Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you recommend using trabecular bone score (TBS) for managing osteoporosis?
Trabecular bone score is a valuable tool in the evaluation of osteoporosis and risk of fracture. It is an indirect indicator of bone microarchitecture. Although TBS predicts fracture risk, it should not be used alone but in conjunction with BMD for deciding whether to treat the osteoporosis and if s...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
How do you approach follow up of young patients with isolated +ANA, but no current clinical signs or symptoms of SLE?
An old study showed that ANA can be positive in patients who develop lupus up to 9 years (average 3 years) before the onset of clinical disease but it was not necessarily isolated ANA as Ro and La antibodies could also be detected long before the onset of the disease (Arbuckle et al., PMID 14561795)...
Do you adjust the dose or the timing of levothyroxine ingestion in patients on anti-acid medications?
Actually, adjusting the timing of levothyroxine ingestion probably doesn’t help much, since the proton pump inhibitors, and other similar drugs, have a duration of action of 12–24 hours. I would recommend checking serum TSH levels after the patient has been on the gastric acid medication for 4–6 wee...
How do you approach the use of buprenorphine/naloxone in pregnant and breastfeeding patients?
If the patient is already on it, many doctors, including myself as an addiction psychiatrist, will simply switch to the same dose without the naloxone component, just to use the minimum necessary meds while pregnant. It’s not a hard and fast rule though. The dose may need titration later in pregnanc...
What treatment regime would you recommend for localized hyperhidrosis affecting the scalp that has failed topical aluminum chloride and oral glycopyrrolate?
I have personally found that oxybutinin is more effective than glycopyrrolate with fewer anticholinergic side effects.
How do you do a levodopa trial in the outpatient setting?
In a patient with Parkinsonism whom I am starting levodopa treatment for, I begin by conducting a detailed motor examination using the MDS-UPDRS III to assess baseline symptoms. Typically, bradykinesia and rigidity respond most consistently and robustly to treatment. While tremor and gait disturbanc...
How would you manage a patient with Crohn's disease on a biologic and presents with non-bloody diarrhea, normal-appearing mucosa on sigmoidoscopy but severe colitis on biopsy with a positive CMV stain?
A few key pieces of information help distinguish CMV colitis from other competing diagnoses in this frequently encountered conundrum. An experienced pathologist will usually be able to tell you: If the CMV immunohistochemistry stain has good controls and whether it is floridly positive or scant. Al...
What other conditions should you consider in someone with presumed Tolosa Hunt but without significant improvement on steroid therapy?
Sufficient workup should ideally be obtained before initiating steroids in order to exclude disorders that may have a similar presentation with quite a different approach to management. These investigations include but are not limited to the following: brain MRI with contrast + thin slices through t...
How would you counsel a young female patient who refuses to use contraception during radiotherapy?
A woman who refuses contraception needs careful psychological and psychiatric assessment and considerable time at the time of consultation to understand why she is refusing, especially since this response is neither rational nor logical. The practitioner needs to take the time to discuss the patient...