Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What clinical tools and/or thresholds do you use to determine driving risk among older patients with mild cognitive impairment?
I like to use the Clinical Assessment of Driver-Related Skills (CADReS). It reminds me to assess multiple domains, and reminds me which part of the MOCA is more pertinent to driving-related skills. If I have concerns, depending on the extent of my concern, I will either then file a concern with the ...
How do you approach recurrent, elevated PMN on wet prep in an asymptomatic patient that has negative STI testing and negative wet prep?
This is a great question and it would really depend on the situation. Firstly, why was a wet prep done in an asymptomatic patient? If it was just for STI screening, then I probably would not do anything unless the patient became symptomatic. For someone with bothersome discharge, I would consider al...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
How do you approach decision-making around initiation of osteoporosis therapy in patients with advanced dementia?
Great question, there are many things that I consider. First, I limit consideration of osteoporosis therapy to patients who have a life expectancy of 1 year or more. This is because the time to benefit from a bisphosphonate is estimated to be about 12 months (Deardorff et al., PMID 34807231). Assumi...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
What measures should we take regarding routine follow-up visits for well patients in surveillance during the coronavirus pandemic?
3-6 months.
How do you approach and manage anorexia and appetite loss in people with advanced cancer?
Anorexia/cachexia is often distressing to patients and families and it is this distress that is the target of many of the interventions for this syndrome as there are, in general, no effective therapies. Patients and families are routinely battling over the lack of eating as this causes further disc...
When do you consider starting short-term DAPT in patients who present more than 24 hours after the onset of a high-risk TIA or minor stroke syndrome?
Immediately. Unless tPA has been given, then at 24 hours.
Do you typically give GI prophylaxis when providing patients with steroid taper for status migrainosus?
I usually do a 3-6 day taper with prednisone, dexamethasone, or medrol dose pack for status migrainous. Occasionally, I have done a 12-day taper if the status migrainous is prolonged. I have not used GI prophylaxis.