Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach the treatment of a patient with solid food esophageal dysphagia and GERD without a detectable esophageal stricture on upper endoscopy?
I would obtain a barium esophagram followed by high-resolution esophageal manometry and 48-hour esophageal pH testing.
Do you adhere to the standard 5-day minimum treatment duration for community-acquired pneumonia, or have you used shorter courses for certain low-risk patients?
This is a question addressing a shorter duration of antibiotic therapy than the current IDSA guidelines for community-acquired pneumonia (CAP) recommend. It has been the topic of several studies, for example, 3-day treatment (Richard T. Ellison III, MD, reviewing Dinh et al., PMID 33773631; Niederma...
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
How do you counsel patients interested in estrogen containing oral contraceptives who have migraine with aura?
Outside of patients whose attacks are suggestive of hemiplegic migraine, I do not typically avoid the use of estrogen-containing OCPs. While it is my understanding that a number of international organizations and many neurologists (as well as Ob/Gyn) recommend their avoidance, there are several revi...
When home BP readings are consistently lower than office measurements, how do you decide whether to intensify, maintain, or de-escalate antihypertensive therapy?
If the home readings can be confirmed to be appropriately measured (i.e., in a hard-backed chair with arm support and checking multiple repeated readings), then I will adjust BP medications to target the average home BP of <130/80 (going lower toward 120/80, if tolerated). However, I have had patien...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
Which factors favor extended dual antiplatelet therapy beyond one year in ACS patients with low bleeding risk?
Selecting an optimal duration of dual antiplatelet therapy (DAPT) for a given patient (whether "extended" or "short" in comparison to one year) must be personalized, with a calculus that considers an individual's competing risks of bleeding and thrombosis as a function of time.Accordingly, without b...
For opiate-related ileus in the postoperative setting, at what point do you consider trialing methylnaltrexone?
I personally have never used this particular PAMORA for post-op ileus. Despite some promising phase 2 trials indicating potential benefit, several Phase 3 RCTs evaluating this drug specifically for post-operative ileus showed no benefit in preventing nausea/vomiting or speeding up time to discharge ...
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...