Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage a patient with inclusion body myositis?
IBM is a slowly progressive disease with no proven treatment to date, unfortunately. The goals of care are to delay decline and maintain remaining muscle strength. The cornerstone of treatment is physical/occupational therapy. Blood flow restriction seems to anecdotally help some patients, pending t...
When do you decide to use liothyronine (T3) for augmentation in treatment for treatment-resistant depression and how do you implement it?
The starting dose is between 5 and 25 mcg daily, and it escalates every 2-3 weeks but only after lab f/u results. Baseline FT4, T3,TSH and f/u labs. Avoid suppressing TSH excessively, to prevent osteoporosis.
In a patient with cryptogenic stroke while on antecedent aspirin 81 mg, how do you decide between single antiplatelet therapy, dual antiplatelet therapy, or antiplatelet agent combined with anticoagulation such as rivaroxaban 2.5 mg BID?
This question assumes that a thorough workup has been completed, and the patient does not have paroxysmal a fib, a PFO, an intracranial stenosis, a hypercoagulable state, or vasculitis. This workup is the most important issue. If all is negative, and the stroke is relatively minor (NIHSS less than o...
How would you best evaluate and manage a patient with hemiplegic migraine and a history of ischemic stroke?
Without further information, I would say that these two conditions, hemiplegic migraine and ischemic stroke, have nothing to do with each other. Hemiplegic migraine should be evaluated and managed as migraine with gepants ideal for abortive treatment and CGRP antibodies for preventive treatment if n...
Do you recommend repeat kidney stone composition testing for a patient with recurrent nephrolithiasis who passed an additional stone but previously already had stone composition testing performed?
Good question. Certainly, if there has been a gap in stone events prior to new development of stones, it is reasonable to confirm both the stone composition and the 24-hour urine chemistry, to see if conditions have changed in a meaningful way. It would be less important, if the patient had regular ...
Is the phosphorus-lowering benefit of patiromer compelling enough to switch a patient with chronic hyperkalemia and hyperphosphatemia from sodium zirconium cyclosilicate to patiromer?
I don't think so but I think Patiromer is a better agent anyway as it does not have sodium in it. Patients with CKD and especially dialysis patients are often volume overloaded. It definitely makes sense to use an agent that does not have sodium in it.
How do you titrate lithium for patients with bipolar affective disorder during pregnancy and immediately after delivery in the context of fluid shifts and changing levels?
Great question! Lithium clearance increases during pregnancy, and some women may require a dose increase to maintain therapeutic benefits. It is not my practice to prophylactically increase the dose during pregnancy, but I do recommend monitoring labs (lithium level, BUN and creatinine, and TSH) ea...
Would you treat a patient for heterotopic ossification prophylaxis if >72 hours after surgery?
RT is very effective in reducing heterotopic ossification that can happen after surgery/trauma to the hips. We have always been taught to do either before 24 or less before surgery or within 72 hours after surgery. The rationale is that RT prevents HO by the inhibition of osteoprogenitor cells proli...
How long do you monitor proteinuria after starting an SGLT-2 inhibitor before considering adding another medication if proteinuria is not at goal?
I would typically wait 2-3 months. Most such patients should be on RAAS blockade which should be maximized if tolerated first.
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
I would use DAPT for three months after the stroke. I do not see evidence for either anticoagulation or protracted DAPT for ICAD.