Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What continuous duration of device defined atrial fibrillation burden warrants initiation of anticoagulation if the patient qualifies by CHA2DS2-vasc score?
The topic is very controversial and there is no agreement either on the continuous duration of a single episode or the total burden required to initiate AC. Most recommendations are expert opinions. I believe that 5 minutes is the most commonly accepted cutoff, which needs to be combined with an ass...
Do you prescribe silvadene cream for patients with a sulfa allergy?
No. I will consider hydrogel wound dressings in those situations
How do you advise an ESKD patient who wants to drink pickle juice to reduce intradialytic muscle cramps?
Salt is addicting! Acknowledge that changing habits is hard. Make a case that the reason for cramps is RATE at WHICH fluid is being removed. Ask the patient to recall the days when the goal of fluid removal was low. During those treatments, the risk and occurrence of cramps were less likely when com...
What patient factors are most important when considering who needs a broader workup for osteoporosis prior to starting therapy?
A workup to rule out secondary causes must be done prior to starting therapy for osteoporosis. A good history and exam are recommended to look for any clues for modifiable factors. At a minimum, one should do CMP, 25-OH vitamin D, TSH, and a 24-hour urinary calcium or calcium/creatinine ratio should...
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
How do you counsel patients with epilepsy who are interested in purchasing a seizure dog?
I recommend getting a dog because it can enhance their quality of life, similar to enjoying a glass of wine or relaxing in a Jacuzzi :-). However, I do not consider it as a medical treatment so it should be at their expense.
How do you recommend incorporating B-lines on lung POCUS as part of evaluating a patient's volume status?
Great question! As you allude to in your question, it is important to address this problem holistically in the context of the patient's history, exam, labs, and other imaging. I find that this happens all of the time, and here is how I typically break them down when applying lung ultrasound. 1) 1-2 ...
What is your approach to deciding when to stop therapy for cutaneous Mycobacterium chelonae infections?
I have an ongoing case of M abscessus cutaneous infection, possibly acquired from a pedicure. This is a similar bug to M chelonea, but even harder to treat. Our approach was to gather the opinion of several experts through email communication. The conclusion was to treat for 6-12 months, and follow ...