Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
If a patient develops intermittent painless hematuria during standard prostate RT do you attribute this to cystitis or would you work it up further?
While acute mucosal deepithelialization may be to blame, painless hematuria may unfortunately mark the beginning of a conundrum. It's good medicine to always develop a broad DDx and remember that radiation injuries are waste basket diagnoses. It's also wise to start with a UA/UCx, and if negative do...
How would you approach a biopsy proven NSCLC patient with mediastinum negative disease and contralateral suspicious spiculated PET avid nodule without pathologic diagnosis?
This is a scenario I have faced before. Sometimes unfortunately in spite of staging studies, the stage a lung cancer patient has might remain a bit unclear. In this situation if this is a functioning patient with good PFTs who is a surgical candidate I would consider treating him like he has 2 separ...
Is there anything you use for patients with anticipatory nausea who has failed Ativan and Zyprexa?
I know of no data, but I would consider hypnosis, mediation and mindfulness, cognitive behavioral therapy, acupuncture, and medical marijuana as possible options for anticipatory nausea refractory to lorezapam and Zyprexa. Hypnosis, mindfulness, and cognitive behavioral therapy are in a sense are re...
What is your preferred treatment to ameliorate bone pain from G-CSF?
Loratadine (or cetirizine) used prophylactically before each dose is very effective. There are published cases : https://www.ncbi.nlm.nih.gov/m/pubmed/24664474/ and my experience is this is effective in a vast majority of cases.
What are your recommendation for vaccines in patients while on immunotherapy?
It's ok to give.
How do you manage a patient with multiple similar appearing ground glass opacities (~8-9) on Chest CT where one has been surgically removed and confirmed to be adenocarcinoma in situ?
This is a common scenario. Determining the stage of lung cancer can be challenging. Many patients, especially those with chronic lung disease, will have multiple non-specific abnormalities seen on CT scans. The patient with multiple GGO's on CT can be especially challenging. GGO's can represent canc...
Are there any treatment related considerations in a patient with HIV who is on antiretroviral therapy and receiving adjuvant radiation for breast cancer treatment?
Though I have not recently treated many breast or cervical cancer patients with HIV disease compared to the mid-80s and 90s, yet I still continue to treat prostate and head and neck cancer patients with the disease. In these cases, it has been my experience that if patients are taking their HAART as...
What is your routine workup and treatment approach to patients with NSCLC NOS discovered in mediastinal nodes but without obvious primary lung lesions or metastatic disease?
Aside from PET/CT and MRI? Depends on smoking history but would strongly consider NGS for mNSCLC
Would you continue treatment of a rectal metastasis in a patient who is found to have radiographic evidence of contained rectal perforation during the treatment?
Good clinical question. In my experience, I have treated quite a few of both rectal and anal cancer cases, but not one from a metastatic nature that I can recall. But, in any event, my clinical instincts/experienced would push me to ask the following questions: Is this a change in his my daily/weekl...
How do you approach incidentally diagnosed mantle cell lymphoma found on a routine screening colonoscopy?
Stage IE MCL would be very rare; this is probably disseminated disease with extra nodal GI involvement which is seen in the majority of such patients. I would treat as disseminated disease, PS and comorbidity permitting per NCCN guidelines.