Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the treatment of restless leg syndrome in pregnancy?
External leg compression device like home Scd’s can be helpful.
Do you pursue a malignancy workup beyond age-appropriate malignancy screening in patients with antibody negative necrotizing myopathy?
This is a great question that speaks to the nuanced (and still-being-elucidated) association between malignancy and the increasingly better sub-divided different autoimmune myositis subtypes:While anti-SRP and anti-HMGCR are the two myositis-specific antibodies (MSA) most closely associated with imm...
Do you pursue a skin biopsy or kidney biopsy in patients whom you suspect have X-linked Alport syndrome?
The approach to the diagnosis of Alport syndrome has changed over the past decade with heavier reliance on molecular genetic testing sometimes prior to or in lieu of tissue diagnosis, however, this is dependent upon many factors including insurance coverage and availability of electron microscopy. G...
In a patient with neurosarcoidosis who required infliximab for initially refractory symptoms but is now stable, how do you decide on the optimal time to de-escalate therapy?
I typically base this decision on several factors: Severity of initial symptoms, tolerability or side effects of treatment, degree/timeline of radiographic improvement, and patient preferences. I begin to consider tapering off or de-escalating infliximab after around 12-24 months of clinical and rad...
When do you check macroprolactin in the evaluation of hyperprolactinemia?
I always check it for prolactin levels that are abnormal, but below 100 ng/mL. Macroprolactinemia is rather common in mild/moderate hyperprolactinemia, but it is very rare as sole cause of hyperprolactinemia when level is higher than 100 ng/mL. Importantly, even real hyperprolactinemia may appear mo...
Would you start anticoagulation in a patient with a history of CVA 1 year ago and high risk APL profile who was never started on anticoagulation, but is now presenting for follow up and without recurrent thrombotic events?
This is a difficult question. The details here are important. Therapeutically, you can go either way in my opinion. Were the positive antiphospholipid antibodies checked again later? Did the patient have an infection when the APS labs were first done? Does the patient have diabetes or other CV risk ...
How do you manage long-term xerosis and xerophthalmia in patients who have completed a course of isotretinoin?
Xeropthalmia can be a real problem. In a study in rabbits, we showed that isotretinoin in doses up to 1mg/kg has effects on meibobian glands similar to those on that occur in sebaceous glands. Meibum is responsible for preventing the tear film from evaporating. The third patient I ever treated devel...
What is your approach to a patient with IgG4RD with past pulmonary involvement (biopsy proven) managed with steroids alone, now with new hematuria/proteinuria, but stable renal function?
Significant hematuria is not a typical feature of IgG4-related kidney disease. IgG4-RKD most commonly presents as tubulointerstitial nephritis (TIN), which presents as mild, non-nephrotic range proteinuria. In fact, urinalysis in the context of TIN is often normal, as the proteinuria is largely non-...
What additional testing besides LAC/APLS, factor V Leiden, prothrombin gene mutation, JAK 2 do you draw for unprovoked cerebral venous sinus thrombosis?
Cerebral venous sinus thromboses (CVST) are often put into the category of "thromboses of unusual sites,"--as opposed to the more common lower extremity thromboses or pulmonary emboli.Provoked causes of CVST include pregnancy or exogenous estrogen use, infection of the head/neck or CNS, head trauma,...
How do you manage nausea in the setting of hydroxychloroquine use?
My method for approaching hydroxychloroquine (HCQ)-induced nausea: Stop HCQ When nausea is gone, restart with just 1/2 tablet every night after food or milk(I recall a study suggesting that nocturnal use caused less side effects, but I cannot find it. If anyone has the source, please chime in). A we...