Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage injection site reactions in patients on subcutaneous biologics such as TNF inhibitors?
Injection site reactions are not infrequent, though the majority are self-limited and do not result in discontinuation of the drug. For those uncommon few individuals whose skin lesions are more prominent and symptoms (such as pain and itch) are aggravating, I first review that they are properly sel...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
How do you counsel elderly patients who demonstrate mild cognitive impairment but do not meet the criteria for a neurocognitive disorder?
I would let them know that mild cognitive impairment (MCI) is an umbrella diagnosis with many different contributing factors as well as risk factors for progression to dementia. Control what you can control. Limit contributing factors such as pain, mood, and sleep optimization, as well as limiting a...
What treatments do you consider for cholinergic urticaria refractory to high dose H1 blockers and omalizumab?
Generally, my initial approach to cholinergic urticaria (CholU) is the same for chronic spontaneous urticaria and other forms of chronic inducible urticaria [1]. Most patients with antihistamine-refractory cholinergic urticaria (CholU) will respond to omalizumab 300 mg monthly. Those individuals wit...
Would you start stone preventative medications such as potassium citrate and thiazide diuretics for patients with recurrent calcium based nephrolithiasis and abnormal 24 hour urine chemistries if they no longer have calculi on most recent imaging testing?
If they have had stones previously they remain at risk of recurrent stones. Would want to know when was the last stone episode. Was there previous treatment? It would be based on the results of the 24 hr urine and how significant is the hypercalciuria, oxaluria, low the citrate and pH are. Most impo...
Do you recommend life long aspirin 81 mg daily for non-specific T2 white matter hyper-intensities on MRI brain?
"Non-specific" means non-specific, indeed, and ASA risks of bleeding increase with age.
What is your preferred oral regime with duration for treatment of onychomycosis?
Back in the old days of the "toenail wars" between terbinafine and itraconazole, I was a speaker for both and learned that the pharmacodynamics of the two drugs favored pulsing for the latter but NOT for the former. Terbinafine does NOT leave the blood for weeks, unlike itraconazole (days), so if th...
What procedures do you recommend for patients interested in xanthelasma removal?
I have had success treating xanthelasma with both hyfrecation (particularly for very small lesions) and fully ablative laser (both CO2 and Erb-YAG).
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
For patients with microcytosis MCV 75-79 and normal Hb, low TIBC, and normal ferritin do you always rule out thalassemia?
Microcytosis is typical in thalassemia. With a normal ferritin and hemoglobin concentration, I would start screening by measuring HPLC, HbA2 levels that are high in beta-thalassemia carriers. (HbA2 can be normal with “mild” thalassemia alleles and for several other reasons.) Microcytosis without iro...