Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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...
How do you manage injection site reactions in patients on subcutaneous biologics such as TNF inhibitors?
Injection site reactions are not infrequent, though the majority are self-limited and do not result in discontinuation of the drug. For those uncommon few individuals whose skin lesions are more prominent and symptoms (such as pain and itch) are aggravating, I first review that they are properly sel...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
What treatments do you consider for cholinergic urticaria refractory to high dose H1 blockers and omalizumab?
Generally, my initial approach to cholinergic urticaria (CholU) is the same for chronic spontaneous urticaria and other forms of chronic inducible urticaria [1]. Most patients with antihistamine-refractory cholinergic urticaria (CholU) will respond to omalizumab 300 mg monthly. Those individuals wit...
Would you start stone preventative medications such as potassium citrate and thiazide diuretics for patients with recurrent calcium based nephrolithiasis and abnormal 24 hour urine chemistries if they no longer have calculi on most recent imaging testing?
If they have had stones previously they remain at risk of recurrent stones. Would want to know when was the last stone episode. Was there previous treatment? It would be based on the results of the 24 hr urine and how significant is the hypercalciuria, oxaluria, low the citrate and pH are. Most impo...