Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you reassure families that no allergy testing is needed for urticaria?
There used to be a Choosing Wisely message about this. Here is a video on it. Diagnostic Testing and Chronic Urticaria Video - AAAAI The 2014 practice parameters on chronic urticaria also discuss this. The practice parameter update is looking at this in a GRADE fashion and will likely have even mo...
How do you determine if pulmonary hypertension is disproportionate to the severity of lung disease?
This is a question we faced on a daily basis in our PH clinic. Patients with parenchymal lung disease like COPD or ILD would get an echocardiogram that showed an elevated RVSP and/or RV dilation/dysfunction and will be referred to our clinic for PH evaluation. Alternatively, the patient already unde...
What is your approach to dental prophylaxis for patients on biologics?
My approach has been to not recommend antibiotics prior to routine dental care for patients on biologic therapy. I'm not aware of any compelling evidence or guidelines supporting preventive antibiotic treatment for such patients. Of course, there may be exceptions to this. Antibiotic prophylaxis mig...
Do you have patients with recurrent nephrolithiasis target a certain urine volume or rather consume fluids as needed for goal of having consistent clear urine?
I think you could go either way. To prevent most types of kidney stones, 2L/day seems to be the minimum urine volume required. For cystine stone formers, I double that amount. My more compulsive patients like having a quantitative goal. The amount of fluid intake roughly equals the urine volume, abs...
Is there any evidence that spironolactone or finasteride therapy increase blood levels of testosterone?
Yes. It seems that both medications can do this at least in the short term. Spironolactone's effect may be more temporary.For spironolactone, an older article: Tidd et al., PMID 152681For finasteride: Stanczyk et al., PMID 23474436
Do you recommend using a risk equation or eGFR alone in deciding when to refer a patient with advanced CKD for vascular access placement?
This is not an easy question, I still rely on patients trajectory, clinical judgement.
What is your approach to diagnosis and treatment to intermittent cheilitis that does not respond to anti fungal therapy?
Clinical features matter. The differential is broad: granulomatous cheilitis, contact dermatitis, irritant dermatitis, lichen planus, and I have even seen SCLE present with cheilitis. Biopsy during a flare can be helpful even if only to rule out some possibilities, and a 3mm punch typically heals qu...
How would you treat disseminated flat warts in an immunosuppressed patient with skin of color?
Hard to imagine Imiquimod working in a dry wart. Thinking back to the genital studies... only the occluded (moist) warts responded. I generally try to curette them over several visits. Compounded cidofovir (off-label, etc.) might be the best bet.
Where do oral and topical JAK inhibitors fit into your treatment algorithm and approach to atopic dermatitis?
When considering systemic treatment for dermatitis, I perform extended patch testing based upon patient's history of cutaneous contactants. This identifies patients with dermatitis that can often be cured by avoiding cutaneous and systemic (i.e. ingestion) exposure to identified allergens. Patients ...
What is your approach to anal pap screening among MSM with HIV, and if routinely recommend, starting at what age (assuming access to HRA)?
We taught our nurses and patients how to do self-collection, which cut down on the amount of time it takes. Multiple guidelines for HPV have been revised in the past few months based on more recent studies (although the emotional reaction to having multiple of my patients diagnosed with anal cancer ...