Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you assess and counsel women with chronic post-lumpectomy or mastectomy pain?
Post-surgical breast pain is not uncommon. Estimates suggest that 25-60% of patients having breast surgery experience persistent pain, with symptoms lasting from months to years following breast cancer diagnosis and treatment (Langford et al., PMID 25439318; Gartner et al., PMID 19903919).Initial as...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
Is there anything you use for patients with anticipatory nausea who has failed Ativan and Zyprexa?
I know of no data, but I would consider hypnosis, mediation and mindfulness, cognitive behavioral therapy, acupuncture, and medical marijuana as possible options for anticipatory nausea refractory to lorezapam and Zyprexa. Hypnosis, mindfulness, and cognitive behavioral therapy are in a sense are re...
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
Are there instances when you recommend 48-hour ambulatory blood pressure monitoring over typical 24-hour studies for evaluation of patients with hypertensive kidney disease?
48-hour ambulatory BP monitoring can be helpful in gathering BP data for patients on hemodialysis with 3-day per week dialysis treatments. However, it is rarely done outside of research.
Are there instances when you recommend 48-hour ambulatory blood pressure monitoring over typical 24-hour studies for evaluation of patients with hypertensive kidney disease?
48-hour ambulatory BP monitoring can be helpful in gathering BP data for patients on hemodialysis with 3-day per week dialysis treatments. However, it is rarely done outside of research.
What workup do you recommend for patients with symptoms suggestive of saphenous neuropathy?
In most cases of isolated saphenous neuropathy, the etiology is pretty straightforward, as it usually occurs after surgery or injury/trauma at the medial knee. Another common cause of more distal saphenous neuropathy is saphenous vein harvesting for CABG surgery (less common nowadays). When there is...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
What duration of antibiotic therapy do you use for a loculated parapneumonic effusion that does not meet criteria for empyema?
It would be great to see more prospective research in this area. I think we should be a bit more nuanced in our approach as it seems to be crude to recommend 4 to 6 weeks of IV antibiotics for every parapneumonic effusion or complicated pleural space. I think that in melding the IDSA and American As...