Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage a patient taking a GLP-1 agonist for weight loss who continues to have symptoms (i.e., nausea, vomiting) related to reduced GI motility despite dose adjustments?
Anecdotally, I’ve had good success using prucalopride at twice-daily dosing (0.5 mg BID or 1 mg BID) in select patients. In my experience, tirzepatide tends to be better tolerated than semaglutide from a gastrointestinal perspective.
Given recent trials for the management of atrial fibrillation with an early ablation strategy (for example, EAST-AFNET 4, EARLY-AF, PROGRESSIVE-AF, STOP-AF), what is your approach to determining the appropriate timing for ablation in patients with atrial fibrillation?
I agree with Dr. @Dr. First Last. I also usually start with an antiarrhythmic drug and then offer ablation if the drug is not tolerated or is ineffectual. This is a shared decision-making process - some patients want nothing to do with drugs and prefer ablation and others want to try multiple drugs ...
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
Do you ever stop tobramycin prophylaxis in a patient with chronic bronchiectasis previously colonized with pseudomonas?
Yes, I will often stop tobramycin if there are issues with tolerance, antibiotic resistance, or treatment fatigue. Further, in more mild bronchiectasis (cylindrical vs. varicoid or cystic morphologies), sputum bacterial cultures will negatively convert on chronic cycled inhaled tobramycin, and this ...
What is your approach to a child with toe walking with a reassuring exam but a family history of difficulty walking?
For all children with toe walking, it is critical to perform a full neurological examination to look for CNS (i.e., CP/HIE or HSP) or neuromuscular (i.e., CMT, myopathy) issues. We also do NCV and EMG (the latter if indicated) even if the examination is normal and have found early CMT in a few of th...
How do you manage persistent pseudomonas positive sputum a patient with non-CF bronchiectasis who has chronic sputum production but is otherwise asymptomatic?
I am assuming the Pseudomonas has persisted despite efforts to eradicate early on; if not, I would consider at least an effort at "eradication" or at least aggressive treatment. If the Pseudomonas has persisted and the person feels well other than sputum production, would aggressively pursue airway ...
How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?
There are two types of autoimmune pancreatitis (AIP): type 1 AIP, which is synonymous with IgG4-related disease (IgG4-RD) involving the pancreas and makes up a large majority of AIP cases, and type 2 AIP, which is largely associated with inflammatory bowel disease. I am assuming from the question th...
Do you continue shots when a patient transfers under your care and has been receiving less than effective doses of AIT, but insist they have been effective?
Yes, I'd continue the shots. For some patients, even lower doses produce a meaningful desensitization and build tolerance. At some point, I would recommend retesting his allergies to objectively confirm the efficacy of the shots.
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
What is your preferred monotherapy antiplatelet agent to continue after completion of DAPT post-PCI for patients with stable ischemic heart disease?
For stable CAD that is more extensive, I have been using Plavix monotherapy based on data from HOST-Exam although I have a discussion with the patient. ASA monotherapy is certainly OK if the patient prefers it. However, the downside to clopidogrel monotherapy is when a patient needs a procedure late...