Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Provided no side effects, to what dose do you increase propranolol or primidone before considering them ineffective for a patient with essential tremor?
If tolerated maximum dose of 250 mg of Primidone bid would be acceptable. This is my personal experience.
How do you approach handling the many-page disability paperwork of neurological disease such as Parkinson's disease?
It can be daunting when one is handed a long form to fill out for disability in advanced PD patients. Admittedly, it is not my favorite thing to do but it will make all the difference in the life of the patient, so it is extremely important to handle it carefully. In the past, I used to have them re...
In a patient who completed 5 years of oral bisphosphonate and has a T score persistently in osteoporotic range, what factors help you decide whether it is appropriate to start a drug holiday vs. switch to an alternative agent?
This is an interesting question concerning a common clinical issue. Unfortunately, I am unaware of any data (evidence-based medicine) that is helpful in answering the question. My response is thus only anecdotal. There is some good data that patients with an inadequate bone density response to three...
How long do you expect gastrointestinal side effects of leflunomide to persist after stopping treatment?
Leflunomide (LEF) has a long half-lasting of about 15 days. So, when dealing with advise events such as gastrointestinal toxicity, these may persist up to several weeks following discontinuation of the drug. Simply discontinuing LEF will prove to be effective in the majority of patients with adverse...
How long would you consider the use of low-dose aspirin in a patient with SLE and high risk aPL profile (without a clinical event)?
I recommend low-dose aspirin (ASA) plus hydroxychloroquine (HCQ) to ALL my systemic lupus (SLE) patients unless they have risk factors for bleeding.I do this based upon the 2017 Italian study by Fasano et al. I explain to my patients that there are uncertainties to this recommendation and that furth...
What is your treatment algorithm for patients with lichen planus?
There are many potential approaches depending on the severity, subtype, comorbidities, and impact on QOL. For "classic" LP (no symptomatic or significant oral involvement)" Typically itch is the primary complaint although the appearance can be understandably upsetting to some patients. Depending on ...
What is your treatment approach to patients with confluent actinic keratoses on lower extremities?
I find these patients can be very challenging to treat. It is difficult to completely clear the AKs and even if there is success initially, these patients will often develop new adjacent lesions or recurrent lesions within a short time. Nonetheless, we have used various approaches to treating these ...
In a patient identified as having APLS because of recurrent pregnancy loss without history of thrombosis, but now has a new DVT/PE during pregnancy despite use of enoxaparin—for how long would you recommend anticoagulation?
First, as far as I know, enoxaparin has not been proven to prevent pregnancy loss in obstetric APS. Second, we know that enoxaparin has not been shown to be as effective as heparin in preventing thrombotic events in APS. Third, the patient is pregnant, a thrombophilic state, separate from APS. All t...
At what age do you recommend annual skin exams in a patient without a personal or family history of skin cancer?
I don't have a specific age but rather it depends on the risk factors: Male, fair skin, and older age are risk factors, certain occupations Evidence of actinic damage Immunosuppression, especially organ transplants Multiple nevi > 50 History of dysplastic nevi Childhood radiation exposure Chronic l...
When do you consider referral to hand surgery for management of joint deformity in RA?
This is individualized to the patient's needs. If a patient is uncomfortable due to pain, quality of life or lack of function due to the deformity, I would arrange a consultation with a hand surgeon. Some patients do get distressed by the cosmetic appearance of the deformities and this is an indicat...