Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage persistent pseudomonas positive sputum a patient with non-CF bronchiectasis who has chronic sputum production but is otherwise asymptomatic?
I am assuming the Pseudomonas has persisted despite efforts to eradicate early on; if not, I would consider at least an effort at "eradication" or at least aggressive treatment. If the Pseudomonas has persisted and the person feels well other than sputum production, would aggressively pursue airway ...
How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?
There are two types of autoimmune pancreatitis (AIP): type 1 AIP, which is synonymous with IgG4-related disease (IgG4-RD) involving the pancreas and makes up a large majority of AIP cases, and type 2 AIP, which is largely associated with inflammatory bowel disease. I am assuming from the question th...
Do you continue shots when a patient transfers under your care and has been receiving less than effective doses of AIT, but insist they have been effective?
Yes, I'd continue the shots. For some patients, even lower doses produce a meaningful desensitization and build tolerance. At some point, I would recommend retesting his allergies to objectively confirm the efficacy of the shots.
What is your preferred monotherapy antiplatelet agent to continue after completion of DAPT post-PCI for patients with stable ischemic heart disease?
For stable CAD that is more extensive, I have been using Plavix monotherapy based on data from HOST-Exam although I have a discussion with the patient. ASA monotherapy is certainly OK if the patient prefers it. However, the downside to clopidogrel monotherapy is when a patient needs a procedure late...
How do you decide whether to reinitiate a GLP-1 agonist after a patient has experienced acute pancreatitis while on this therapy?
Will not try it again, given the seriousness of the side effect, and in most cases, there are alternatives.
How do you counsel patients on GLP-1 agonists for weight loss who wish to space out their medication or take a "drug holiday" to temporarily increase their appetite?
Will not try it again, given the seriousness of the SE and given that alternatives are available.
Would you recommend against starting SGLT2 inhibitors in patients with a history of struvite nephrolithiasis who also have proteinuria and chronic kidney disease?
Yes! Although SGLT2 inhibitors are helpful in most patients with proteinuric chronic kidney disease, they can also exacerbate some coexistent conditions. Increasing glycosuria predisposes patients to UTIs. For patients with struvite stones, SGLT2s would likely exacerbate the infection and increase s...
What adjunctive therapies beyond an antisecretory agent (e.g., PPI, H2RA, etc.) do you find most helpful in managing the acute symptoms of PUD?
A meta-analysis of studies indicates that overall healing rates for duodenal ulcers with sucralfate range from 60% to 90% at 4-6 weeks of treatment. This data confirms sucralfate's effectiveness for its primary approved indication. The data for gastric ulcers is more nuanced and somewhat contradicto...
How would you prioritize physiotherapy and cognitive behavioral therapy for functional movement disorders in a resource-limited setting where access to both might be constrained?
I have a dedicated clinic for people with functional movement disorder/functional neurologic disorder (FMD/FND) in New York City and even in a city like New York, it is difficult or actually impossible to refer patients for appropriate therapy.For some people with rather straightforward cases, a ref...
What are some practical tips for caring for resource-limited patients with severe, Hurley Stage III hidradenitis suppurativa?
HS can be a really expensive disease, so this is a great topic. For wound care, ordering gauze and supplies through Amazon can be a big savings. Hidrawear, clothing made to hold bandages for HS, can also be covered by insurance. If you need order forms, you can reach out to the company www.hidrawear...