Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach Covid vaccine counseling in patients with rheumatic disease and history of pericarditis/serositis?
This response would be more specific to those with idiopathic pericarditis. I encourage it as long as there is no temporal relationship between any prior pericarditis and covid-19 vaccine the pt experienced. For example, another abstract presented at AHA.2022 was incidence of complications in rilona...
Do you commonly recommend oral minoxidil, dutasteride, or a combination of both for patients with androgenic alopecia?
Neither of these medications are approved for AGA, and treatment considerations are different in men vs. women. Oral minoxidil at low doses is very safe and generally well tolerated, and a great option for patients with irritation from topical use. It avoids potential side effects of finasteride, wh...
How do you treat episodes of profuse sweating in Parkinson’s patients?
By far most common situation is OFF-related hyperhidrosis, such as overnight OFF, and so this needs to be explored with patients paying close attention to when these things tend to happen and whether they correlate with motor worsening; trials of dopaminergic dose alterations could be considered and...
What is your preferred medical treatment of carpal tunnel syndrome that recurs after carpal tunnel release?
I am supposing that patient has initial recovery and symptoms are happening at least after a year. A good history to know is it really CTS or tenosynovitis. A repeat EMG/NCV test and compare from pre-release surgery to see how much improvement happened. If numbers are close to normal and surgery don...
How do you use colchicine for gout in patients with chronic kidney disease or end-stage renal disease on hemodialysis?
As a last resort agent and with a lot of caution. For prophylaxis, half a 0.6 mg pill two times a week, carefully monitoring CBC and CK levels. If medication interactions are of concern, then do not use. For flares, a much better alternative would be glucocorticoids or even anakinra. NSAIDs could be...
How do you choose between azithromycin and roflumilast in the management of a patient with severe COPD who remains symptomatic with frequent exacerbations despite maximal dose LABA/LAMA/ICS with demonstrated compliance and proper inhaler technique?
Zithromax 250 mg on Monday, Wednesday, and Friday. I would consider roflumilast only in patients who are phenotypically and physiologically chronic bronchitis patients.
How do you explain fleeting, post-RT breast pain to patients, and what do you recommend as management?
It is common, underreported, and appears to be nerve related. I recommend assurance as intensity and frequency improve with time.
How would you evaluate and treat an older teenage patient with severe perioral dermatitis with histology demonstrating a granulomatous dermatitis and all stains have come back negative?
Minocycline (rarely use but for this, I would) with weekly ivermectin and Elidel. I have done a prednisone taper as well to calm it down. Isotretinoin or dapsone...
What are your recommendations regarding sexual activity for a couple when one of them is diagnosed with a HPV-positive oropharyngeal cancer?
We always counsel patients regarding the etiology of HPV if they have a p16+ tumor. We tell them that this is an infection most likely acquired through sexual activity and that the latency period is approximately 20 years from the time of exposure until the time of a cancer diagnosis. We note that o...
Do you recheck screening labs (ESR, BUN/Cr, urinalysis, ANA, etc) for patients with recurrent small vessel vasculitis of unknown origin with each flare?
If the recurrences occur 6 or more months apart, I would recheck the studies to exclude SLE. If the episodes are chronic, I would recheck at least once a year for the same reason or whenever there are new suggestive symptoms of LE.