Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage adjuvant endocrine therapy for a postmenopausal patient with early stage HR+ breast CA who develops an ischemic CVA on an AI?
This is a vexing problem that I myself have had to deal with. My patient developed a TIA on aromatase inhibitor (AI). Work up was negative for predisposing risk factors. The choice was easy in this case. This woman was told by her family friend, who was a doctor, that AIs cause stroke and she refuse...
In which scenarios do you use vaginal estrogen in patients with history of HR positive breast cancer?
A recent study (McVicker et al., PMID 37917089) supports the likely safety of vaginal estrogens in breast cancer survivors. Limitations of this study are that it primarily included lower-risk individuals with stage I-II disease and women 50+. In addition, the level of data is limited by the retrospe...
Have you adopted the use of low dose morphine for treatment of cough in patients with IPF?
Yes, I selectively use low-dose morphine for the treatment of chronic cough (lasting more than 8 weeks) in certain patients with idiopathic pulmonary fibrosis (IPF).This includes individuals who demonstrate somewhat preserved lung function (specifically, a forced vital capacity [FVC] of 45% or more ...
What aspects on history and physical exam could help differentiate genetic muscular dystrophy from immune-mediated myopathy?
Great question, and one that comes up all the time in clinical practice. Unfortunately, the question gets a little bit complicated because of the heterogeneity of the musculodystrophies, metabolic myopathies, and neuropathies that can mimic myositis (not to mention the phenotypic variation between t...
How do you determine duration of therapy for patients who have responded well to voclosporin therapy?
Determining the duration of therapy for patients who have responded well to voclosporin therapy in lupus nephritis involves several considerations, including patient-specific factors, disease activity, and risk of relapse. Here is a suggested approach:The duration of therapy is determined by the ren...
How do you manage the wide array of emotions like anger and disappointment patients may have when they first learn of an incurable relapse of an early stage cancer?
This is a really tough question and there is no easy or straight-forward answer. When I consider situations like this, however, I try to follow these guidelines: I use initial diagnostic uncertainty to my advantage. A diagnosis of relapse is almost never made instantaneously (a suspicious lesion on...
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
How long do you continue surveillance with imaging and sputum cultures in a patient with NTM with no indications for treatment?
Since NTM lung disease typically develops over years, it is reasonable to monitor the patient with periodic HRCTs, even if the patient is relatively asymptomatic. I typically do this every 12 months in an otherwise stable patient. The reason for this is because we know that in up to 2/3 of patients,...
How do you manage osteoporosis in patients with anorexia nervosa (who often are young women < 40)?
There are several considerations when a diagnosis of osteoporosis is made in an anorexic female. 1. The bone mineral density study simply provides you with information for how much calcium per unit area is present in the bone. Based on this information a T score is provided. However, a T score of -2...