Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When tapering moderate to high doses of long term steroids do you routinely monitor for adrenal insufficiency?
This is always a good question on which to reflect. In general, moderate dosing of steroids (> or = 20 mg prednisone equivalents) for 5 days or less do not need a taper and pose low risk of adrenal suppression, and by extension chronic adrenal insufficiency. Up to date suggests that up to 3 weeks is...
How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?
There is no good evidence based answer to this great question. In general, if celiac patients have persistent symptoms and exam findings of inflammatory arthritis or enthesitis, I offer non-biologic DMARDs depending on the severity of symptoms. If very mild, we can use hydroxychloroquine and escalat...
Is there any adjunct therapy to help with tamoxifen-induced leg cramps?
When a patient is complaining of leg cramps, it is important to make sure that the patient is not complaining of signs or symptoms of a deep vein thrombosis. If this is not a concern, one may consider checking electrolytes to make sure no other potential explanation. Otherwise, tonic water can be he...
Do you recommend EMG/NCS in all patients with clinical findings of carpal tunnel syndrome?
In my experience as a neurophysiologist, a typical Carpal Tunnel Syndrome (with all the classical signs and symptoms) can be diagnosed with high certainty by examination and history alone. My recommendation would be that when the symptoms are mild and the presentation is typical, conservative treatm...
Would it be prudent to complete long term cardiac monitoring (ie. 30 day) in a patient with a new typical appearing lacunar type thalamic infarct and history of hypertension?
This is a really good question. Until this year, I probably would have said that looking for AF in patients with a clear lacunar stroke is not needed. But the recent results from the STROKE AF trial (Bernstein et al., PMID 34061145.) suggest that long term monitors (implanted monitors, so a little d...
What conditions do you screen for in patients with hyperacusis?
Hyperacusis is a non-specific complaint and can be related to a number of different, unrelated pathologies. Screening for specific conditions is largely dictated by other associated signs and symptoms and whether the hyperacusis is unilateral or bilateral. Common conditions include 7th cranial nerve...
What strategy do you use to determine the appropriate timing to resume osteoporosis therapy after a drug holiday?
A drug holiday (drug sabbatical) is given to reduce the likelihood of an atypical femur fracture. Such fractures have characteristic x-ray appearances and are found from below the lesser trochanter to the supracondylar flare of the distal femur. While the overall incidence of these fractures is low,...
Do you ever consider treatment outside of the peripartum period in a patient with a history of obstetric APS?
I agree with Dr. @Dr. First Last that the patient should be treated with prophylactic low molecular weight heparin and low dose aspirin in any future pregnancies. Dr. Broder makes the very important point that modifiable cardiovascular risk factors should be particularly attended to in persons with ...
Do you hold tocilizumab for patients who are diagnosed with Covid and are with mild to moderate symptoms or non-hospitalized?
I generally hold all immune suppressive medications, once a patient is diagnosed with COVID19 to allow for faster clearance of the infection. Inhibition of IL-6 and other immune modulating interventions should be reserved only for hospitalized severely ill patients where the immune system hyper-acti...
How do you approach a potential drug holiday in a patient with osteoporosis who has had improvement in BMD after several years of denosumab therapy?
If a patient on denosumab has achieved BMD of the spine and hip that are in the high osteopenia range or normal BMDs (T score above -1), and the patient has not fractured and is not on glucocorticoids or hormone depleting agents for breast or prostate cancer, can have denosumab stopped. However, at ...