Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When and for whom should we consider adding bempedoic acid to the lipid lowering regimen?
Bemepedoic acid is approved in the US for use as an adjunct to statin therapy in patients with established ASCVD (secondary prevention) or those with heterozygous Familial Hypercholesterolemia who require additional LDL- cholesterol reduction. More recently it has also been approved for primary prev...
After corticosteroids, what second line agent do you select to treat drug induced hypersensitivity syndrome (also known as DRESS syndrome)?
see reference
How do you medically manage uncontrolled Graves' disease in a patient awaiting surgery who is intolerant to methimazole and PTU and refusing RAI?
Although this seems like a difficult situation, one must remember that in the past, patients were prepared for surgery with beta-blockers + KI, with excellent outcomes.Feek et al., PMID 6892650Therefore, I do not think you need to treat this patient with lithium, risking lithium toxicity, to prepare...
Do you repeat a lumbar puncture in a patient living with HIV diagnosed with and treated for neurosyphilis and if so, when?
This is a complex issue, and there isn't a one-size-fits-all approach. There are no hard and fast guidelines in place. If the initial CSF abnormalities include only reactive CSF VDRL, along with modest protein elevation and mononuclear pleocytosis (both of which are consistent with HIV infection), a...
What role do anti-seizure medication levels, such as levetiracetam, serve in seizure-free patients?
In patients with epilepsy who are being treated with antiseizure medication, the change in doses has to be driven by clinical data, mainly by seizure recurrence and/or adverse events. If a patient has been seizure-free and is not having adverse events, there is no need to check for blood levels, as ...
Would you start potassium citrate in a patient with recurrent nephrolithiasis of unknown stone composition who has hypocitraturia and alkaline urine pH?
I would be slow to start potassium citrate for a patient with alkaline urine and stones of unknown composition. Alkaline urine predisposes to calcium phosphate kidney stones, and potassium citrate would likely make the urine more alkaline and worsen the formation of calcium phosphate stones. First, ...
Do you recommend testing for HPV in patients with oral lichen planus?
When I read this question I, too, thought the poster meant HSV; however I was surprised to find that there is actually some literature on HPV in LP, specifically in the etiology of LP-associated carcinoma. However, given that the role of HPV is still not clear and that the failure to recognize a mal...
Do you prioritize dietary modifications and exercise over early pharmacologic interventions, such as metformin or insulin, for women diagnosed with gestational diabetes?
Most women with gestational diabetes are diagnosed in their late second/ early third trimester after a standard oral glucose tolerance test. Some women may be diagnosed earlier in their pregnancy and perhaps even had undiagnosed pre-gestational diabetes. Rarely, a patient can develop type 1 diabetes...
How do you approach the management of patients on lamotrigine who develop a minor rash?
Lamictal rash can be dangerous but if we stop or switch lamictal for any rash during treatment we can run out of options soon. Get a good history and pictures, if possible. How long have they been on lamictal and was there a recent dose change or did the pharmacy change their generic brand? Have an...
How often should TSH levels be monitored in patients with a history of Graves' disease who are in remission with negative TSI/TBII antibodies and off medical therapy?
If Anti-thyroid drugs are discontinued when an TSH receptor antibodies are still positive, recurrent hyperthyroidism often develops within a few months. On the other hand, if the drug is discontinued when antibodies are negative (not “normal“ but still detectable), then recurrent hyperthyroidism is ...