Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Which non-pharmacologic treatments for neuropathic pain have you found most effective?
There is data supporting a positive role for lifestyle changes, primarily physical exercise, suggesting that consistent engagement can reduce neuropathic pain. They included aerobic, resistance, and balance programs for anti-sedentary behavior.
What factors do you consider prior to offering a trial of ICS/LABA therapy versus a methacholine challenge test in patients with suspected asthma but normal pulmonary function testing?
If there is a high suspicion of asthma, have the patient obtain a portable electronic spirometer. If peak flows/FeV1 drops >15% correlate with symptoms, start Rx and follow spiro results. If low suspicion for asthma or very mild symptoms, do methacholine.
What criteria do you use to determine when to start a steroid-sparing agent for hypersensitivity pneumonitis?
This is a very challenging question, acknowledging the difficulty in confidently establishing the diagnosis of HP, limited evidence in general to guide the treatment of HP, and recent small observational studies that conflict prior small observational studies. To attempt to answer, breaking down int...
Which fracture sites outside of the classical spine and hip are considered to be osteoporotic fractures even in the absence of a bone density diagnosis?
Any bone that sustains a fragility fracture can result from osteoporosis. The definition for fragility fracture is a broken bone that occurs after a low-energy trauma, such as a fall from standing height or less, or lifting something light. They are a type of pathologic fracture, which means they ha...
What is your approach to using stimulants in treating children with both ADHD and autism?
I think the most important thing to understand is that stimulants can be helpful but perhaps less frequently helpful and often with more side effects than in children with ADHD only. So low expectations with awareness of and preparation for the potential of significant worsening is key. A few other ...
Would you refer a patient for parathyroidectomy if they have normal calcium levels, mild hyperparathyroidism, and evidence of osteopenia?
It is important to be certain the patient has primary hyperparathyroidism by demonstrating by ultrasound or sestamibi scan the presence of an adenoma. Often patients with an elevated PTH and a normal calcium are also vitamin D deficient and have parathyroid hyperplasia. It is also important to rule ...
What are your recommendations for managing perivascular dermatitis with eosinophils unresponsive to high-dose antihistamines, a prednisone taper, and topical steroids?
I would check and treat for scabies.
What is your treatment algorithm for excoriation disorder?
Neurotic excoriation, also known as skin-picking disorder or excoriation disorder, is part of the obsessive–compulsive spectrum. There is no FDA-approved pharmacological treatment. The gold standard, evidence-based therapy is Habit Reversal Therapy (HRT), a form of cognitive behavioral therapy that ...
What is your approach to patients who insist on testosterone replacement therapy despite normal testosterone levels on repeated labs?
I explain that with a normal testosterone level there is no indication for testosterone replacement. Hormone replacement is always about evaluating risks and benefits. With a normal testosterone level the risks outweigh the benefit. I offer to evaluate causes for patient’s symptoms such as sleep apn...
Do you recommend osteoporosis medication in postmenopausal females on anastrozole with very low Vitamin D (4.5)?
A vitamin D level of 4 is very low and should be corrected before any osteoporosis therapy is considered. Severe low D is associated with decreased Ca absorption and sometimes low serum Ca. Giving an anti-resorptive could result in hypocalcemia. Sometimes D levels that low are associated with muscul...