Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What interventions have you found most effective for reducing ED utilization in patients with PNES?
I have a frank discussion regarding the difference between epilepsy and PNES and the differing modes of treatment. I also refer them to our behavioral health department for cognitive behavioral therapy. That seems to decrease their ER visits.
In terms of contraception, what do you recommend for patients with a history of hormone receptor-negative compared to hormone receptor-positive breast cancer?
Avoid oral contraceptives. Prefer barrier contraception and IUD.
How long after starting an antiepileptic drug do you check levels?
Based on the half-life of AED and sometimes case-to-case based. General guidelines is 2-4 weeks of starting the AED.
Provided no side effects, to what dose do you increase propranolol or primidone before considering them ineffective for a patient with essential tremor?
If tolerated maximum dose of 250 mg of Primidone bid would be acceptable. This is my personal experience.
How do you approach handling the many-page disability paperwork of neurological disease such as Parkinson's disease?
It can be daunting when one is handed a long form to fill out for disability in advanced PD patients. Admittedly, it is not my favorite thing to do but it will make all the difference in the life of the patient, so it is extremely important to handle it carefully. In the past, I used to have them re...
In a patient who completed 5 years of oral bisphosphonate and has a T score persistently in osteoporotic range, what factors help you decide whether it is appropriate to start a drug holiday vs. switch to an alternative agent?
This is an interesting question concerning a common clinical issue. Unfortunately, I am unaware of any data (evidence-based medicine) that is helpful in answering the question. My response is thus only anecdotal. There is some good data that patients with an inadequate bone density response to three...
How long do you expect gastrointestinal side effects of leflunomide to persist after stopping treatment?
Leflunomide (LEF) has a long half-lasting of about 15 days. So, when dealing with advise events such as gastrointestinal toxicity, these may persist up to several weeks following discontinuation of the drug. Simply discontinuing LEF will prove to be effective in the majority of patients with adverse...
How long would you consider the use of low-dose aspirin in a patient with SLE and high risk aPL profile (without a clinical event)?
I recommend low-dose aspirin (ASA) plus hydroxychloroquine (HCQ) to ALL my systemic lupus (SLE) patients unless they have risk factors for bleeding.I do this based upon the 2017 Italian study by Fasano et al. I explain to my patients that there are uncertainties to this recommendation and that furth...
What is your treatment algorithm for patients with lichen planus?
There are many potential approaches depending on the severity, subtype, comorbidities, and impact on QOL. For "classic" LP (no symptomatic or significant oral involvement)" Typically itch is the primary complaint although the appearance can be understandably upsetting to some patients. Depending on ...
What is your treatment approach to patients with confluent actinic keratoses on lower extremities?
I find these patients can be very challenging to treat. It is difficult to completely clear the AKs and even if there is success initially, these patients will often develop new adjacent lesions or recurrent lesions within a short time. Nonetheless, we have used various approaches to treating these ...