Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What dosing range of oral minoxidil do you prescribe for patients with hair loss?
I have really enjoyed adding this to our AGA treatment algorithm. I like to start at half of the 2.5 mg tab for women daily and the full tab for men. I then increase at each follow-up based on the patient's tolerance for AEs (increased hair elsewhere, BP, edema, lightheadedness). I max out at 5 in w...
Is it sufficient to maintain patients with atrial fibrillation and established PAD on a DOAC or VKA alone, or is there an additional benefit to adding an antiplatelet agent for CVD benefit?
If they have medically managed PAD with no recent intervention/revascularization, anticoagulation alone should be sufficient especially if their bleeding risk is not low. In general, most patients on anticoagulation for AF do not need to also be on anti-platelet agents for secondary prevention. Exc...
What’s your approach to recurrent “idiopathic” Erythema Nodosum that failed NSAIDs?
Next step in treatment would be SSKI with gradual dose titration upward to improve tolerance. For recurrent cases of EN, perform pharyngeal culture to look for strep.
Does vitamin D supplementation in primary hyperparathyroidism increase the risk of kidney stones?
Hyperparathyroidism does increase the risk of developing kidney stones. A study in New England Journal of Medicine, Broadus et al., PMID 7351950, reported that patients with elevated concentrations of 1,25-dihydroxyvitamin D are at increased risk for kidney stones. The reason is that 1,25-dihydroxyv...
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
How do you determine when to transition off pegloticase to other uric acid lowering therapies?
When to transition patients off of pegloticase is a question that is frequently posed to me by my colleagues and by my patients. Pegloticase is not a drug meant for long-term therapy but rather to achieve specific targeted clinical outcomes. I usually recommend once those outcomes are achieved, that...
What additional testing is recommended with heterozygous HFE C282Y mutation whose ferritin is elevated and transferrin saturation percentage is at baseline?
Here, both serum ferritin and transferrin saturation are significantly elevated. Assuming the patient is asymptomatic and LFTs are normal, this profile is suggestive of iron overload. I assume Hb is normal? Would do MRI to look for hepatic iron overload.
What is the appropriate management of arthralgias associated with bosutinib?
Arthralgias have been reportedly associated with the use of all TKIs. The mechanism of this adverse event is not clear. Most of them respond to management with anti-inflammatory agents. When very severe (e.g., grade 3 or 4) transient treatment interruptions and dose reductions may be indicated. In s...
How would you approach asymptomatic hepatic sarcoid?
Hepatic involvement in sarcoidosis is very common. In old autopsy series, as many as 70% of unselected cases of sarcoidosis were found to have granulomatous inflammation in the liver. Today, many possible cases are identified incidentally by more advanced diagnostic testing techniques such as PET sc...
How do you approach the bronchoscopic evaluation of a cavitary lesion of the lung?
I think transbronchial biopsy is very helpful in the diagnosis of a cavitary lesion of the lung. I usually send it both for pathology and culture. I also believe it should be dealt with in a multidisciplinary approach and biopsy should be offered to those whose diagnoses are not clear or straightfor...