Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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.
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.
What dosing range of doxycycline do you recommend for short-term and long-term management of ocular rosacea?
Short term, Doxycycline may be used at 100mg BID for 2-4 weeks, especially in severe cases. It can then be tapered to 100mg QD once a partial clinical response is documented, but where residual disease and symptoms still exist, or to 50mg QD if there is a complete clinical response. Longterm, doses...
How do you approach hormone replacement therapy for premenopausal patients following pelvic radiation therapy?
Most patients who undergo pelvic radiation will become menopausal. Physiologically, the outcome is similar to surgical menopause because sufficient doses of radiation result in complete loss of ovarian function. In contrast, after natural menopause, the ovaries continue some types of endocrine funct...
What is your approach to the use of NSAIDs in patients with a history of gastric sleeve/bypass?
The use of nonsteroidal anti-inflammatory drugs in someone with a history of gastric bypass and/or sleeve surgery is risk prohibitive. Not only is there a risk of gastrointestinal bleeding, but more importantly, there can be effects on the previous surgical, anastomosis, and other untoward effects. ...
How do you approach recurrent costochondritis in an SLE patient with nephritis who is otherwise controlled on MMF and HCQ but can't take NSAIDs?
I do the following: I reassure them it is not cardiac or pulmonary. If I'm not 100% sure, then I send to cardiology (especially in my high-risk patients) because patients can occasionally chest wall tenderness for non-musculoskeletal chest pain. Ask them to work on proper posture (I'm convinced tha...