Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you implement antipsychotics in the management of agitation in Alzheimer’s patients?
The answer to how you implement antipsychotic medication in the management of agitation in a patient with Alzheimer's dementia involves several steps, outlined here: Ensure the agitation is not related to an acute medical condition and/or delirium. In this case, it is important to treat the underlyi...
What nutritional supplements do you recommend for patients with ALS?
I do not recommend specific supplements. If the question relates to the PEG formula, we use basic formulas and higher caloric versions if needed.
Do you recommend continuous glucose monitoring for patients with Type 2 diabetes who are not on insulin?
When CGM technology was first commercialized, the sensors were bulky, uncomfortable, not very accurate, expensive, and required calibration with a blood glucose meter. Now they are quite small, comfortable, much more accurate, much cheaper, and no longer require calibration. It is a matter of time b...
Would you start once-weekly tirzepatide over once daily basal insulin in a patient with Type 2 diabetes with inadequate control on oral antihyperglycemia drugs?
The issue examined in the paper cited of whether insulin or GLP-1RA is a better strategy in the setting of inadequate control of T2D was a hot question in the first part of this century but has been examined repeatedly and is now codified in global guidelines -- GLP-1RA should be used before insulin...
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
Do you recommend parathyroid imaging testing for patients with recurrent nephrolithiasis who are incidentally found to have an elevated PTH but who do not have hypercalciuria, hypercalcemia, hypovitaminosis D, or chronic kidney disease?
Yes, but with caveats. The “yes” is because hyperparathyroidism is a surgically curable disease if done by an experienced parathyroid surgeon. The caveat is if previous stone analyses have not shown a substantial calcium phosphate component, the stone formation may be due to other causes and unaffec...
What are preferred sleep aids in elderly patients with dementia?
Melatonin 3-6 mg because of their loss of melatonin-secreting potency with age. Doxepin 10 mg because of the cost of 3 and 6 mg versions. If restless legs or limb movements during sleep, gabapentin or pregabalin. Pregabalin can be better tolerated with less next-day sedation (also can be an issue wi...
Do you recommend obtaining a DEXA scan for patients with recurrent nephrolithiasis and hypercalciuria of unknown etiology?
I think this is an important question. I agree with Dr. @Dr. First Last. In my practice, if the patient is female, especially peri- or postmenopausal, I generally recommend a DEXA scan. If bone density is borderline or low, I typically refer the patient to an endocrinologist in our Bone Clinic for c...
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
Do you hold anticoagulation prior to performing bronchoalveolar lavage?
Can do BAL on anticoagulation. Anticoagulation does not increase the risk of bleeding for BAL.