Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you adjust the dose or the timing of levothyroxine ingestion in patients on anti-acid medications?
Actually, adjusting the timing of levothyroxine ingestion probably doesn’t help much, since the proton pump inhibitors, and other similar drugs, have a duration of action of 12–24 hours. I would recommend checking serum TSH levels after the patient has been on the gastric acid medication for 4–6 wee...
How do you approach the use of buprenorphine/naloxone in pregnant and breastfeeding patients?
If the patient is already on it, many doctors, including myself as an addiction psychiatrist, will simply switch to the same dose without the naloxone component, just to use the minimum necessary meds while pregnant. It’s not a hard and fast rule though. The dose may need titration later in pregnanc...
What treatment regime would you recommend for localized hyperhidrosis affecting the scalp that has failed topical aluminum chloride and oral glycopyrrolate?
I have personally found that oxybutinin is more effective than glycopyrrolate with fewer anticholinergic side effects.
How do you do a levodopa trial in the outpatient setting?
In a patient with Parkinsonism whom I am starting levodopa treatment for, I begin by conducting a detailed motor examination using the MDS-UPDRS III to assess baseline symptoms. Typically, bradykinesia and rigidity respond most consistently and robustly to treatment. While tremor and gait disturbanc...
How would you manage a patient with Crohn's disease on a biologic and presents with non-bloody diarrhea, normal-appearing mucosa on sigmoidoscopy but severe colitis on biopsy with a positive CMV stain?
A few key pieces of information help distinguish CMV colitis from other competing diagnoses in this frequently encountered conundrum. An experienced pathologist will usually be able to tell you: If the CMV immunohistochemistry stain has good controls and whether it is floridly positive or scant. Al...
What other conditions should you consider in someone with presumed Tolosa Hunt but without significant improvement on steroid therapy?
Sufficient workup should ideally be obtained before initiating steroids in order to exclude disorders that may have a similar presentation with quite a different approach to management. These investigations include but are not limited to the following: brain MRI with contrast + thin slices through t...
How would you counsel a young female patient who refuses to use contraception during radiotherapy?
A woman who refuses contraception needs careful psychological and psychiatric assessment and considerable time at the time of consultation to understand why she is refusing, especially since this response is neither rational nor logical. The practitioner needs to take the time to discuss the patient...
How do you manage anticoagulation in a patient with DVT from likely malignant mechanical obstruction?
This is a very difficult situation to manage. Would promptly initiate therapeutic anticoagulation as long as no increased risks for bleeding. The surgery to remove the uterine mass is likely urgent. I would confirm with gynecologic oncology (or the team planning on removing the mass) that it is not...
How do you approach a patient who develops a rest tremor after chemotherapy?
Like many questions in Neurology, this question can be simple or rather complex to answer. If the patient is felt to have a drug-induced tremor, withdrawal of the offending drug or drugs should be the first choice whenever possible. In the chemotherapy setting, a common scenario would be when a dopa...
How frequently do you recommend EKGs in pediatric patients on antipsychotics, especially in patients taking antipsychotics with more QTc risk?
AACAP recommends baseline EKGs only in patients with a family history of cardiac problems (sudden cardiac death in young/arrhythmia in close relatives), personal or family history of arrhythmia/other cardiac abnormalities, personal history or symptoms including syncopal attacks, and palpitations to ...