Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you try combination ketorolac and cortisone injections in a patient with severe knee OA who refuses surgery and had partial responses to injections of cortisone and ketorolac separately?
Clinical use of intraarticular injection of ketorolac has gained some popularity, especially in the orthopedic community, although the I.A. route is not an approved indication by the FDA. As such, its use is off-label, which may make reimbursement difficult in the U.S. Nonetheless, there have been s...
What holistic treatments do you recommend for patients with migraine without aura?
Before considering alternative or holistic treatments, first, assess whether both preventive and abortive treatments have been taken correctly and if there is no evidence of medication overuse. Cost and side effects often limit compliance. Lifestyle modification (which could be broadly considered as...
Do you avoid sodium zirconium cyclosilicate use in your patients with ESKD and hyperkalemia who also have peripheral edema?
I don't. The extra salt intake is a problem but so is the hyperkalemia. In general, I am conservative in giving potassium binders in hemodialysis patients because of the risk of polypharmacy.
For which patients or under which circumstances do you recommend a 9-month over a 6-month course of isoniazid for treatment of LTBI?
The preferred regimens now for the treatment of latent TB infection are shorter rifamycin-based regimens. We have options of 3 months of isoniazid and rifapentine given once weekly, or 4 months of rifampin given daily, or 3 months of isoniazid and rifampin given daily. Isoniazid-only regimens are no...
How would you counsel a female to male transgender patient regarding VTE risk with testosterone therapy, who has additional mild-moderate risk factors for thrombosis?
If physiologic concentrations of testosterone are not exceeded and the hematocrit is monitored to avoid a pathologic level of erythrocytosis, the risk for thrombosis from testosterone GAHT does not appear to in excess of the general population. I would refer you to the following two articles that pr...
What scented alternatives do you recommend patients with fragrance allergies try to replace perfumes/colognes?
My approach is to initially advise for the first 3 months a strict personal care “product elimination diet” free of fragrances, botanicals, and essential oils for patients who test positive to fragrance-related allergens. “Product elimination diet” is a term coined by expert Canadian dermatologist S...
What is your approach to symptomatic superficial thrombosis of the pelvic veins occurring in the immediate postpartum period?
I would strongly consider anticoagulation in this scenario given the high risk of thrombosis in the postpartum period.Generally, there is a low threshold to place patients on prophylactic dose anticoagulation for six weeks postpartum (personal history of thrombosis, inherited thrombophilia) given th...
How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?
This is a relatively unusual situation in that idiopathic subglottic stenosis is typically not managed with systemic immunosuppression. The typical therapies are endoscopic and include dilatation (+/- intralesional corticosteroids), endoscopic resection, and cricotracheal resection. A recent large t...
How do you counsel patients with mild congenital myopathy about exercise limitations?
There are many reasons why all patients with muscle disorders should exercise. Many studies have shown improvements in aerobic capacity and some have shown improvements in functional capacity (i.e., 6MWT). Furthermore, many patients with neuromuscular disorders tend to avoid exercise and this is a c...
How can I maximize my efficiency in the clinic?
I have found that my time is better spent if I: 1. Get in an ~hour before official work schedule time period. 2. See all my OTVs on Mondays (or Tuesdays for holidays). I found that seeing them on Thursday or Fridays allows for more visits on the following Monday because of weekend issues. No simulat...