Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you explain fleeting, post-RT breast pain to patients, and what do you recommend as management?
It is common, underreported, and appears to be nerve related. I recommend assurance as intensity and frequency improve with time.
How would you evaluate and treat an older teenage patient with severe perioral dermatitis with histology demonstrating a granulomatous dermatitis and all stains have come back negative?
Minocycline (rarely use but for this, I would) with weekly ivermectin and Elidel. I have done a prednisone taper as well to calm it down. Isotretinoin or dapsone...
What are your recommendations regarding sexual activity for a couple when one of them is diagnosed with a HPV-positive oropharyngeal cancer?
We always counsel patients regarding the etiology of HPV if they have a p16+ tumor. We tell them that this is an infection most likely acquired through sexual activity and that the latency period is approximately 20 years from the time of exposure until the time of a cancer diagnosis. We note that o...
Do you recheck screening labs (ESR, BUN/Cr, urinalysis, ANA, etc) for patients with recurrent small vessel vasculitis of unknown origin with each flare?
If the recurrences occur 6 or more months apart, I would recheck the studies to exclude SLE. If the episodes are chronic, I would recheck at least once a year for the same reason or whenever there are new suggestive symptoms of LE.
What prescription or over-the-counter therapies have you found effective for helping vitiligo patients cover active areas?
As Dr. @Dr. First Last mentioned, selecting the correct topical steroid strength based on location is important. We have had patients make great progress (even without nbUVB therapy / xTrac) by alternating every 1-2 weeks with a topical steroid and a non-steroidal (i.e., Pimecrolimus cream or Tacrol...
How do you approach tapering off JAK inhibitors in patients with rheumatoid arthritis who are in sustained remission?
My approach to treatment changes for RA patients who are in remission is usually not specific to the kind of medications they are on. Unless the patient has adverse events, I tend to continue the medication or combination of medications that got them into remission. As we know, RA is a chronic condi...
How do you approach methotrexate management in patients with rheumatoid arthritis and moderate NASH but no fibrosis per FibroSURE?
In this scenario of a patient with defined NASH by Fibrosure or alternative biomarker or predictive index of fibrosis, I would refer for baseline Fibroscan (transient elastography) to determine the degree of steatosis and presence/degree of fibrosis. NAFLD is common in our population with an estimat...
Is there a role for low dose aspirin in a patient with AVN in four large joints who has underlying well-controlled SLE and positive APLs but no history of clots?
AVN in SLE patients is common, most often in the context of glucocorticoid use. Thus, in this case, there is no evidence that APLAs are the etiology. Moreover, to the best of my knowledge, there is no evidence that primary prevention with aspirin in the setting of APLAs is effective. So I would not ...
What is your approach to discussing risk of adverse cardiovascular events in patients with RA whom you are considering starting a JAK inhibitor?
I would refer to the recommendations in the January 28, 2022, position statement by the American College of Rheumatology. This statement emphasizes the importance of shared decision making between the rheumatologist and the patient. There are many options available to treat RA that do not have a sim...
How does failure to recover clinically after >2 years in a patient with suspected diabetic amytrophy shift diagnostic and therpeutic approach?
The natural history of diabetic amyotrophy is to improve after deficits have reached a nadir; the improvement can be incomplete, but usually occurs within 12-18 months from the onset of symptoms. Therefore, if there are persistent but stable deficits 2 years after the onset of symptoms this may repr...