Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend dosing potassium citrate three times or two times daily for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I recommend twice daily dosing to help with compliance. I monitor 24-hour urine citrate and increase the dose rather than frequency if adequate urine levels are not achieved. Stephen B. Erickson, MD
Is there a particular prokinetic agent that you recommend if a patient has failed both PPI and TCA in the treatment of suspected functional dyspepsia?
In general, the evidence to support the use of prokinetics in functional dyspepsia (FD) is not strong. The rationale for using a prokinetic agent for FD is to improve gastric emptying time in the subset (about ¼) of patients who delayed gastric emptying which is usually mild. The three prokinetic ag...
Do you transition to oral antibiotics to treat uncomplicated Staphylococcus aureus bacteremia after patients have improved with intravenous antibiotic therapy?
I agree with Dr. @Dr. First Last, further these are tissue drugs more than bloodstream drugs. That’s why they don’t work well in bacteremia.
How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?
There are other causes of elevated bone alkaline phosphatase e.g. osteomalacia. Check blood calcium, magnesium and phosphate, PTH and 25-OH-vitamin D. If PTH is elevated and no CKD, check 24-hour urinary calcium and creatinine.
How do you approach pain management needs for patients well-established on buprenorphine/naloxone?
Buprenorphine has high affinity but low activity at mu receptors, and as a result, buprenorphine provides limited analgesia and will not likely provide adequate relief of severe pain in most patients.Continue suboxone treatment. In case of acute pain, consider oxycodone 5 mg tabs, 1-2 q 4 hours as n...
What is the preferred treatment regimen for cardiovascular syphilis, specifically syphilitic ostial coronary artery disease?
The standard treatment with benzathine pen G 2.4 MU IM, 1-3 doses at weekly intervals, depending on likely duration of syphilis, should be sufficient. Most likely there is no need for especially high dose penicillin therapy. I can understand a theoretical rationale for it, for urgent or potentially ...
What type of visual disturbance qualifies as a visual aura?
Visual aura should be a time-limited neurologic event (5 minutes to 60 minutes) with or without migraine headache. It can contain positive (e.g., flashes of light) and/or negative (e.g., scotoma) visual phenomena. It is often toward one side of the visual field but is binocular (comes from both eyes...
Do you typically obtain an EEG in patients undergoing workup for cognitive dysfunction?
I do not obtain an EEG unless something in the patient's history leads me to suspect seizures.
How do you transition patients between different long-acting injectable antipsychotics?
When it is time for the next dose of LAI #1, administer LAI #2 instead. Use an equivalent dose to produce equivalent dopamine receptor activity. To determine the equivalent dose, consider the maximum recommended dose of #1 to be equivalent to the maximum recommended dose of #2. With all the sophisti...
How often should lupus anticoagulant be checked in patients with SLE if prior was negative or if prior was positive?
The key question when considering retesting for any laboratory test, including antiphospholipid antibodies (aPL), is: How would a positive or negative result change the patient's management or prognosis? This question helps guide the decision-making process by focusing on the potential clinical impl...