Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
Are there instances when you recommend 48-hour ambulatory blood pressure monitoring over typical 24-hour studies for evaluation of patients with hypertensive kidney disease?
48-hour ambulatory BP monitoring can be helpful in gathering BP data for patients on hemodialysis with 3-day per week dialysis treatments. However, it is rarely done outside of research.
Are there instances when you recommend 48-hour ambulatory blood pressure monitoring over typical 24-hour studies for evaluation of patients with hypertensive kidney disease?
48-hour ambulatory BP monitoring can be helpful in gathering BP data for patients on hemodialysis with 3-day per week dialysis treatments. However, it is rarely done outside of research.
Do you recommend vitamin K2 supplements in patients with osteoporosis?
The answer, as with most vitamin supplementations, cannot be answered with high-level evidence to support a "yes or no". A bit of background and then a brief review of available evidence.Vitamin K is thought to be important for bone health because it activates several proteins involved in bone forma...
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
This happens all the time now. I tell them that those results were flagged as outside the reference range (I don't use the term abnormal) but that they are not clinically significant. It does not always work if there is a patient who is super anxious or hyper-focused. Typically, if they need a lot m...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
This happens all the time now. I tell them that those results were flagged as outside the reference range (I don't use the term abnormal) but that they are not clinically significant. It does not always work if there is a patient who is super anxious or hyper-focused. Typically, if they need a lot m...
Is there evidence that certain PPIs provide superior clinical efficacy compared to others in real-world practice?
While there are some differences between PPIs in terms of metabolism, bioavailability, and duration of acid suppression, generally speaking, in clinical practice, the efficacy of different PPIs is comparable. With that said, some differences include dexlansoprazole's dual-release nature which genera...
How do you approach prescribing statins in patients with an ASCVD <7.5% but have a strong family history and/or elevated LDL (but <190)?
When considering statin therapy for patients with an ASCVD risk of less than 7.5%, but with a strong family history of cardiovascular disease or elevated LDL cholesterol levels, the decision is nuanced. Here’s how I approach this situation: Shared Decision-Making: Involve patients in the discussion...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...