Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When would you consider treating an asymptomatic patient with follicular lymphoma?
The decision of when to initiate treatment of low-grade follicular lymphoma is, of course, part art and part science. It largely remains the standard of care to defer initiation of treatment when not required, but when is it required? The question identifies symptoms attributed to disease as a clear...
How often and in what way do you monitor patients who are receiving teprotumumab (Tepezza) for thyroid eye disease?
A week or two after completion unless having an issue.
Are there instances when you recommend oral phosphate for patients with recurrent nephrolithiasis?
Yes. There have been two studies both done long ago looking at the effectiveness of oral phosphates in preventing kidney stones. The first using K Phos Neutral was done at Mayo and showed a decrease in the frequency of stone passage. The second, done in a California system, used K Phos Acid and show...
How long do you wait to repeat a 24 hour urine stone risk study after stopping topiramate in patient with recurrent calcium based kidney stones attributed to the medication?
Assuming normal or near normal GFR, topiramate should be effectively eliminated after approximately 5 days, and urine pH should have returned to its pretreatment level. If more data is desired, a 24-hour urine supersaturation could be collected then. Topiramate predisposes to kidney stones by inhib...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
In obese men presenting with gynecomastia, elevated estrogens, and hypogonadism, what clinical factors would push you to obtain testicular and/or adrenal imaging to rule out an estrogen-producing tumor?
It is not generally necessary or useful to measure serum estradiol in the evaluation of acute (tender and/or growing) gynecomastia. The widely available estradiol assays are generally immunoassays that are not accurate at the low estradiol concentrations in men. In addition, it is not uncommon to se...
What are the best biologics for a pediatric patient with extensive guttate psoriasis that is poorly controlled on topicals?
Fortunately, we have a number of options for treatment of pediatric psoriasis that work well. With a guttate presentation, I would always recommend sending a throat swab and checking perianal skin to rule out Group A Strep as clearing this is an important step in getting the psoriasis under control....
How do you start and manage therapeutic SC heparin for acute thrombosis in pregnancy as the patient approaches delivery?
This is an excellent question and my approach to such a patient has changed over time. In my experience, therapeutic subcutaneous UFH is incredibly unpredictable--women may come in in labor on therapeutic UFH thinking that they will be able to get an epidural, but despite waiting hours and hours, th...
Do you recommend Hyaluronic Acid Therapy for vaginal dryness in female patients post pelvic RT?
I do not. Not saying you shouldn’t though. I recommend coconut oil which can be used with a vaginal dilator, for intercourse or purely for hydration. If ineffective, I will refer back to gynecology. There may be a role for topical estrogen depending on the cancer histology.
Are there situations when you a 1K dialysis bath as a long-term outpatient prescription for patients with ESKD?
I cannot think of a situation where this would be needed, and based on available data I recommend against it.In the hospital setting, there is some data that doing dialysis with a 1K bath is beneficial and can reduce mortality, see Singh et al., PMID 34476092.The same cannot be said for long-term di...