Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
How do you counsel patients on pelvic floor physical therapy who are initially very hesitant to try it?
I typically will inform patients that I can understand the hesitation of pursuing pelvic floor physical therapy, as it involves exercising muscles in a sensitive area of the body. However, patients who have completed pelvic floor PT have a significant improvement in their symptoms, with some studies...
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...
Do you scale up 2nd generation anti-histamines to 4x daily in acute urticaria in the pediatric population as you do in adults?
Severe urticaria is certainly a therapeutic challenge. Updosing 2nd generation antihistamines in children has been studied, more trials need to be done. For refractory urticaria in children, I will often recommend 2X the recommended dose of a 2nd generation antihistamine in the morning and maximize ...
What therapies have you most effective in managing the pruritus associated with lichen amyloid?
Lichen amyloidosis itch would respond extremely well to Nemolizumab. See the report by Talias group. Makes sense as we found that IL31R and OSM are key factors in pathogenesis.Gabriela Soto-Canetti et al., JAAD Case Reports 2025If Nemo is not available, MTX works.Methotrexate for the Treatment of Re...
How do you decide the right time to transition to hospice?
Talking about hospice is one of the hardest jobs we have. It's hard because we don't like doing it, because we often don't know how to do it well, and because we angst about doing it too early or too late. It's an important thing to think about. I actually think perhaps the most important factor in ...
What is your preferred screening tool for colon cancer in an average-risk patient?
For their first time screening, I universally recommend a colonoscopy (in the absence of contraindications or social barriers) to evaluate for polyps, followed in 5-10 years by a yearly FIT or Cologuard every three years (unless the patient has a strong preference for a repeat colonoscopy). Repeat c...
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
In what situations would you recommend metformin in addition to aggressive lifestyle interventions for patients with prediabetes and obesity?
So based on studies such as the Diabetes Prevention Program and newer meta-analyses such as Comparison of the Efficacy of Metformin and Lifestyle Modification for the Primary Prevention of Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials (Vajje et al., PMID 38021728). Lifestyle modif...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...