Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Which brand/preparation of levothyroxine do you recommend to treat hypothyroid patients with alpha-gal allergy?
Alpha-gal syndrome is a type of food allergy to meats. None of the generic or brand-name thyroid medication tablets contain meat. In general, in patients with food intolerances, I recommend Tirosint capsules which contain only levothyroxine and glycerol BUT the capsule is made of gelatin derived fro...
Would you treat a sputum culture positive for Aspergillus niger despite an atypical CT chest and a negative serum galactomannan in an immunosuppressed patient who is too high risk for bronchoscopy?
What is your treatment approach for a young female who has an idiopathic small right elbow effusion with synovial thickening that has resulted in limitation in her range of motion?
I might aspirate the joint, send for gram staining, cell count, culture, and crystals, check serology to rule out autoimmune like RA or lupus, tick-born disease, and X-ray the joint. If all is negative, consider a short course of steroids, even synovectomy.
Do you recommend carotid ultrasound screening at some point post definitive H&N XRT?
That is a great question and something that has frequently crossed my mind. However, this is not something I have routinely ordered for my patients. One of the reasons is the lack of adequate long term follow-up. This is usually seen a few years post-RT and many patients are lost to follow-up 4-5 ye...
Is there a minimum work-up necessary in patients with an ANA greater than 1:160 and no clinical symptoms suggestive of lupus (i.e., specific antibodies, UA)?
My personal practice has been to get the "ANA subtypes" and a UA for prot/Cr ratio, but I do this with the idea of needing to have a complete picture. Clinical symptoms are still king.
How would you approach a patient with end stage kidney disease on peritoneal dialysis who has an adequate Kt/V but persistent azotemia?
This question could serve as the springboard for a very lengthy discussion/ debate regarding PD "adequacy"- a term that ought to be outlawed! That said, I will try to be brief. First off, it must be recognized that Kt/V (by default meaning that for urea) is a very poor measure of the quality of dial...
What is your approach to evaluation in patients who present with erythromelalgia?
Erythromelalgia is a tough condition to treat. I usually break it down into diagnostic workup and treatment as follows: Diagnostic workup: I usually just get a CBC yearly to look for myeloproliferative disorders. Treatment: I have not had a lot of luck with topicals being too effective, so I usuall...
Would you consider switching choice of P2Y12 inhibitor for patients with ISR (non-ACS presentation), with acceptable bleeding risk?
There is no need to change P2Y12 inhibitor in case of ISR without ACS. There are no studies that suggest such approach is indicated or can be helpful. Also, patients are taking their current P2Y12 inhibitor for a while and they are used to the medications. Changing the medication can raise cost with...
How do you apply the CDC PrEP guidelines for cisgender women, particularly when faced with underreported risk behaviors or uncertain partner HIV status?
This can be quite difficult, especially in places like where I live in Texas, where PrEP literacy is low. There is still a lot of education that needs to take place in the community about how HIV is still a threat that you can do something about, particularly for women. On a global basis, getting th...
Do you recommend avoiding ESAs in pregnant patients with anemia of chronic kidney disease who also have preeclampsia?
Yes