Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage an ESKD patient who complains of severe fatigue after hemodialysis, but does not experience intradialytic or post-dialysis hypotension and has not responded to dry weight adjustments?
Difficult but unfortunately not uncommon situation. My theory is that more frequent dialysis would be beneficial to avoid dramatic electrolyte and fluid shifts that occur with intermittent hemodialysis. Would see if peritoneal dialysis or home hemodialysis would be an option. If not, maybe 4 days pe...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
What is your preferred approach to a patient with incidentally found low ceruloplasmin?
I repeat it, but also take a thorough history and physical with attention to a diagnosis of Wilson's disease. If repeat comes back less than 19 again, then 24 urine copper and liver US/fibroscan, and maybe optho exam.
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
What is your preferred workup for a patient who has a biopsy consistent with “dermal hypersensitivity reaction”?
When encountering a patient with a biopsy consistent with "dermal hypersensitivity reaction," it's crucial to acknowledge the inherent non-specificity of such a diagnosis. In my role as the Director of the Contact Dermatitis Clinic at Penn, I've found that clinical pathologic correlation becomes inv...
Do you use combination therapy for persistent MSSA bacteremia?
I don’t think I’ve ever come across a situation where the problem wasn’t source control…
In a patient with selective IgM deficiency who is completely asymptomatic in terms of infections, what is your typical laboratory work up?
B cell phenotyping, lymphocyte subsets, IgG to diphtheria, tetanus and S pneumonia. Evaluate the humoral function, as it is important to know and possibly follow with time, but with an asymptomatic treatment is not warranted.
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...