Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients with AUD about non-alcoholic (NA) beverage consumption?
I am not aware of any data to help with answering this question, so I am here offering my expert opinion only. I think of non-alcoholic beverages similar to how I think about vaping nicotine. There are incontrovertible harms associated with both alcohol and inhaled tobacco. The harms of vaping nicot...
Do you change your pre-operative insulin dosing when patients are NPO for surgery, but also just recovering from newly resolved DKA?
For patients immediately recovered from DKA (e.g., within 72 hours), my first priority would be to delay any non-emergent surgery until the etiology of DKA has been evaluated and (if possible) addressed and the DKA has been definitively resolved with conversion off of continuous insulin and resumpti...
Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?
This is a good question. Extensive atraumatic ON of the femoral head will probably not respond to any medical therapy; eventually, the patient will need a replacement. However, ON that is from a systemic insult (drugs, alcohol) is often bilateral so if the other hip is less affected or not affected,...
How do you approach the management of older adult patients with dementia who repeatedly aspirate with oral intake but whose family/HCP may be unwilling to accept the aspiration risk associated with comfort eating?
This is a challenging situation where clinicians play a crucial role in providing education to families and caregivers. However, before we provide education, it’s important to assess the knowledge of families and caregivers around dysphagia and aspiration in persons with dementia (e.g., “What have o...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?
Assuming donor stool is available, if the patient is not expected to need another course of antibiotics in the foreseeable future, I would recommend FMT.
Would you use oral cefixime as an alternative treatment for early syphilis in cases of benzathine penicillin G shortages?
Based on in vitro activity against T. pallidum and the study you cite, cefixime 400 mg BID for 14 days likely is effective for treatment of early syphilis (Klementová et al., PMID 40795115). However, I see no advantage over the recommended option of doxycycline (100 mg BID for 14 days) when BPG isn'...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...