Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you routinely provide anticipatory guidance about the genitourinary syndrome of menopause?
I talk to all women about vaginal dryness and pain with penetrative intercourse during well-woman exams when I am doing a pelvic exam, starting around age 40. I think it is helpful for them to be prepared for the possibility of GSM as they go through menopause. I emphasize how common it is and how w...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
Are there scenarios that new visits/consults with patients can be done virtually amidst the COVID-19 outbreak?
Starting 3/16, we began offering lower-complexity / lower-risk patients the option of having a Tele-medicine consult vs re-scheduling to a later date. This offer has been extended broadly to all new consults at our facility when the provider indicates that s/he can extend comparable service virtuall...
How do you monitor blood glucose levels in patients without preexisting diabetes who are starting capivasertib?
Capivasertib inhibits phosphorylation of downstream AKT substrates. By blocking AKT, an obligatory node in insulin signaling that mediates GLUT4-dependent glucose uptake in muscle and adipose tissue and suppresses hepatic glucose production, capivasertib reduces peripheral glucose uptake and increas...
Have you used lithium for agitation in dementia?
Non-pharmacologic approaches are first indicated. If they fail, then a psychotropic treatment algorithm is indicated, which generally starts with a serotonin reuptake inhibitor. Lithium would not be considered standard or first-line treatment for agitation in Alzheimer's disease, and in most other m...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
Would you recommend continuing Accutane in a teenage female who has experienced a drop in calcium to 8.8 and reductions in albumin and protein levels one month into therapy?
I am curious to know why these labs were checked? And isn't 8.8 a relatively normal calcium level?
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...
What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?
Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.I am a big believer in considering combination therapy as initial th...