Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you specifically counsel patients on conservative measures such as hand warming in the treatment of SSc associated digital ulceration?
While Raynaud’s is nearly universal in Systemic sclerosis, digital ulcerations occur in approximately 30% of these patients yearly and tend to recur, with 2/3rd developing another one despite the use of vasodilators. Irreversible tissue loss, osteomyelitis, gangrene, and amputation are unfortunate c...
What screening recommendations do you provide for patients with a Nevus of Ota with ocular involvement?
Patients with Nevus of Ota are at increased risk of glaucoma. I have patients get a yearly ophthalmology exam.
How do you treat significant keloidal acne scarring on the back of a teenager?
Firstly, their acne needs to be controlled and stable prior to treating the scars themselves unless any of the keloids are particularly symptomatic. My decision-making is shared with the patient and based on many different factors including skin type, pain tolerance, insurance coverage/budget, scar ...
What is your ferritin threshold to prescribe iron to female adolescent athletes who have symptomatic iron deficiency without anemia?
Since ferritin should be truly reflective of iron levels as we should not expect elevated hepcidin levels in a young athlete. There, I would use 30 ng/mL which has a 98% specificity and 92% sensitivity for absent marrow hemosiderin. Also, since there is expected ongoing iron loss (0.6 mg/L of sweat ...
How do you approach treating nail lichen planus?
I would first start be determining the extent of cutaneous and mucosal involvement, as that often is more troublesome to the patient than the nails and may impact choice of treatment. Often, any systemic therapy directed at cutaneous/mucosal LP will also probably improve nail LP. Topical steroids to...
In a patient with APS and obesity during pregnancy when switched to LMWH, do you cap the dose of dalteparin as per manufacturers labeling at 18,000U per day or do you use weight based dosing?
Hi @Dr. First Last, We use enoxaparin in our institution, but the general principle that we follow is that we do not cap LMWH dose at a set threshold. I am assuming that you're referring to thromboprophylaxis and not the management of a VTE in the past 6 months. We monitor anti-Xa levels in obese p...
When do you recommend checking blink reflex in patients with Bell's Palsy?
I have personally found that blink reflex testing is not as important as emphasized in the literature for the cases of facial palsy that are referred to our Lab. This is because most facial nerve EMGs that we see, are severe cases with profound axonal injury that show poor recovery after 3-4 weeks. ...
How do you approach a patient with discordant breast cancer risk prediction scores for prevention?
It's not uncommon to come across discordant lifetime breast cancer risk estimates between routinely used risk assessment models such as Gail, TC V8.0, Claus, and CanRisk. These models differ widely in the risk elements, ability to incorporate results from germline panel testing/PRS, and their streng...
What is a reasonable atrial fibrillation percentage burden that would benefit from systemic anticoagulation for a patient with an elevated CHA₂DS₂-VASc score?
Patients with implanted devices can have an accurate measure of their AF load which has raised the question of whether ANY AF should be anticoagulated. Healey et al., PMID 22236222 is often erroneously quoted as saying that 6 minutes is all that is needed. That was their cutoff for inclusion as subc...
What is your approach to treatment of skin-limited cryoglobulinemic vasculitis in patients with Sjogren's syndrome who lack evidence of neurological or renal involvement?
I have given this patient Rituximab prior with success.