Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach initiating belimumab in a patient with serologic evidence of prior hepatitis B infection?
The patient in question is a patient who has serologic evidence of resolved hepatitis B infection. Of note, testing for hepatitis B is not a formal recommendation before starting belimumab. However, it is also important to point out that testing positive for hepatitis B was an exclusion criterion in...
Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?
I do not think there is a "right" answer to this question. First, I would want more evidence of distal renal tubular acidosis than urine chemistries. Specifically, I would do a urinary acidification test. If positive for distal RTA, and there is no other suggestion in the history or physical examina...
What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?
PFTs are often obtained in patients with systemic sclerosis to evaluate for interstitial lung disease. Low DLCO on PFTs can signify an increased probability of PH, but it is by no means specific. Echocardiograms are readily available, offer additional information about possible causes of PH (e.g. LV...
Do you counsel your patients on the potential decreased effectiveness of oral contraceptives while on Sarilumab?
As someone who focuses on reproductive health, I personally don't counsel on this. From professional drugs interaction resource: "Plasma concentrations of drugs that are CYP450 substrates may decrease following the initiation of interleukin (IL) inhibitors, tumor necrosis factor (TNF) blockers, or i...
What are magic mouthwash alternatives that you would recommend?
Many of our patients will make their own DIY MMW per Phil's My Pharmacist (YouTube) instructions -- uses benzocaine/Cepacol lozenges -- they say it's much more effective than the compounded one from the pharmacy. It is also more economical.If the majority of bothersome mucositis is in the oral cavit...
Do you pursue any additional testing in your patients with chronic kidney disease who are found to have "small hypodensities too small to characterize" on renal ultrasound?
Renal cell carcinoma in dialysis patients and to a lesser degree in patient with CKD is not uncommon. As such, I would like to re-image these patients after 6 months or so. Usually, these cancers grow slowly and don't cause major disease but it is variable.
What is your approach to a toddler-aged patient with speech apraxia without other autistic features?
Evaluate for a hearing issue, broader developmental concerns, and dysarthria/bulbar symptoms. The diagnosis and management of childhood speech apraxia can be made by pediatric SLP.
Is there a role for Vitamin D supplementation in the treatment of Hashimoto’s thyroiditis?
Although there is some evidence that vitamin D may play a role in immune function, there is no credible evidence that vitamin D has a role in the management of autoimmune thyroid disease including Hashimoto's and Graves's disease.
Do you periodically check a urine culture for patients without dysuria but who have a history of struvite kidney stones and urinary tract infections with urease producing organisms?
Struvite nephrolithiasis is caused by a high urine pH (usually>7.0). Typically, a urine this alkaline requires urinary infection with a bacterium that produces urease, (Proteus, Providencia, Klebsiella) which in turn splits naturally occurring urea into ammonium, driving the pH to supraphysiologic l...
What biologics have you found to be most effective in treating hidradenitis suppurativa?
I'll answer the easy part of the question first. For insurance coverage, the HS Foundation website has wonderful prior auth letter templates for biologics, laser therapy, and other treatments. I have had a lot of successes in getting off-label biologics covered with them. It doesn't always work, but...