Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
How do you balance the risks versus benefits of starting a statin in a patient with MASLD and a persistent but mild elevation in their AST/ALT?
I no longer hesitate to start a statin despite mild ast/alt elevation. I might just check lfts again in a few months, but if there is a clear indication for the statin we go ahead and do it.
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
How do you approach the management of aortic stenosis in an elderly, frail patient with multiple comorbidities who is symptomatic but considered high risk for surgical aortic valve replacement?
In an older patient with severe aortic stenosis (AS) who is not a candidate for surgery, there are 3 treatment options – TAVR, balloon aortic valvuloplasty (BAV), and medical management.In the original PARTNER trial, 358 patients with severe AS who, in the judgement of at least 2 cardiac surgeons, w...
Other than oxybutynin or mirabegron, what pharmacological and non-pharmacological treatments would you consider for increased urinary frequency (not caused by infection, medications, or resulting in incontinence)?
There are a lot of other treatment modalities, all with benefits and potential side effects to weigh. The place to start, of course, is with behavioral modifications like afternoon/evening fluid management, caffeine reduction, timed voiding, urgency suppression techniques ("biofeedback"), and pelvic...
What is your preferred treatment for arthralgias from AIs?
I usually reassure patients that this is common, and can improve on its own. Because everyone is different i give them options. Duloxetine has the advantage of improving arthralgias, hot flashes and mood. However, a lot of patients are opposed to taking more medication. Acupuncture is effective, and...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
Is there a maximum duration for raloxifene use?
There is relatively scant data on long-term raloxifene use in patients with osteoporosis, but generally, there are no recommendations for a drug holiday. The primary endpoint in the pivotal registration trial, MORE, was incidence of vertebral fracture, and the difference between the raloxifene and p...