Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you decide when an older patient's weight loss warrants an extensive workup versus a more focused or watchful approach?
I always start with the standard cut off of 5% of normal body weight in 6-12 months. If this cut-off is met, then I probe about intentional or unintentional. Many older adults are not eating enough protein (they need more than the RDA recommendation) -- I encourage 1-1.3 (sometimes 1.5) g/kg protein...
How do you decide when an older patient's weight loss warrants an extensive workup versus a more focused or watchful approach?
I always start with the standard cut off of 5% of normal body weight in 6-12 months. If this cut-off is met, then I probe about intentional or unintentional. Many older adults are not eating enough protein (they need more than the RDA recommendation) -- I encourage 1-1.3 (sometimes 1.5) g/kg protein...
What are the clinical prompts that lead you to consider deprescribing bisphosphonate therapy in older adults with osteoporosis?
As a Geriatrician, the essence of my practice is to determine, on regular review (reconciliation), whether an older adult’s medication is appropriate to continue or continue at the same dosing on the basis of physiology, pathology, and/or risk modification. We know well today that medications for os...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
How do you approach a referral for findings of intestinal metaplasia on a biopsy of an irregular z-line?
It is true that intestinal metaplasia of the GEJ is not Barrett's esophagus but it increases the risk of cancer like it is in the stomach. In the last 5-10 years, it has attracted more attention. Now, pathologists are starting to describe complete vs incomplete intestinal metaplasia. A good study wi...
Do you recommend routinely monitoring pancreatic markers such as amylase and lipase while receiving GLP1 R agonist or dual agonist therapies to determine their risk of pancreatitis?
Absolutely not. We know that changes in amylase and lipase levels on these drugs are very common. For example, if you look at the supplementary data across the SUSTAIN series of phase 3 trials with subcutaneous semaglutide, the average person had about a 15-30% rise in their amylase/lipase. Further,...
How does the presence of myositis alter your interpretation of cardiac enzymes when evaluating acute chest pain?
Troponin T and CK-MB are not reliable for cardiac issues in myositis as regenerating muscles produce these enzymes. This is especially true if the patient has an active disease with weakness and CK elevation. Troponin I is not much affected by muscle enzymes and should be used as a parameter to eval...
Would you consider using steroids in patients with respiratory failure caused by aspiration pneumonitis?
For aspiration pneumonitis alone, typically no. If there are other indications for steroids, for example, acute COPD or asthma exacerbation, then I would. I would also focus on addressing the aspiration to prevent future events. I have also seen providers use antibiotics if aspiration pneumonia vers...