Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the optimal anti androgen dose of spironolactone when treating female hirsutism?
My experience with this issue has primarily been in treating women with PCOS who have hirsutism and so these comments are limited to that condition. First, it is important to establish normal renal function and electrolytes before starting. It is also important to know if the patient is on an ACE-I ...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
Under what circumstances would you test for hypercortisolism in a patient with insulin resistance?
The American Diabetes Association meeting that just finished up featured the CATALYST study that found hypercortisolism by an abnormal dexamethasone suppression test was present in 24% of patients with difficult-to-control type 2 diabetes. For insulin resistance alone, I suspect the prevalence would...
When is a biopsy necessary to diagnose relapsing polychondritis?
Since there are no specific lab tests for Relapsing Polychondritis, the diagnosis is based on clinical manifestations. Criteria proposed by McAdam et al. PMID 775252 require three or more of the following clinical features to confirm the diagnosis: Bilateral auricular chondritis Non-erosive, seroneg...
How do you approach HS patients with persistent HS lesions on the trunk?
I have a similar approach to HS in other areas, but surgical procedures are a little easier when it comes to positioning. I definitely trying intralesional triamcinolone. After the studies on higher dose, I use 40mg/cc since it has the potential to permanently heal nodules, abscesses, and tunnels. D...
In extremely obese patients with spontaneous DVT/PE who have been anticoagulated for > 6 months, do you feel comfortable reducing the DOAC to prophylactic dose or do you prefer continuing full dose indefinite anticoagulation?
According to the ISTH guidelines (Martin et al., PMID 34259389) in patients with a BMI >40 kg/m2 or weighing >120 kg, it is suggested to use the standard doses of apixaban or rivaroxaban for VTE treatment and prevention regardless of BMI and BW. The ISTH did not discuss dose reduction after 6 months...
What lifestyle modifications do you recommend for patients with hidradenitis suppurativa?
It's important to approach this carefully since many patients have been told many myths that cause shame and stigma. I usually don't bring up smoking cessation or weight loss during the first visit. It's better to build a good relationship and trust, then address those. I always recommend patients g...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
How long does it take the hypothalamic-pituitary-gonadal axis to recover from secondary amenorrhea in the setting early onset and chronic use of oral combined contraceptive pills?
About 6 months after cessation of OCs.