Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach the management of a patient with a new diagnosis of cardiomyopathy in pregnancy without clinical signs of heart failure?
This is a great question. I think the timing of the cardiomyopathy and if it was incidental (although not sure why you would check an echo if there were no symptoms).Peripartum CM is a difficult entity to manage. In some cases, the optimization of patients with GDMT is limited due to post-partum bre...
What lab monitoring do you perform for patients taking isotretinoin?
I am a lab minimalist. I do ALT(past months have eliminated the AST) and fasting TGs at the start. Then at month 2 or max dose 1 mg/kg, I check ALT and fasting TGs. If there are any elevations at baseline, will check at month one which is usually 0.5mg/kg for me, and then month 2 (at the max dose) a...
What therapies have you found most effective for treating lower extremity DSAP?
I have had patients improve significantly with niacinamide 500mg po bid, and/or topical cholesterol/lovastatin. I have not had significant response to PDT.
What is your approach to leflunomide and statin use in RA patients?
Caution is advised if leflunomide or teriflunomide must be used in patients who are currently receiving or have recently received treatment with other hepatotoxic agents, such as statins. Liver enzymes (ALT, AST, and bilirubin) should be measured prior to initiation of leflunomide/teriflunomide ther...
What recommendations do you make for patients with lower abdomen eczema from nickel in their belt buckle?
This is a common clinical scenario in the United States as there are no legal limits on the use of nickel in objects in contact with the skin. Belt buckle dermatitis on the lower abdomen is almost pathognomonic for nickel allergic contact dermatitis (ACD). There are several consumer test kits to det...
How do you counsel patients regarding contraception use while taking mycophenolate/mycophenolic acid?
There are some data that mycophenolate mofetil may decrease the effectiveness of oral contraceptives. In patients who are taking MMF and taking oral contraceptives as their form of contraception, an additional form of contraception is preferred. However, this is not an absolute recommendation. Mycop...
In a patient who fractures after several years of denosumab therapy, would you wait 6 months after the last denosumab injection to start an anabolic agent or could start an anabolic agent sooner?
In a patient on any antiresorptive drug who fractures, we should consider an anabolic drug. A fracture does not always mean the drug has failed but we should consider changing to an anabolic since we have good evidence that anabolics have superior fracture risk reduction. Denosumab is of course mor...
What is your approach to screening for complete heart block in an asymptomatic pregnant patient with negative SSA and positive SSB antibodies?
There are case reports of congenital heart block (CHB) due to anti-RNP antibody in anti-SSA/SSB-negative pregnant women (Izmirly et al., PMID 28709760). However, it is so rare that too many fetal heart monitoring tests would need to be done to identify these rare events. The amount of time and money...
Do you use anticoagulation in cancer patients who develop an unprovoked superficial vein thrombosis?
It depends on the extent of the thrombus and clinical circumstances. Superficial vein thrombosis is triggered by the presence of malignancy. For distal minimal symptomatic thrombosis, I would consider time limited anticoagulation. For more proximal and symptomatic thrombosis, I would consider more e...
Do you change your monitoring strategy for a high risk prostate cancer after XRT if the initial PSAs have never been very high?
In general, a patient whose volume of cancer is out of proportion to their PSA makes me nervous. So, I'm much more worried about the patient with a PSA of 5 and multiple cores positive for high volumes of Grade Group 4-5 cancer than I am about the patient with a PSA of 5 and a single positive core s...