Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend checking a serum phosphorus level in patients with recurrent nephrolithiasis?
For patients with pure calcium phosphate or mixed calcium phosphate/oxalate nephrolithiasis, l routinely check serum phosphorus as part of a panel that also contains serum calcium, PTH, creatinine, and 25-vitamin D, looking for primary hyperparathyroidism, a surgically curable cause of these stones....
Is there an age cutoff where you consider the risks of monoclonal antibody therapy outweigh any potential benefit(s) in early-onset dementia?
A brief discussion of dementia terminology is worthwhile to avoid confusion regarding diagnostic classification and treatment rationale. As is well known, there are many dementias, and the descriptor “early onset” can be used for childhood dementias, such as Rett syndrome, and also for disorders suc...
Is there an age cutoff where you consider the risks of monoclonal antibody therapy outweigh any potential benefit(s) in early-onset dementia?
A brief discussion of dementia terminology is worthwhile to avoid confusion regarding diagnostic classification and treatment rationale. As is well known, there are many dementias, and the descriptor “early onset” can be used for childhood dementias, such as Rett syndrome, and also for disorders suc...
Do you escalate treatment in patients with myositis who achieve clinical remission but continue to have elevated CPK?
Typically, patients who are doing well and in remission can have low levels of CK abnormality, which needs to be monitored but not treated. Post myositis improvement, some patient's muscle membrane remains leaky or not perfect, leading to some low levels of elevated CK, which has no clinical signifi...
How do you manage gram-negative bacteremia in a patient with an aortic bypass graft, for whom there is low clinical suspicion for active graft infection?
This is a very nuanced question, and thus, there is no perfect answer. If there is low suspicion for graft infection and the bacteria is not commonly associated with biofilms (like a simple E. coli) and the bacteremia clears quickly, I would likely treat for a couple of weeks and monitor (and even c...
How does the location or type of psoriasis affect your initial biologic choice?
Scalp and palmoplantar psoriasis are always tough. Inverse and nail psoriasis as well, but I don't find as much of a disconnect with inverse psoriasis (nb: it tends to be one of the "easier" to treat areas of psoriasis once you've made the diagnosis, evidenced by the rather stronger efficacy results...
What is your next step in management for patients who develop sexual side effects on an SSRI (anorgasmia, low libido, etc.) but are responding well to therapy?
Managing side effects from SSRI medications is a key component of treating patients in the outpatient setting who are suffering from depression and/or anxiety. This is doubly true given the fact that primary care is often the most accessible, and often most trusted, source for patients to make their...
How do you approach treatment change in patients with psoriasis who have been stable on an IL-17 or IL-23 agent but then begin to have breakthrough skin disease?
It really depends on where the patient is in their treatment journey. Patients who have tried and failed other biologics I try to optimize response by: increasing the biologic dosing frequency if insurance will allow, adding topicals, particularly newer ones like tapinarof or roflumilast, adding ph...
What is your experience managing patients with chronic spontaneous urticaria occurring only at night?
When I have patients with Chronic Spontaneous Urticaria (CSU) that is not responding like CSU should to medications, the first thing I wonder is if this is really CSU. In these situations, I will order additional lab work-up for CSU and conditions mimicking CSU, as discussed in a recent review in JA...
Do you recommend a waiting period to conceive after prostate radiation?
Yes, I typically advise that men and their partner use contraception for at least 3-4 months after the last fraction of radiotherapy based on the fact that the maturation cycle of sperm is estimated at approximately 2- 2.5 months. I typically counsel men prior to treatment that there is a chance (bu...