Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you routinely prophylactically anticoagulate patients undergoing systemic chemotherapy outside of the perioperative period?
No, I don’t routinely advise prophylactic anticoagulation for outpatients with gynecologic malignancies while on systemic chemotherapy who have not recently undergone surgery. However, such treatment may be considered for gynecologic cancer patients who are at high risk for venous thromboembolic dis...
How do you manage patients blood pressures while on anti-angiogenic TKIs?
Advise patients to take BP daily, and inform us if the BP is high.
Do you recommend starting SGLT2 inhibitors for patients with a normal creatinine but who have microalbuminuria and are unable to tolerate ACEi or ARBs?
In a patient who cannot tolerate RAAS inhibition with standard-of-care ARB or ACE-I, I still would still consider starting SGL2 in a patient with microalbuminuria. In a diabetic patient, an SGL2 inhibitor would definitely be indicated, perhaps with an MRA. The mechanism of benefit in SGL2 is debatab...
How would you treat inflammatory arthritis in a patient with Sjogren's syndrome and ILD (on mycophenolate) that is not responsive to hydroxychloroquine?
Fortunately, the Sjögren's Foundation has worked hard in providing us with evidence-based guidelines to answer these sorts of questions. I would go by the "Treatment Guidelines for Rheumatologic Manifestations of Sjögren's." The working group using the Delphi consensus process did all the hard work ...
How would you approach the work up of SLE in a patient over 80 years old?
Elderly onset lupus is uncommon and in the past twenty-five years has been reported to occur in as few as 6% of patients to as many as 19% of patients with the diagnosis of lupus. Typical clinical presentations tend to include arthritis/arthralgias, fever, weight loss, lymphadenopathy, serositis, si...
What is your treatment approach to persistent chillblains lesions in the absence of systemic lupus?
In idiopathic chillblains/perniosis, I think treatment centered on lifestyle modifications is key. As this is a cold-associated dermatosis, counseling patients to wear warm gloves or socks and avoiding cold exposure is important. Beyond lifestyle modifications, I typically start with a high-potency ...
How do you approach screening for additional malignancies in patients with a history of CTCL?
There is no need to do anything out of ordinary. Usual age-appropriate cancer screening and skin cancer screening (many of these patients received light and radiation therapy) is sufficient. The rest should be guided by presenting symptoms. For smokers and other people with specific risk factors, th...
What is your approach to considering geriatric patients for complex PCI given their overall frailty and increased risk of complications such as bleeding and stroke?
I would do everything I could with respect to medical and lifestyle therapy for such a patient. They are at very high risk for a bad outcome in the cath lab.
How do you manage an elderly, high risk prostate cancer patient who refuses any local therapy?
In general, for patients who refuse treatment, I try to understand their goals and their fears. Often, elderly patients state that they are ready to die, and don't want to prolong their lives. If I think that treatment is likely to significantly improve the quality of their lives, I will explain why...
When would you consider initiating GDMT for new onset HF in the geriatric population?
I would always treat with GDMT but would start low and slowly advance watching for AE's.