Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend progesterone for endometrial protection in a young woman on estrogen replacement therapy for iatrogenic menopause after definitive radiation therapy for locally advanced cervical cancer?
For women with a uterus, I give a combination of estrogen and progesterone therapy, even after definitive radiation therapy. Transdermal preparations have the advantage of bypassing first-pass effect of the liver, but oral combinations are also acceptable.
Would you consider recommending parathyroidectomy for primary hyperparathyroidism patients with high calcium and PTH levels, even without traditional criteria, based on recent studies showing reduced anxiety and depression?
Let the patient decide.
How do you define treatment-resistant depression in your practice?
Well, technically, treatment-resistant depression is defined as no meaningful response after at least two trials of antidepressants at therapeutic doses and durations (≥8 weeks). The first step is to rule out inadequate dosing (try to reach the max dose), poor adherence, and medical comorbidities th...
How do you approach the treatment of anxiety disorders in children with a significantly family history of bipolar disorder?
First, I always question the validity of a family history of bipolar disorder and clarify as best as possible bipolar 1 vs. 2. Nine times out of ten, it is "mood swings" that with further clarification were never formally diagnosed and were anger outbursts/irritability. If there is bona fide bipola...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
Do you recommend starting with oral or intramuscular B12 supplementation in patients with newly diagnosed deficiency?
Good question - the answer has some nuances. When making this decision, I think about two things: 1) The severity of the deficiency/urgency of repletion and 2) the likely etiology of the deficiency. Regarding #1, if a patient has symptomatic anemia or neuropsychiatric symptoms, regardless of etiolog...
What treatment modalities have you had success with for treating extensive molluscum in the pediatric population?
I've had very good success with the use of oral cimetidine, 400 mg PO tid in children. Usually, they remain on this tx for 4-6 weeks with sig clearing beginning by the 1st 2-3 weeks. I also use tretinoin gel 0.1% qd-bid to the more stubborn lesions if necessary.
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
Do you start more than one medication for alcohol use disorder simultaneously (e.g., disulfram with gabapentin, acamprosate, or naltrexone) or do you start one agent at a time?
Depends on the patient and what medication they are opting to start. If they're having any post-acute withdrawal symptoms, one of my favorite combos is naltrexone + gabapentin, which is probably the situation I am most often starting multiple meds right off the bat. Otherwise, I generally try to avo...