Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you pursue MR imaging in patients who present for migraine evaluation?
Age Criteria: Extreme of ages is an indication for Neuroimaging. Especially if it's a new patient. (Ages 6 and under and 50 and above.) Onset Criteria: Any new-onset headache (even full-filling migraine criteria) with onset < 6 months and change in headache pattern (both symptoms or severity) < 6 mo...
Do you maintain an age cutoff for the use of triptans in healthy older patients without cardiovascular risk factors?
I do not have an age cutoff for the use of triptans in older patients. I do not perform routine screening for coronary artery disease in aging patients already on triptan therapy. I do recommend 5HT1f agonist or CGRP antagonist over triptans if they have documented CAD, peripheral vascular disease o...
When do you consider vascular imaging in patients with Raynaud's and what type of imaging modalities do you utilize?
I typically do not do any vascular imaging studies on patients with Raynaud phenomenon if they have typical symptoms. I do perform nailfold capillaroscopy in patients with new-onset Raynaud to help determine the presence of or risk for future development of connective tissue disease. Studies suggest...
Despite the lack of evidence, do you utilize glucosamine and chondroitin sulfate for osteoarthritis?
There have been numerous placebo-controlled trials and meta-analyses addressing this question over the last couple of decades, most concluding that neither glucosamine, chondroitin sulfate nor the combination provides better symptom relief than placebo (Fransen et al., PMID 24395557, Miller and Cleg...
How frequently do you check AED levels in patients with stable epilepsy?
Once a year except in adults except for women in childbearing age every six months. In patients with liver /kidney disease, more frequently. In children, it's different the younger the kid the higher the frequency.
What is your preferred OCP protocol when the aim is reduction of sebum production in teenage female acne?
I tend to choose Ortho-Cyclen (Sprintec) or Yaz or newer OCP slynd which is dros only. I have had excellent results as monotherapy (plus a topical retinoid) or in combo with oral Aldactone. OCP with WINLEVI for those who do not want Aldactone has also been successful for me.
What is the earliest time to check PSA after prostatectomy?
The half-life of PSA in the circulation is about 3 days, so there is no point checking PSA within the first 15 days (5 half-lives) as any detectable PSA at that point may just represent residual PSA that has yet to be cleared. Most surgeons I have worked with generally wait 4-6 weeks, which should b...
What have you found effective for the chronic fatigue that is often seen in patients with SLE or Sjogren's despite overall good disease control?
I am not surprised this question has not been answered yet. This is a tough and common clinical scenario, huh?However, there is a lot we can do for patients. And we can help many of these patients.1. The 1st question out of my mouth to the patient is:"How many hours of sleep do you get per night? Is...
What is your first line treatment for a patient with epilepsy who is homeless and has a history of poor adherence?
It is likely an indication of my being old school, but if a homeless person needs medication they can’t afford and will take only intermittently, I would suggest phenobarbital. In spite of cognitive and other issues, in this situation, it is inexpensive, has a very long half-life, so withdrawal and ...
What is your approach to treatment of benign fasciculation syndrome?
Most of my patients end up being reassured that it is not a worrisome disease and opt for OTC treatments or no treatment. If there are any signs of hyperirritability on EMG/NCS I send CASPR2 antibodies and a free neuromuscular disorders panel, but assuming those are negative treatment is supportive....