Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...
How do you approach management of osteoporosis in patients post lung transplant?
Osteoporosis in patients with lung transplants is essentially glucocorticoid-induced osteoporosis. Most patients with severe lung disease have a long history of glucocorticoid exposure. Post-transplant, these patients are often on long-term glucocorticoids. The primary pathophysiology of chronic glu...
How do you approach management of patients with psoriatic arthritis who have significant improvement in skin disease, but ongoing inflammatory arthritis despite multiple DMARDs and/or biologics?
Psoriatic arthritis is a heterogeneous disease and often the severity of MSK involvement and psoriasis are not well correlated. This is also true regarding treatment response. The approach to management in these cases depends on several factors:Psoriasis type and severity: If the patient has mild ps...
Do you ever utilize a steroid pulse in patients who are pregnant with status migrainosus?
According to ACOG, if steroids are use oral prednisone 20mg po QID x2d or methylprednisone dosepak is preferred over dexamethasone due to lower fetal exposure. Dexamethasone could be considered even parenterally if these do not work and attack is particularly refractory. However, they recommend that...
How is your experience with point-of-care INR systems for home monitoring of vitamin K antagonists?
Point of care (POC) INRs are reliable and can be used to monitor patients once their INRs have been stabilized on warfarin. In fact, there is data on better time in the therapeutic range for self-testing and also self-management of dosing. However, this needs to be done in conjunction with a warfari...
What is the typical work-up completed to rule out other conditions prior to making a diagnosis of fibromyalgia (other than history and physical exam)?
I agree with Don and will just add a few things. The workup to a large part depends on how long the person has had similar symptoms. In an individual who has had many regional pain conditions and lifelong issues with sleep, fatigue, or other symptoms of FM, there is very little work up needed. Howev...
How would you counsel a patient with systemic sclerosis who wants to consider microneedling on the face or other skin which is not clearly involved with scleroderma?
Microneedling is a cosmetic procedure that utilizes multiple small needles to create tiny holes in the skin that stimulate the skin’s own "healing process", which, entails the production of collagen and elastin. While regardless of the specific device used, it is considered a relatively safe procedu...
What is the utility of MRI for identifying disease activity in myositis patients when physical exam and labs are inconclusive?
Agree with @Dr. First Last, however, I want to caution about sensitivity and specificity of muscle MRI for a particular situation you are suggesting i.e., to evaluate if patient has active or inactive disease, has not been studied or proven. The muscle MRI, in general, has good sensitivity and speci...
Do you ever use ocular ultrasound in evaluation of papilledema?
As a neuro-ophthalmologist, I never use ultrasound to make a diagnosis of papilledema. I do use it to reveal optic nerve head drusen that also cause axoplasmic flow stasis and can mimic papilledema. A high quality set of fundus photos is very useful for determining the presence of optic disc edema.
What treatment options would you recommend for a patient with severe generalized pustular psoriasis who has a history of colon cancer (s/p chemotherapy) and well-controlled HIV?
I'd feel comfortable doing an IL17 or IL23. Bimekizumab would be my first choice with it's higher efficacy with almost all types of psoriasis. There's also a small dataset showing it worked quite well for GPP in a subset of japanese patients. IL36 is my favorite drug for GPP but I'm not aware of an...