Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to tapering chronic steroids in patients who are at high risk of HPA suppression?
There are rare cases when the adrenal function never seems to recover. The ACTH recovery happens before cortisol so that it can be monitored as a marker. When I get a consult about tapering GCs in a patient on long-term therapy, I usually let the primary team (e.g., rheumatologist) cut back on predn...
What workup do you recommend for otherwise healthy migraine patients that develop dizziness with episodes?
The workup should exclude other potential causes of vertigo including CNS disorders, and Meniere's disease, with neurology examination, MRI brain, videonystagmography, or electronystagmography. An article also evaluated vestibular migraine versus migraine without vertigo and found in several studies...
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
How do you approach management for patient's with HIV on ART with persistent low level viremia but no new resistance mutations identified?
The US Department of Health and Human Services describes the different levels of virologic response related to ART[1]: Virologic suppression: A confirmed HIV RNA level below the lower level of detection of available assays. Virologic failure: The inability to achieve or maintain suppression of viral...
Is a history of provoked DVT a contraindication to starting testosterone replacement therapy in a middle aged man with symptomatic hypogonadism who is on anti-coagulation?
The data on testosterone replacement and thromboembolic disease is not so clear but there is likely a link and should be noted in patients at high risk (e.g smoking, prior event, erythrocytosis). It’s important to discuss the risk benefits with the patient but as long as they are on anticoagulation,...
Can anabolic agents be used in a patient with history of radioactive iodine treatment for hyperthyroidism?
This is an interesting question. When PTH was approved it had a black box warning for patients who had a history of radiation to the skeleton due to risk of potential osteosarcomas. The black box has been removed for the duration of use. Since we have another anabolic agent without that black box, I...
How would you approach the workup of unilateral chorea with a normal MRI?
I would first rule out Sydenham chorea by checking ASO titers, DNase B titers, ESR, and CRP, and performing an echocardiogram and EKG. I would also recommend an MR angiogram if not already done for Moya-Moya. Following that, I would check copper levels, ceruloplasmin, serum amino acids, serum lactat...
How do you manage dry eye syndrome due to lacrimal or meiobian gland dysfunction after external beam radiotherapy?
I have also found autologous serum (AS) or platelet-rich plasma (PRP) eye drops/tears to be extremely useful (provided by an ophthalmologist). Dry eye can also be exacerbated by graft vs. host disease, which I have anecdotally seen worsened within radiation fields and is characterized by a lasting m...
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.