Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the choice of basal-bolus insulin vs correctional insulin alone to manage hyperglycemia in a hospitalized older adult with type 2 diabetes and significant frailty?
Frail older adults with type 2 diabetes, compared to their less-frail counterparts, may have less predictable oral intake, and you may have more difficulty obtaining an accurate medication reconciliation. You may need to review facility records or speak to multiple collateral historians to find out ...
Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?
I advocate for the use of LMWH. I see a surprising number of patients on unfractionated heparin with PTTs indicating either homeopathic (<35s) or supratherapeutic (>120s) levels of anticoagulation. The 2025 ACC/AHA Guideline for the Management of Patients With Acute Coronary Syndromes summarizes cli...
Do you recommend fluid restriction in addition to other management strategies for patients with hyponatremia due to SIADH?
Fluid restriction is the mainstay of therapy in patients with SIADH. To correct hyponatremia due to SIADH, electrolyte-free water intake must be less than urinary electrolyte-free water excretion assuming no significant non-renal fluid losses. The degree of fluid restriction may be lessened by the u...
Is there anything you use for patients with anticipatory nausea who has failed Ativan and Zyprexa?
I know of no data, but I would consider hypnosis, mediation and mindfulness, cognitive behavioral therapy, acupuncture, and medical marijuana as possible options for anticipatory nausea refractory to lorezapam and Zyprexa. Hypnosis, mindfulness, and cognitive behavioral therapy are in a sense are re...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How have you integrated the new HPV self-swab collection into your routine cervical cancer screening, particularly in those with prior abnormal results?
I offer patients the option of an HPV self-swab when a speculum exam cannot be completed for various reasons (Eg: vaginismus, h/o pelvic trauma etc...) and patients have been relieved to have this option! Studies have shown that those with access to self-collected testing kits have higher screening ...
How have you integrated the new HPV self-swab collection into your routine cervical cancer screening, particularly in those with prior abnormal results?
I offer patients the option of an HPV self-swab when a speculum exam cannot be completed for various reasons (Eg: vaginismus, h/o pelvic trauma etc...) and patients have been relieved to have this option! Studies have shown that those with access to self-collected testing kits have higher screening ...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...