Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you have your patients with recurrent nephrolithiasis stop supplements such as turmeric?
That is a good question and a hard one to answer since supplements may contain a variety of ingredients of unknown quantity or impurities. I think it also depends on the stone type. For example, excessive amounts of vitamin D, as were advised by some "practitioners" during COVID, can cause or aggrav...
Do you delay pegloticase in a patient with an active gout flare?
I don’t. The patient should be on prophylactic colchicine (if their renal function allows), and part of their pre-treatment involves the systemic administration of corticosteroids anyway such as hydrocortisone (used in the initial drug trials) or methylprednisolone (Solu-Medrol). It is known that du...
How do you approach the evaluation of patients referred for chronic lyme disease and counsel patients regarding this entity?
"Chronic Lyme disease" is a term that needs careful definition before one can accurately evaluate and treat a patient. Is this chronic symptomatology with physical findings in a patient who actually had documented infection with B. burgdorferi in the past? Or are there no objective findings, no phys...
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...