Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?
RA-ILD occurs in about 7-10% of patient with RA. It is more common in males and in those with a history of smoking. Most are seropositive. The typical pattern on HRCT in 50-60% of RA-ILD patients is a UIP pattern followed by NSIP, OP, and even LIP is some cases. An experienced clinician with the hel...
Do you typically give GI prophylaxis when providing patients with steroid taper for status migrainosus?
I usually do a 3-6 day taper with prednisone, dexamethasone, or medrol dose pack for status migrainous. Occasionally, I have done a 12-day taper if the status migrainous is prolonged. I have not used GI prophylaxis.
What immunosuppressant will you choose in a patient with necrotizing myopathy partially responding to IV steroids and IVIG with a history of non Hodgkins lymphoma?
The decision should be taken in collaboration with the patient’s oncologist; however, Rituximab would be a reasonable choice to add given that IMNM generally responds well to it (particularly anti-SRP) and that it has a favorable safety profile concerning malignancy.
Which patients with rectal cancer who have not received neoadjuvant treatment do you offer adjuvant radiation to?
In order to answer this question, we may need to step back and first review the indications for radiation treatment in the neoadjuvant setting.Neoadjuvant concurrent chemoradiation or short course radiation treatment is considered to be part of the standard treatment (recommended by guidelines) for ...
In hospitalized patients with significant lower extremity edema, how can you integrate bedside POCUS findings with clinical assessment to guide the decision to start empiric anticoagulation for suspected DVT before formal imaging?
Great question! Especially if the significant lower extremity edema is asymmetric, it sounds like your clinical suspicion would be quite high. When you order a "duplex" study, the sonographer is using 2D ultrasound (aka B mode... white dots on black screen) + Doppler ultrasound (color and spectral)....
What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?
Important question as I've seen clinicians incorrectly interpret anti-Sm-RNP as anti-Smith antibody.The different autoantibodies (RNP, Smith, Sm/RNP) react to different antigens as follows: Anti-RNP can react to multiple components (antigens) of the U1 small nuclear RNP particle (snRNP), Anti-Smith ...
What medications have you found helpful in the treatment of stimulant use disorder?
There are no accepted pharmacotherapies for stimulant use disorder and the most important component of an integrated pharmacopsychosocial approach is the psychosocial part. Two medications that are probably the best in my hands (but certainly not evidence-based) are ADHD medications and mood-stabili...
How do you approach stimulant-related insomnia for pediatric patients who are otherwise good responses to low-dose stimulant treatment for ADHD?
Clonidine 0.1 mg qhs is my first choice if I have to use something. However, first consider decreasing the stimulant dose or changing to a shorter-acting stimulant. Or go with Strattera so you can use a lower dose of stimulant. Or go with guanfacine so you can also use a lower dose of stimulant. Sti...
Is there a role for routine LP in HIV patients with disseminated histoplasmosis even in the absence of CNS signs/symptoms?
I would not recommend routine LP in the absence of CNS symptoms as it is unlikely to change the management of the infection in someone who has disseminated disease. Prolonged therapy will still be used and as opposed to Cryptococcal meningitis where intracranial pressure management is critical, ther...
Is Metformin contraindicated in patients using long term oxygen therapy at home?
If a patient is stable at home without hypoxia on oxygen and eGFR is over 30 cc/min, I would be comfortable with prescribing metformin at a dose appropriate to the eGFR. Metformin should be stopped for any pulmonary decompensation or hospital admission.