Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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...