Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you offer iron supplementation to a patient with iron studies that are normal (including normal ferritin) except for low iron saturation?
The answer is absolutely and positively yes. A low percent saturation of transferrin has an extremely high concordance with absent marrow hemosiderin and frankly, in today’s parlance is the best indicator of “iron need”. While the ferritin is marvelous at confirming iron deficiency if low (with or w...
How do you approach treating acute and chronic Demodex folliculitis?
Demodex folliculitis is often a diagnosis of exclusion and is considered when treating refractory rosacea, bacterial or fungal folliculitis. The organism can be found on normal skin and is seen on KOH prep of a skin scraping. Combination treatments with oral and topical medications have been found t...
Do you routinely perform mammograms for women that underwent nipple-sparing mastectomy with reconstruction after a breast cancer diagnosis?
We don’t perform mammograms routinely for this subset unless clinically indicated.
How do you manage patients with rapidly progressing vitiligo?
I treat rapidly progressing vitiligo very similarly to rapidly progressing alopecia areata. Sort of like a medical emergency. Literature review suggests one should suspect rapid progression when the patient is developing new spots every month. This is especially distressing in patients of ethnic b...
How do you follow patients with Bronchus Associated Lymphoid Tissue Lymphoma treated with 2 Gy x 2 fractions?
For patients with localized MALT lymphoma of the lung, in a distribution amenable to definitive RT, I would typically treat with 24 Gy in 2 Gy fractions. The risk of in-field progression with this dose is expected to be very low. Given the rarity of the presentation, I have only treated a handful of...
How do you approach management of a patient with Sjogren's disease and lung mass biopsy revealing amyloidosis?
A lung mass showing amyloid in SjD may reflect systemic amyloid or local/focal amyloid. Interdisciplinary assessment is recommended (Fraenkel et al., PMID 34101376). Organ systems involved will guide the expertise needed.Immunohistochemistry and molecular studies are needed to define if there is an ...
How do you decide on an outpatient maintenance diuretic regimen for patients approaching discharge for ADHF?
Good question. More from my personal observational experience. I reduce the dose to minimal once the patient is well compensated clinically and other pillars are tolerated well. If the SGLT2i, ARNI, and beta blockers are already on board and the patient coming off the IV lasix, I will add low-dose M...
How would you approach the work up of a patient with nasal septal perforation, a negative infectious workup, and negative ANCA titers?
This clinical scenario can be difficult for the rheumatologist to evaluate, and close collaboration with colleagues in ENT would be essential. Causes of nasal septal perforation include trauma, infectious etiology, and autoimmune conditions such as granulomatosis with polyangiitis or microscopic pol...
Is whole body PET scan sufficient to rule out cardiac involvement in sarcoidosis?
Whole-body PET scans, particularly using 18F-fluorodeoxyglucose (FDG), play a significant role in evaluating sarcoidosis, including cardiac involvement. Recent studies have investigated the effectiveness of whole-body PET scans in diagnosing isolated cardiac sarcoidosis and assessing both cardiac an...
What treatments would you recommend for rosacea patients with persistent, soft/non-fibrotic cysts on the dorsal nose recalcitrant to chronic doxycycline and topical therapies?
Can consider a trial of a different oral antibiotic (such as a macrolide), or intralesional triamcinolone if lesions are discrete. However, I would likely proceed with a course of oral isotretinoin if there are no contraindications, given the recalcitrant nature of the disease. Doses usually range b...