Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach an asymptomatic patient with evidence of intense radiotracer activity at the left sternoclavicular joint on bone scan with a history of SAPHO syndrome on Humira?
Any other area light up? Bone scans are sometimes challenging to read as they can light up with degenerative changes or prior damage and do not always represent active disease. Can consider an MRI of the joint to better determine whether there's disease activity or only prior damage. If it's really ...
How do you choose between the different vitamin D analogs for patients with CKD, an elevated PTH, and a normal 25-hydroxy vitamin D level?
In patients with pre dialysis CKD and elevated PTH, I would recommend using ER Calcifediol, which is a 25 D compound. It has been shown to be more effective than Vit D and it does not result in hypercalcemia, hyperphosphatemia, or FGF23 as is seen with VDRAs, calcitriol, paricalcitol, or doxercalcif...
What are your preferred strategies to manage mild to moderate rectal ulceration causing tenesmus and discomfort after chemoradiation for rectal adenocarcinoma?
Radiation-induced proctitis or tenesmus -- important to determine if the cause is external or internal to anal verge. Also important to rule out rectal fissures as this typically requires a different approach (Analpram cream and high fiber diet, +/- GI evaluation). If the cause is internal to anal v...
What is the appropriate interval to obtain a hydroxychloroquine level after making a dosage adjustment?
Hydroxychloroquine has an initial whole-blood half-life of around 5 days, while its terminal half-life is around 40 days (Costedeau-Chalumeau et al., PMID 27745934). The former is relevant to evaluating whole blood levels after a dose change.This was confirmed in the PLUS study (see figure 2 in Cost...
What is your process for considering alternative imaging modalities for cardiac imaging when POCUS is limited by patient conditions, such as emphysema or body habitus?
When POCUS is limited, a multi-faceted process that considers the clinical question, patient characteristics, the strengths and limitations of available imaging techniques, and the available resources should be implemented. The most important question is what you are specifically trying to evaluate....
In a young male patient with hypogonadotropic hypogonadism and fertility goals, would starting testosterone replacement therapy affect fertility chances?
Men with hypogonadotropic hypogonadism due to congenital hypogonadotropic hypogonadism or acquired hypogonadotropic hypogonadism due to structural disease (e.g., a pituitary macroadenoma) typically require gonadotropin therapy to optimize spermatogenesis and fertility. For men who have hypogonadotro...
How do you counsel patients with non-statin associated inflammatory myopathies about statin use?
Patients with non-HMGCR-associated myositis could try statins, keeping in mind that they could develop statin-associated muscle symptoms (SAMS). Therefore, would start with fluvastatin/pravastatin/pitavastatin (that are less likely to cause SAMS) at a low dose and slowly escalate if there are no sid...
What medications have you had success with for patients with high functioning ASD and co-morbid ADHD and anxiety?
First, separating the problem and likely cause of the presenting symptoms or symptoms that you want to treat will be important for such patients. ASD kids will have stereotypic behaviors that may look like OCD or anxiety but may not be. Separating this is particularly important because regular presc...
Would you have a patient temporarily discontinue methotrexate while receiving a FAST or FAST FORWARD regimen for breast irradiation?
I favor continuing as the dose of MTX is low for RA and in CMF era with much higher methotrexate dose, RT plus MTX was well tolerated.
How do you manage withdrawal symptoms of SNRIs that exist even after slow taper?
Another strategy is to do a custom ultra-slow taper. You need to be able to trust the patient can follow through with the instructions. The venlafaxine XR capsule can be opened and sprinkled on food. You can decrease by very small amounts (<1 mg) by taking fewer and fewer beads over time (e.g., remo...