Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients on how to use vaginal estrogen?
Vaginal estrogen comes in multiple formulations: creams, tablets, suppositories, and rings. Because vaginal estrogen does not become systemic, there is no need to add progesterone for uterine protection when using vaginal estrogen. Likewise, there is no concern for systemic effects of estrogen when ...
Do you recommend that your patients with COPD avoid gabapentin or pregabalin entirely, given the increased rate of exacerbations noted in patients on these medications?
No, I don't exclude gabapentin or pregabalin as therapeutic options for patients with COPD. The study of Rahman is a cohort study that suggests an interesting association but has limitations, including residual confounding variables and a lack of smoking information on the study population. The issu...
When do you consider starting an antiplatelet in a patient with stoke due to septic emboli?
If no ICH or microbleed on MRI and the patient has a strong indication for home antiplatelet, would continue single antiplatelet. Would NOT start for septic embolic stroke. Also avoid medical DVT prophylaxis for the first 1-2 days after endocarditis-related strokes. Initial vessel imaging with CTA o...
What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?
I would put CPPD arthritis high on the differential, as the wrist is a common site for CPPD arthropathy in the elderly. In the right context, septic arthritis is a possibility, particularly if the patient is immunosuppressed. Indolent infections such as fungal or mycobacterial are possibilities. Les...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
Should methotrexate be stopped prior to radiation therapy if a patient has rheumatoid arthritis?
I have not stopped as dose of MTX for RA is low (7.5 mg) and there is data of CMF with RT for breast cancer with higher dose of MTX showing no significant increase in morbidity.
What is your approach to counseling severely frail older adults regarding their planning for invasive life-sustaining therapy?
My approach is pragmatic, evidence-based, and bi-directional. Patients/family make the decision, but I ensure they are fully informed about the pros and cons and provide them time to think through.
What is the recommendation for women with migraine with aura who are planning to undergo IVF hormone therapy?
I would not change my migraine management approach. With pregnancy planning, I would avoid medications that are not recommended in pregnancy. I would counsel on the safety of different acute and preventative treatments in pregnancy.
How do you distinguish normal post-operative pain and swelling in an extremity from a post-operative complication such as hemorrhage, surgical site infection, etc.?
That is a good question. I would first ask the patient if their pain (and/or swelling) is any different (or worse). A change in the pain (or the recurrence of pain) could be a sign of a postoperative complication. Swelling beyond the first postoperative day, especially with erythema/warmth, could in...