Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
What techniques do you use in the lab to reduce the amount of contrast that needs to be used in patients with CKD?
Avoid LV angiogram. Use ECHO instead to assess LV function.
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
Would you avoid SGLT2 inhibitors in patients with nephrostomy tubes?
I probably would unless a compelling reason to use. I worry about risk of infection and would imagine that depending on the reason for the nephrostomy tubes might limit the potential upside of using these agents. Maybe in future years as we gain more experience in non-study populations my answer wil...
For which patients could you consider direct oral amoxicillin challenge as opposed to skin testing for penicillin allergy de-labeling?
If a patient can be identified as low-risk by history they should be considered for either historical removal of the label of direct oral challenge. If the history is not compatible with allergy (e.g. they have a family history or have tolerated another drug like Augmentin), historical de-labeling i...
Is there a role for biologics to improve lung function in patients who have severe asthma with daily symptoms and reduced lung function but do not experience frequent exacerbations?
Biologic therapy in severe asthma not only reduce exacerbation but also improve lung function based on several RCT.
When do you recommend the use of oral testosterone replacement over injectable testosterone?
Oral testosterone was approved by the FDA for men who have low testosterone levels due to specific medical conditions, such as genetic disorders like Klinefelter syndrome or pituitary conditions causing damage to the pituitary gland.
How should we approach the management of PCOS in transgender men seeking virilization?
Manage metabolic aspects only by controlling risk factors for CVD, OSA, fatty liver disease.
How would you approach a finding of osteoporosis (Z score -4.5) in a recently postpartum patient who had DEXA sent for long-term low-dose glucocorticoid use?
Ensure adequate calcium, vitamin D, and magnesium. I would check the PTH level and a 24-hour urine for calcium and creatinine.
Do you recommend increasing dietary potassium intake for blood pressure management in non-CKD patients with hypertension?
Yes! The AHA guidelines from 2017 list a heart-healthy diet like the DASH diet (which has natural sources of potassium from fruits and vegetables) as strong recommendation (class I) supported by the highest level of evidence (level A). It is even recommended to use potassium supplements if not contr...