Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What dietary advice do you provide your patients with calcium oxalate nephrolithiasis?
High water intake (at least 2.5L of urine volume per day) Low sodium and low animal protein intake (high dietary sodium and high animal protein correlate with higher urine calcium) Normal dietary calcium balance around 1000mg per day (maintain bone health and ensure adequate dietary calcium to bin...
How do you advise patients with sickle cell disease on contraception?
According to both the "ASH Pocket Guidelines" and the National Heart Lung and Blood Guidelines for health maintenance in Women with sickle cell disease, progestin only and barrier methods of contraception are the preferred recommendations for contraception. Combined hormonal agents can be considered...
Would you consider thrombophilia testing in a pregnant patient with VTE?
I would not check antiphospholipid antibodies in a pregnant woman with thrombosis unless she had a history of autoimmune disease or other concerning findings. However, if it were checked, I would make sure that it is a true positive. DOACs often cause a false positive LAC. I have had patients with f...
How do you manage polymorphous eruption of pregnancy (formerly PUPPP)?
A fellow resident assured me that the only thing that gave her some relief was otc itch-x.
Do you repeat images in patients with venous thrombosis to inform decision about duration of anticoagulation?
The short answer is "no". I do reimage many people near the end of the 3-6 months of treatment, but it doesn't really change my mind about duration of treatment in most instances. I use repeat imaging to help me understand how much of the clot resolved and thus, determine what their new baseline is....
For a patient who would benefit from an anabolic agent for osteoporosis, do you prefer romosuzumab over teriparatide in the absence of contraindications to either agent?
Both teriparatide and romozosumab are excellent drugs to treat osteoporosis with documented risk reduction in fractures. TPTD reduces spine fracture about 85% and romozosumab about 75%. Both are excellent. They have very different biologies with TPTD being a remodeling-based anabolic and romozosumab...
What is your approach to patients with PMR on steroids over a prolonged initial course who start to experience weakness concerning for steroid myopathy?
One of two approaches, similar to the case in inflammatory myopathy: either increase steroid dose (pain/weakness increase argues for steroid myopathy; decrease means there is need for higher dose/longer taper) or decrease steroid dose (increase in symptoms means there is need for more/longer steroid...
How would you approach a young patient with a history of APLS and VTE, desiring hormone replacement therapy after oophorectomy?
I think the answer is not straightforward. What APLAs are positive and what was/is the titer? Were there other risk factors at the time of the clot (smoking, oral contraceptives, etc...) My general recommendation would be to avoid estrogens in patients with APLAs. I can imagine a scenario where the ...
Is there any role in continuing apixaban in a patient with occlusion of the right internal jugular vein with chronic postthrombotic change to prevent a recurrent DVT?
Yes
Do you hold anticoagulation prior to prostate brachytherapy?
Yes, but always per the patient's cardiologist's recommendation. Also not even after the designated time for withholding meds may still be anti coaged so we get pt/ptt morning of the procedure.