Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you decide when data patients bring to you for review/interpretation from a direct-to-consumer CGM is clinically useful and has it changed any of your management decisions in metabolically at-risk patients?
This is a tough question, as there is obviously published data for FDA-approved CGM devices, as published below: CGM Device Comparison | American Association of Clinical Endocrinology However, for those provided by independent companies, it would depend on whether or not they have independent third-...
Do you switch from 0.15 mg to 0.3 mg epinephrine at 55 lbs or 66 lbs?
Dr. @Dr. First Last, thank you for posting this question. I see variances in practice among both allergy and primary care practices on when a patient is prescribed the 0.3mg dose of epinephrine. Our practice is to switch patients to 0.3mg when they are 25 kg to prevent underdosing and inadequate res...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
What are your preferred second-line medications for trigeminal neuralgia?
My FIRST-LINE medication for trigeminal neuralgia is botulinum toxin. I write about its application in face pain, including trigeminal neuralgia, in Chapter 16 of my book, HEADACHES: Why You Have Them - What You Can Do About Them.
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...
When do you consider extended steroid tapers for acute asthma or COPD exacerbations?
The data doesn't support extended tapers - 5 days of 40 pred equivalent are non-inferior, and extended courses can cause harm, including increases in mortality. I only use extended tapers for patients who have, in the past have rapid symptom recrudescence with the typical shorter course. Typically, ...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...
What is your approach to treating patients with decompensated heart failure when their hypervolemia is refractory to oral furosemide?
Depending on the oral dose, it may just be a problem of underdosing or even perhaps non-adherence. We would typically transition to intermittent IV Lasix dosing with close monitoring, if minimal response, we can double the dose to try and get to the ceiling effect of Lasix, depending on the renal fu...