Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you consider the use of clonidine in gabaergic withdrawal and how do you approach the risk of masking the autonomic signs of withdrawal when it is used?
There is limited and indirect evidence for the use of clonidine in "benzodiazepine-sparing" protocols for gabaergic withdrawal treatment. Generally, an anticonvulsant is used along with clonidine in this context. This "new" data recapitulates old, mainly European, studies combining beta-blockers wit...
How do you differentiate between hyperactive delirium and excited catatonia?
This is a highly complex distinction to make for several reasons, not the least of which is that the two conditions can coexist in the same patient at the same time. This has been demonstrated in some recent studies of mainly intensive care delirious patients, though the reported very high incidence...
What strategies have you found most effective for supporting weight loss in patients with bipolar disorder while minimizing the risk of mood destabilization?
If residual depressive symptoms are present, then the addition of bupropion is helpful. If the weight gain is deemed due to necessary psychiatric medication, then the addition of metformin often works. Of course, for the management of weight, diet and exercise need to be encouraged (in addition to t...
How do you manage long-term pain associated with sensory ganglionopathy?
There is no difference in the management of neuropathic pain from sensory ganglionopathy vs. neuropathic pain caused by a typical length-dependent distal sensory polyneuropathy, like diabetic.
Would you give treatment to a male patient with subjective dysuria but no objective pyuria with Ureaplasma urealyticum detected by PCR from urine?
No treatment is indicated. First, dysuria alone in males is not an STD symptom; published research is clear that discharge is required to suspect urethritis. The absence of urine WBCs (i.e. no pyuria) is a pretty good substitute for examining for discharge - not perfect but makes urethritis unlikely...
How would you recommend dosing the MMR or other live vaccines for patients with rheumatoid arthritis on immunosuppressive medications such as DMARDs and anti-TNF alpha therapy?
It is rarely necessary for any live virus vaccine to be mandatory as most employers will accept waiver letters, as will most countries requiring yellow fever vaccination to enter. The risk of disease exposure, illness must be balanced against disease flare holding therapy. Fortunately, with the adve...
Do you routinely treat chronic sacral osteomyelitis when there is no plan for debridement or flap?
I would treat acute febrile cellulitis with a relatively brief course of antibiotics but not with a long course of IV antibiotics attempting to cure osteomyelitis, if surgical debridement is not performed.
Do you stop ACEi or ARB medications in patients with ESKD who are on hemodialysis and have issues with chronic hyperkalemia?
I don't. I don't think it contributes much to the hyperkalemia. I usually try to correct the potassium using modifications of the potassium bath, dietary changes and if still high potassium binders.
How would you approach a patient with anti-scl70 ab positive sine scleroderma complicated by ILD who also has seropositive RA with active arthritis?
This scenario can be looked at in different ways. For example, does this patient have scleroderma that explains the ILD and seropositive RA to explain the arthritis? Or, does this patient have seropositive RA which explains both the arthritis and the ILD? I favor the latter explanation. In this scen...
Do you recommend obtaining both a parathyroid ultrasound and a parathyroid nuclear medicine scan when evaluating a patient with recurrent calcium based nephrolithiasis who is found to have an elevated PTH level, hypercalcemia, and hypercalciuria?
Yes. The scenario you describe is typical for primary hyperparathyroidism. Appropriate treatment includes removing the parathyroid adenoma. However, finding a parathyroid adenoma can be difficult. An enlarged one may be no more than a few millimeters in diameter. Our radiology staff recommends both ...