Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage daytime somnolence without a clear cause?
Throw a broad net out for the evaluation because we don't know how much has a physiological component and how much is mental/emotional. At intake, I get a moderately comprehensive set of labs. Rating Scales like HAMA, HAM-D, PHQ-9, Epworth Sleepiness Scale, and a ROS (Review of Systems) are done. I...
How would you approach the treatment of a patient with solid food esophageal dysphagia and GERD without a detectable esophageal stricture on upper endoscopy?
I would obtain a barium esophagram followed by high-resolution esophageal manometry and 48-hour esophageal pH testing.
When would you recommend uric acid-lowering therapy for a patient with asymptomatic hyperuricemia without comorbidities but with family history of gout?
I would not recommend treating asymptomatic hyperuricemia unless the patient has clinical gout or concern for proven urate nephropathy (such as with uric acid kidney stones). The family history component is important to acknowledge that the patient may be at greater risk in the future, however, it d...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
How do you counsel a patient with hypothyroidism who complains of persistent hypothyroid symptoms despite achieving normal TSH values with levothyroxine?
This is a complicated question without an easy answer. Many patients express dissatisfaction with their health status despite normal thyroid function (Peterson et al., PMID 29620972). Obviously, causes of symptoms other than hypothyroidism need to be ruled out such as anemia, autoimmune diseases, sl...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?
Overall, the risk of contrast-induced nephropathy is much less than what we fear. In many studies, we underutilize CT because we're concerned about contrast-induced nephropathy. If there is a good reason to get the CT with contrast, then I think it should be done. And just monitor Cr.
What are some practical ways to incorporate cardiac POCUS in the primary care setting?
In the primary care setting, I find cardiac POCUS most helpful for triage of undifferentiated patients and for monitoring of changes such as volume status, keeping in mind: Cardiac POCUS has a wide spectrum of accessibility for novice users, from systolic function and chamber sizes (attainable) thro...
What are some practical ways to incorporate cardiac POCUS in the primary care setting?
In the primary care setting, I find cardiac POCUS most helpful for triage of undifferentiated patients and for monitoring of changes such as volume status, keeping in mind: Cardiac POCUS has a wide spectrum of accessibility for novice users, from systolic function and chamber sizes (attainable) thro...
What is your strategy for counseling patients who don't qualify for colorectal cancer (CRC) screening under the current guidelines but are concerned with its increasing incidence at a younger age?
When counseling patients who are concerned about increasing rates of colorectal cancer among younger patients but do not qualify for screening based on current guidelines, I take the following approach: I try and elicit if there is any specific reason for their concern (signs, symptoms, family hist...