Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you alternate CT stone scans and renal ultrasounds for stone monitoring in your patients with recurrent nephrolithiasis with the goal of limiting radiation exposure?
No. Although I share your concern about radiation and expense, the purpose of monitoring kidney stone patients is to detect small differences in stone burden from year to year. Ultrasound is less accurate than CT for this purpose. Avoiding contrast views decreases CT radiation exposure and is my mon...
How do you perform patch testing in patients who are allergic to adhesives?
True allergy to the Scanpor tape most often used in patch testing is rare, even in patients allergic to colophony, p-tert-butyl phenol formaldehyde resin, rubber, or acrylate-based adhesives. What is more common, especially in atopic patients with microbial dysbiosis driving their dermatitis, is fla...
How do you approach treating neuropathic itch?
Localized Neuropathic Pruritus: Life-changing OTC topical called Dermeleve. Key ingredient is strontium, which interferes with the calcium-dependent receptors and calcium channels that are necessary for itch signaling. Works in about 5 minutes, lasts for about 5 hours. STUNNING EFFICACY. It burns li...
What is your stepwise approach to a patient with erosive gingivitis?
The most important test here is DIF. You can be >1cm away from lesional mucosa in the mouth to obtain an accurate diagnosis, so any dermatologist can do this; best spot is usually the labial sulcus or the lower mucosal lip.While awaiting this result, topical treatments can often be surprisingly help...
How do you dose gabapentin in patients with renal failure?
There are many algorithms available online about the renal dosing of gabapentin. However, it should be emphasized that the recommendations are not based on large patient studies; therefore, the efficacy of the reduced doses for neuropathic pain is not certain (Raouf et al., PMID 28184168).
Do you start PAP in patients who have an overall AHI of less than 5 but demonstrate significant apneas/hypopneas in REM sleep?
In general, there is a very poor relationship between AHI and symptoms, particularly sleepiness. Some patients with a low AHI are quite sleepy and others with a high AHI have no symptoms. Thus, in general, if a patient has an elevated AHI, even if minimally elevated, and I have no other explanation ...
Should JAK inhibitors and anti-IL6 medications be avoided in patients with known diverticulosis?
The development of diverticulitis, including complications such as bowel perforation, has been reported in patients taking JAK and IL-6 inhibitors (for example, see here and here). As a result, a history of diverticulitis is a relative contraindication for these agents (and carry a “use with caution...
In difficult cases, what is your approach to find a causative agent of fixed drug or fixed food eruption?
I don't think there is any answer other than advising the patient of the natural course/behavior of the eruption and having them keep a strict journal of all intake until the culprit is determined. Data on testing has been mixed at best (Jayasundera & Watts, PMID 38336399) -- though there may be a r...
How frequently do you check lab work in patients with stable myasthenia gravis?
It depends on what medications they are on! If patients are on pyridostigmine only (some mild ocular MG cases), none. If patients are on monotherapy with eculizumab or ravulizumab, I check none. On steroids: at least twice a year A1c, BMP, annual DEXA scan for osteoporosis, annual eye exam. On azat...
How do you manage patients with SLE undergoing assisted reproductive therapy with estrogenic effects?
For patients undergoing any form of assisted reproductive technology (ART), it is important to assess their SLE disease activity. If a patient has moderate to severe SLE disease, I recommend delaying ART until we have better control of their disease. Once we plan to move forward with ART, I check an...