Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you define treatment-resistant depression in your practice?
Well, technically, treatment-resistant depression is defined as no meaningful response after at least two trials of antidepressants at therapeutic doses and durations (≥8 weeks). The first step is to rule out inadequate dosing (try to reach the max dose), poor adherence, and medical comorbidities th...
How do you approach the treatment of anxiety disorders in children with a significantly family history of bipolar disorder?
First, I always question the validity of a family history of bipolar disorder and clarify as best as possible bipolar 1 vs. 2. Nine times out of ten, it is "mood swings" that with further clarification were never formally diagnosed and were anger outbursts/irritability. If there is bona fide bipola...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
Do you recommend starting with oral or intramuscular B12 supplementation in patients with newly diagnosed deficiency?
Good question - the answer has some nuances. When making this decision, I think about two things: 1) The severity of the deficiency/urgency of repletion and 2) the likely etiology of the deficiency. Regarding #1, if a patient has symptomatic anemia or neuropsychiatric symptoms, regardless of etiolog...
What treatment modalities have you had success with for treating extensive molluscum in the pediatric population?
I've had very good success with the use of oral cimetidine, 400 mg PO tid in children. Usually, they remain on this tx for 4-6 weeks with sig clearing beginning by the 1st 2-3 weeks. I also use tretinoin gel 0.1% qd-bid to the more stubborn lesions if necessary.
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
Do you start more than one medication for alcohol use disorder simultaneously (e.g., disulfram with gabapentin, acamprosate, or naltrexone) or do you start one agent at a time?
Depends on the patient and what medication they are opting to start. If they're having any post-acute withdrawal symptoms, one of my favorite combos is naltrexone + gabapentin, which is probably the situation I am most often starting multiple meds right off the bat. Otherwise, I generally try to avo...
How effective have you found acupuncture for treatment of chronic migraine?
I would prefer to educate a patient interested in acupuncture for severe headaches about all the other treatments that are available. However, if they would still like to pursue acupuncture, I would support them, just like Dr. @Dr. First Last would say. Some patients can get better, although it is n...
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...