Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are your recommendations for management of patients with familial polycythemia due to EPOR mutation during pregnancy?
This is not a question that has a definitive answer since I know of no reports dealing directly with this uncommon situation and I have never treated such a patient. I have, however, successfully treated many pregnant vera patients, who have a constitutively-active erythropoietin receptor (EPOR) due...
Do you escalate treatment for reactive lymphadenopathy in an otherwise stable and asymptomatic patient with lupus?
With today's medical evidence, I do not treat my patients' lymphadenopathy (LAD) alone. However, lupus-reactive LAD tends to occur with active disease. I am a big believer in the treatment goal of "remission (without steroids); if remission is unachievable, then low disease activity using the safest...
Do you recommend routine genetic screening (i.e., periodic fever panel) in a pediatric patient where you strongly suspect a periodic fever syndrome?
Genetic testing for periodic fever syndromes is potentially very informative and rather inexpensive. My approach is to generally obtain genetic testing in patients with suspected periodic fever syndromes as part of their initial laboratory evaluation with the exception of typical cases of PFAPA (Per...
How do you taper off Clonazepam in women with epilepsy who are family planning?
Is she only on clonazepam and how much dose? Is she on additional AEDs and how many? Has she failed other AED and what are the other options I can add simultaneously while tapering off clonazepam? What type of epilepsy patient has? These are some of the considerations to keep in mind before switchi...
How do you manage patients with recurrent periorificial dermatitis?
I typically use oral doxycycline, whenever possible, and often the low subantimicrobial doses work as well as higher doses and are much more tolerable for patients. If they can't take antibiotics or prefer to avoid oral ones, I will use some combination of topical metronidazole, clindamycin, and top...
At what heart dose would you prospectively refer a patient to cardiology due to anticipated long term risks?
If a patient had prior BCT and now inflammatory, I would refer given the most likely plan for additional chemotherapy and RT. In general, I refer for cardiac oncology based on a combination of cardiac risk factors (HTN, DM, HLP), family cardiac history, anthracycline receipt, and cardiac dose (ex. I...
How do you approach urate-lowering therapy in patients with advanced chronic kidney disease?
I lower uric acid independent of GFR. There is little evidence to support limiting uric acid-lowering therapy. This misinformation came out due to combining fears that the incidence of allopurinol reactions would increase in patients with renal insufficiency. Allergic reactions are related to exposu...
How do you approach the use of bisphosphonates in reproductive-aged women?
This is an extremely difficult situation. I think it would be better to change this question to a discussion of a woman of childbearing potential since a woman of reproductive age with osteoporosis could have hormone failure and therefore is not of childbearing potential per se. A woman with celiac ...
What workup do you recommend for patients with low back pain and imaging concerning for spina bifida occulta?
In cases of suspected spina bifida occulta, imaging of the entire spine and Neurosurgery referral are usually recommended. MRI is generally considered the imaging modality of choice, which can also detect other coexisting abnormalities such as tethered cord, while CT can be helpful in better imaging...
What is your approach to treating tophaceous gout in patients whose uric acid is below 5 prior to initiating uric acid lowering therapy?
The finding of tophi is associated with elevated total body uric acid. If this is a true serum uric acid, it is conceivable the patient is a high urine excretor to explain the low serum uric acid. Checking uric acid excretion could elucidate this. Alternatively, low serum uric acid level could be a ...