Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What lab monitoring and frequency do you recommend in an otherwise healthy young patient on biologics for psoriasis?
Yearly QuantGold testing in low risk patients has been shown to be unnecessary and actually carries a significantly higher risk of false positive than true positive. Unfortunately, many insurers still require yearly testing. I don't know of any data to support any other yearly lab testing for the dr...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?
I do most of the time but it depends on the indication and patient's weight and age. For soft indications, I usually give 2.5 mg bid, but if there is a significant risk (stroke, clots, etc), I will give a full dose of 5 mg bid.
Do you feel there is a role for triple-phase budesonide in the management of patients with celiac disease who refuse to follow a gluten free diet?
I do not believe it does. Budesonide is useful for acute gluten exposures and type 1 RCD but will not correct the inflammatory cascade associated with chronic gluten exposure and has significant side effects with long term use.
What continuous duration of device defined atrial fibrillation burden warrants initiation of anticoagulation if the patient qualifies by CHA2DS2-vasc score?
The topic is very controversial and there is no agreement either on the continuous duration of a single episode or the total burden required to initiate AC. Most recommendations are expert opinions. I believe that 5 minutes is the most commonly accepted cutoff, which needs to be combined with an ass...
Do you prescribe silvadene cream for patients with a sulfa allergy?
No. I will consider hydrogel wound dressings in those situations
How do you advise an ESKD patient who wants to drink pickle juice to reduce intradialytic muscle cramps?
Salt is addicting! Acknowledge that changing habits is hard. Make a case that the reason for cramps is RATE at WHICH fluid is being removed. Ask the patient to recall the days when the goal of fluid removal was low. During those treatments, the risk and occurrence of cramps were less likely when com...
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...