Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach adding colchicine to a patient who is on a stable statin regimen?
This is a good question and a tough situation, since the drug-drug interaction here can be as subtle as myalgias but as severe as rhabdomyolysis (rare but happens). If you can avoid long-term colchicine in this situation, it is always best. These situations (hypercholesterolemia and crystal arthropa...
What weight neutral language do you recommend to be used for charting in patients with obesity to avoid further medical stigmatization?
This is an interesting question which I have seen tackled in multiple ways by different providers, which I believe are all valid. There is a more common method of noting obesity as a condition rather than a characteristic of the patient. For example, "A patient with PMHx of Obesity" rather than "An ...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you decide when data patients bring to you for review/interpretation from a direct-to-consumer CGM is clinically useful and has it changed any of your management decisions in metabolically at-risk patients?
This is a tough question, as there is obviously published data for FDA-approved CGM devices, as published below: CGM Device Comparison | American Association of Clinical Endocrinology However, for those provided by independent companies, it would depend on whether or not they have independent third-...
Do you switch from 0.15 mg to 0.3 mg epinephrine at 55 lbs or 66 lbs?
Dr. @Dr. First Last, thank you for posting this question. I see variances in practice among both allergy and primary care practices on when a patient is prescribed the 0.3mg dose of epinephrine. Our practice is to switch patients to 0.3mg when they are 25 kg to prevent underdosing and inadequate res...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
What are your preferred second-line medications for trigeminal neuralgia?
My FIRST-LINE medication for trigeminal neuralgia is botulinum toxin. I write about its application in face pain, including trigeminal neuralgia, in Chapter 16 of my book, HEADACHES: Why You Have Them - What You Can Do About Them.
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...