Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
What are your preferred second-line medications for trigeminal neuralgia?
My FIRST-LINE medication for trigeminal neuralgia is botulinum toxin. I write about its application in face pain, including trigeminal neuralgia, in Chapter 16 of my book, HEADACHES: Why You Have Them - What You Can Do About Them.
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...
When do you consider extended steroid tapers for acute asthma or COPD exacerbations?
The data doesn't support extended tapers - 5 days of 40 pred equivalent are non-inferior, and extended courses can cause harm, including increases in mortality. I only use extended tapers for patients who have, in the past have rapid symptom recrudescence with the typical shorter course. Typically, ...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...
What is your approach to treating patients with decompensated heart failure when their hypervolemia is refractory to oral furosemide?
Depending on the oral dose, it may just be a problem of underdosing or even perhaps non-adherence. We would typically transition to intermittent IV Lasix dosing with close monitoring, if minimal response, we can double the dose to try and get to the ceiling effect of Lasix, depending on the renal fu...
Do you use daptomycin interchangeably with staphylococcal beta-lactams for ease of dosing on discharge for patients with serious MSSA infections (endocarditis, bacteremias, etc)?
I don’t use daptomycin interchangeably with antistaphylococcal beta-lactams for serious MSSA infections, and I think doing so routinely is a mistake. For invasive diseases like endocarditis, prolonged or complicated bacteremia, and deep-seated foci of infection, the outcome data consistently favor b...
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...