Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...
How do you manage pregnant individuals with newly diagnosed idiopathic intracranial hypertension?
Pregnancy in IIH is managed the same as if the patient did not have IIH with one caveat. IIH patients should stay within the recommended weight gain their obstetrician targets. Pregnancy is not a cause of IIH, but the excessive weight gain that can occur can trigger or worsen IIH. Labor and delivery...
How do you counsel parents of children with atopic dermatitis about preventing recurrent Staph infections?
For recurrent Staph infections, I recommend bathing daily, as well as giving a bleach bath 2-3 nights per week. If they are struggling with multiple or recurrent abscesses, and/or other family members are also having recurrent Staph infections, that is when I recommend intranasal mupirocin. I typica...
How long are you comfortable with keeping pediatric patients on oral antibiotics for acne?
I start all acne patients on a topical retinoid and if they need an oral antibiotic, I will prescribe that with a follow-up at 3 months. It takes about that long for a topical retinoid to kick in. If they need a couple of months longer, that's okay, but I might add topical or oral spironolactone to ...
Do you recommend using anastrazole in men developing gynecomastia while on testosterone replacement treatment for hypogonadism depending on pre-treatment estradiol level?
There is no role for aromatase inhibitors (e.g., anastrozole) for the prevention of gynecomastia. A randomized trial of anastrozole for the treatment of gynecomastia demonstrated no benefit compared to placebo.There is no reason to administer prophylactic therapy prior to the initiation of testoster...
How would you approach chronic Achilles tendonitis that persists despite rest and physical therapy?
When situations like this arise, the first step is to re-evaluate the duration of symptoms and ensure the full trial of conservative management (rest, ice/heat, NSAID/Tylenol, PT) has been done. Oftentimes, it takes months to fully recover, even with these measures. If the symptoms persist despite a...
How would you approach chronic Achilles tendonitis that persists despite rest and physical therapy?
When situations like this arise, the first step is to re-evaluate the duration of symptoms and ensure the full trial of conservative management (rest, ice/heat, NSAID/Tylenol, PT) has been done. Oftentimes, it takes months to fully recover, even with these measures. If the symptoms persist despite a...
What factors would lead you to extend the duration of antithyroid drug therapy in a patient with Graves' disease who is clinically euthyroid at 12 months but has risk factors for recurrence?
One should never discontinue methimazole after an arbitrary period of time without checking anti-TSH receptor antibody levels. If they are positive or even “normal” but not undetectable, the patient will inevitably have a recurrence of their hyperthyroidism relatively quickly (Laurberg et al., PMID ...
What oral treatment options would you offer a patient with severe onychomycosis who is also on methotrexate for another condition?
I prefer pulsed terbinafine at 250 mg daily x1 week every other month. Dr. Zaias showed in a comparative study that pulsed terbinafine works as well as giving it daily for 3 months, and since the patient is only taking this for 1 week every other month, risks for hepatotoxicity are minimal.
Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?
There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weis...