Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to prescribing RIPE for 6 month vs rifapentine/moxifloxacin for 4 months in the treatment of drug sensitive TB in the US?
There are many things that have to be taken into consideration before deciding on using the rifapentine-moxifloxacin regimen instead of the standard RIPE regimen for drug-susceptible TB. The regimen is only recommended for people with pulmonary TB at this time. People with extra pulmonary TB were no...
Do you usually recommend a modified diet for Clostridioides difficile infection (CDI)?
Post-infection IBS is common after C. diff infection, and some of these patients have dietary intolerances. Other than avoiding foods that exacerbate these symptoms, I do not recommend any particular diet. I also do not recommend probiotics, in keeping with society guidelines.
What laboratory workup do you perform in patients with symptoms consistent with erythromelalgia?
The usual CBC with differential, as well as CRP, ANA, ESR, and Rheumatoid Factor.
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...
How do you approach management of osteoporosis in patients post lung transplant?
Osteoporosis in patients with lung transplants is essentially glucocorticoid-induced osteoporosis. Most patients with severe lung disease have a long history of glucocorticoid exposure. Post-transplant, these patients are often on long-term glucocorticoids. The primary pathophysiology of chronic glu...
How do you approach management of patients with psoriatic arthritis who have significant improvement in skin disease, but ongoing inflammatory arthritis despite multiple DMARDs and/or biologics?
Psoriatic arthritis is a heterogeneous disease and often the severity of MSK involvement and psoriasis are not well correlated. This is also true regarding treatment response. The approach to management in these cases depends on several factors:Psoriasis type and severity: If the patient has mild ps...
Do you ever utilize a steroid pulse in patients who are pregnant with status migrainosus?
According to ACOG, if steroids are use oral prednisone 20mg po QID x2d or methylprednisone dosepak is preferred over dexamethasone due to lower fetal exposure. Dexamethasone could be considered even parenterally if these do not work and attack is particularly refractory. However, they recommend that...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
How is your experience with point-of-care INR systems for home monitoring of vitamin K antagonists?
Point of care (POC) INRs are reliable and can be used to monitor patients once their INRs have been stabilized on warfarin. In fact, there is data on better time in the therapeutic range for self-testing and also self-management of dosing. However, this needs to be done in conjunction with a warfari...
What is the typical work-up completed to rule out other conditions prior to making a diagnosis of fibromyalgia (other than history and physical exam)?
I agree with Don and will just add a few things. The workup to a large part depends on how long the person has had similar symptoms. In an individual who has had many regional pain conditions and lifelong issues with sleep, fatigue, or other symptoms of FM, there is very little work up needed. Howev...