Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you switch from 0.15 mg to 0.3 mg epinephrine at 55 lbs or 66 lbs?
Dr. @Dr. First Last, thank you for posting this question. I see variances in practice among both allergy and primary care practices on when a patient is prescribed the 0.3mg dose of epinephrine. Our practice is to switch patients to 0.3mg when they are 25 kg to prevent underdosing and inadequate res...
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...
What treatment modalities have you had success with for treating extensive molluscum in the pediatric population?
I've had very good success with the use of oral cimetidine, 400 mg PO tid in children. Usually, they remain on this tx for 4-6 weeks with sig clearing beginning by the 1st 2-3 weeks. I also use tretinoin gel 0.1% qd-bid to the more stubborn lesions if necessary.
Should HCQ be continued in an asymptomatic SLE patient who has received renal transplant?
As far as I know there is not a definitive answer to this question due to a lack of clinical trials. My approach is to continue it at a dose adjusted for renal failure. My thought process is that both lupus and chronic renal failure increase the risk of cardiovascular events significantly. Plaquenil...
How should we approach the recommendation of intermittent fasting for weight loss in patients with pre-existing cardiovascular conditions, given the observed association of increased CV mortality with eating durations of less than 8 hrs?
I will admit my prejudice on this topic. I don’t understand the biologic plausibility of shortening the time during which meals are consumed to 8 consecutive hours a day with no snacking for 16 hours a day (but without calorie restriction) in order to lose weight. This would be like saying “have bru...
What is your approach to monitoring patients referred for high titer +RF and +CCP but without active symptoms of inflammatory arthritis?
It has been well described that patients with a +RF and + CCP autoantibody may develop clinically active RA up to two decades or more (potentially lifelong) after the detection of these autoantibodies in a patient. It is now thought that there is a preclinical phase of autoimmune diseases including ...
What is a reasonable approach to coronary calcification that is incidentally found on CT in a patient who does not have symptoms suggestive of angina?
This patient needs aggressive medical therapy and risk factor modifications. Statins will be the primary lipid-lowering agent but other agents as needed to get an LDL under 70. Hypertension needs to be identified and controlled. Aspirin is also a consideration depending on the extent of coronary cal...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
Do you routinely check digoxin levels, and if so, when would you consider using Digibind in chronic digoxin use patients?
The subanalysis of the DIG trial gave some insight into the value of keeping digoxin levels below 1.0. If HF patients, I tend to look at the levels for that reason. I rarely use digoxin for AF as there is little evidence of benefit with some evidence of harm. Re: use of digibind, I limit this if t...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...