorticoid induced osteoporosis to romosozumab if a patient sustained a fragility fracture 1 year into treatment with teriparatide?
This is an interesting question for which there is no evidence-based medicine. It would be important to know what bone was broken. If it was a vertebral fracture I would likely suggest a change to romosozumab because vertebral fractures are usually not traumatic and are the purest osteoporotic fract...
How soon after radioactive iodine therapy for hyperthyroidism should Methimazole be resumed?
In patients pretreated with methimazole, there is a risk of recurrent hyperthyroidism following radioiodine (RAI) administration, with possible adverse cardiac effects, especially in older persons or in those with cardiac disease (reviewed in Walter et al., PMID 17309884). However, resumption of met...
What is the utility of checking reverse T3 in clinical practice?
I have never routinely ordered it, only when forced to by certain rare patients who are reading Dr. Google or other information they find. They think it will change their plan, it never does.
In patients with active IBD and rectal cancer, do you take any precautions before starting TNT?
First, I would be sure that the patient really needs TNT. If a patient has active inflammatory bowel disease, they will not tolerate TNT very well. If a patient has inactive IBD, there is not likely to be much added morbidity. I would be very hesitant to use TNT if someone has really active IBD. The...
What could explain discordant iron studies?
This is an incredibly common question, largely generated by the zeal to use the serum ferritin and failure to appreciate the need for an overnight fast when ordering the TSAT (the ferritin does not require fasting). The most common culprit in this situation is iron containing vitamins. Prenatal vita...
How do you decide whether to use lung POCUS versus CT as the next step when a chest X-ray is equivocal for pneumonia?
Lung ultrasound is a quick, safe, and inexpensive test to perform. If the patient already has a chest X-ray and it is equivocal for pneumonia, I always perform a lung ultrasound. It is useful for evaluating an inflammatory vs. non-inflammatory interstitial process. It is better than an X-ray to dete...
How do you manage residual hyperpigmentation after breast irradiation?
There are definitely options, including modified Kligman formula cream (4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide) for 8 weeks as initial treatment; this - or some iteration of it - is what is typically used for cases of post-inflammatory hyperpigmentation (PIH) or melasma. ...