Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend genetic testing for patients with a family history of polycystic kidney disease and who meet the imaging criteria, but the specific genetic variant in the family is unknown?
This is an interesting and evolving area. I think this is somewhat dependent on a patient's own interest after discussing the following things: In some cases, even with family history and imaging criteria, a genetic diagnosis may not be available from testing (due to inability to detect or perhaps i...
How does your approach to subsegmental PE differ from segmental PE both diagnostically and therapeutically?
My approach to subsegmental PE and segmental PE generally tends to be very similar. I am aware of the CHEST guidelines which indicate patients can safely be observed with subsegmental PE, but like a recent study showed (Rouleau et al., PMID 37531107), uptake of these guidelines is slow and many pati...
How do you manage patients with ice-pick headaches?
Ice-pick headaches, previously known as jabs & jolts and now often referred to as stabbing headaches, also manifest as stabbing face pain, which can be mistaken for trigeminal neuralgia due to lack of awareness. They can strike the head or the face suddenly, resembling lightning bolts. While common ...
Do you restrict topical diclofenac use in your patients with chronic kidney disease?
It is a great question. I normally don't but I always do it with a touch of hesitation. I believe the absorption is minimal but it also depends of the degree of use. At this time, when narcotics are in restricted use and oral NSAIDs are not a good option in patients with CKD, topical NSAIDs may be t...
Do you evaluate patients for low health literacy prior to discussing treatment options?
To answer this question - I do not routinely evaluate for low health literacy in my patients. This may not be the correct approach, but here is my rationale. I assume low health literacy and work up from there during each consultation. Even patients who are highly educated and/or have a background i...
In patients presenting with classical findings of primary hyperparathyroidism (i.e mild hypercalcemia, high 24hr urine calcium, elevated 1,25 Vit D but normal PTH), can spontaneous normalization of calcium be explained by episodic hypersecretion of PTH?
PTH secretion is always about 70% basal, related to the mass of parathyroid tissue, and about 30% episodic. Patients with primary hyperparathyroidism can have superimposed secondary hyperparathyroidism. High urinary calcium suggests a negative calcium balance. PTH is not "normal" if calcium levels a...
What is the optimal management of pain and loss of function due to pathologic compression fractures?
I explain to my patients if they have an acute compression fracture that they are likely to experience pain for approximately 2-3 weeks that will gradually resolve. I often give them some type of pain relief using Tylenol or ibuprofen and if severe, a more potent analgesic for a short period of time...
For how long would you treat Klebsiella aerogenes folliculitis of the face manifesting as a cystic lesion?
My recommendation would be to treat for 7-10 days. It is more typical to see gram-positive organisms causing facial folliculitis so I would choose an antimicrobial that has gram-positive coverage as well if possible, based on sensitivity. Additionally, I would ask the patient (if male, to change to ...
When would you consider treatment with steroids in patients with diabetic radiculoplexus neuropathy?
Steroids (pulse IV methylprednisolone) are the only treatment for diabetic amyotrophy supported by randomized placebo controlled trial (Dyck PJB et al., Neurology 2006; 66(5, Suppl 2):A191.) The soonest the treatment is started after onset of symptoms, the best. I will treat most patients presenting...
Do you recommend adjusted adult cancer screening for patients who have been on long term biologics and/or tsDMARDs since childhood?
I recommend routine adult cancer screening with the exception that I suggest annual dermatology evaluation for patients who are taking chronic immunosuppression.