Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is an EMG/NCS required to clinically diagnose Guillain barre syndrome?
GBS remains a primarily clinical diagnosis, characterized by rapidly progressive large fiber sensorimotor deficits with early arreflexia, supported by albuminocytologic dissociation in cerebrospinal fluid. EMG/NCS can be normal or non-specific in up to half of the patients in the first week and only...
How frequently do you monitor EKGs for patients newly initiated on lacosimide?
In patients who are over the age of 50, smokers, or others with a higher risk of heart disease, I get an EKG at baseline and then at a maintenance dose. During treatment, if the patient reports any new potential cardiac symptoms like palpitations, PVCs, SOB, etc, I will get another EKG.
How would you treat pemphigus foliaceous in an elderly patient intolerant to oral steroids?
It depends on the extent of the disease and the severity of symptoms. Home wet wraps, when they can be done, can be essentially as effective as oral steroids in many situations, but can be time intensive. I provide the patient with instructions and a pound jar of triamcinolone ointment. Be careful s...
What maintenance therapies do you most commonly recommend for patients with improving genital lichen sclerosis?
Betamethasone dipropionate with clotrimazole cream is my treatment of choice to provide a sufficiently potent corticosteroid while mitigating the risk of secondary Candida infections. Adjust the frequency of application from daily to once weekly to every other week for severe symptoms vs maintenance...
What is your approach to managing asymptomatic ORN of the mandible?
Do nothing until you have to.
In a patient with sickle cell disease on hydroxyurea who is planning to have a family, for how long should they be off the drug before trying to conceive?
There is some consensus that pregnant women should not take hydroxyurea and should stop taking this when found to be pregnant. (Smith-Whitley, PMID 25472967) As far as I know, there is no data on how long hydroxyurea should be discontinued in either men or women before attempting pregnancy. In fact,...
Is there a role for vascular intervention in patients with renal artery stenosis found during work up of resistant hypertension?
The ASTRAL, STAR, and CORAL trials all attempt to this question in different patient populations. A portion of CORAL participants met the diagnostic criteria for resistant hypertension. What I have taken away from the data is that renal artery intervention can be helpful in fibromuscular dysplasia i...
What is the next best anti-hypertensive medication to start after mineralocorticoid receptor antagonists in patients with primary aldosteronism?
I have had a good experience with calcium channel blockers and combined alpha/beta-blockers such as carvedilol in patients with PA. They are my first and second choices after MRA. If tolerated, pushing the MRA dose to get a PRA> 1 ng/ml/hr is important. I check for proteinuria, and if present, I add...
How do you counsel HIV patients with an undetectable viral load on breastfeeding?
People who are virally suppressed on ART are at very low risk of transmission to infants through breastfeeding, less than 1%-- however, the rate is not 0, and any infant with HIV is heartbreaking. The risks are particularly high in infants who are transitioning to solid foods (potentially related to...
Do you take any special approaches with patients with recurrent nephrolithiasis who first developed stones prior to adulthood but have negative kidney stone disorder genetic test findings?
No. My pediatric kidney stone consultants tell me kidney stones in childhood are relatively common. If genetic testing is negative (or even if it is positive), I treat them starting with general dietary modification, tailored to their urinary supersaturation data and stone composition, if known. Ste...