Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
How do you approach the management of newly discovered prediabetes in adults over the age of 65?
We know that even at the same given HgA1c, a 90-year-old patient and a 30-year-old patient have different patterns in their day-to-day sugars. The 90-year-old patient will have a wider amplitude of sugars above and below a given average sugar level. Therefore, while a given HgA1c gives us an idea of...
What additional screening/management, if any, would you recommend to a patient whose annual mammogram showed heterogeneously or extremely dense breast tissue?
As of now, the USPSTF has stated that there is insufficient evidence to support adjunct screening modalities in women with dense breast tissue (category C or D). The other issue to consider is that some insurance does not cover adjunct screening since it is not considered "screening" per se. That sa...
What additional screening/management, if any, would you recommend to a patient whose annual mammogram showed heterogeneously or extremely dense breast tissue?
As of now, the USPSTF has stated that there is insufficient evidence to support adjunct screening modalities in women with dense breast tissue (category C or D). The other issue to consider is that some insurance does not cover adjunct screening since it is not considered "screening" per se. That sa...
How can I incorporate neuromuscular ultrasound into my practice with limited prior experience?
I think it's awesome when anybody is willing to implement a new tool into their established clinical workflow. My suggestion, if you are already an EMGer, would be to start small and simple with a focus on upper extremity focal neuropathy and practice, practice, practice.Carpal tunnel syndrome and u...
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...