Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage persistent, irregular menstrual bleeding following insertion of a hormonal IUD (assuming no structural abnormalities or coagulation disorders)?
Levonorgestrel IUDs are frequently used to control heavy menstrual bleeding, so it can be incredibly frustrating to patients (and physicians) when they don’t. It is important to remember that bleeding patterns following insertion of a Levonorgestrel IUD may be difficult to predict, but will generall...
Do you generally utilize calcium channel blockers on an as needed basis for patients with Raynaud's phenomenon?
Can certainly help when patients have conditions that trigger Raynaud's. If otherwise healthy, I discuss keeping the extremities protected from excessive cooling.
What should the LDL target be in patients with prediabetes and high lipoprotein (a) with family history of coronary artery disease?
I don’t think that using Lp(a) to guide treatment is quite ready for prime time yet. It’s an independent predictor of risk compared to the rest of the lipid panel, but as far as I am aware, we do not yet have data that treating people based on it makes a difference. What I may do in this scenario is...
Under what circumstances do you recommend POCUS guidance for lumbar puncture?
If the circumstances allow for it, I would use ultrasound for guidance for LP every time a LP is performed. This allows for continued practice in identification of the landmarks and improves accuracy in POCUS when it's truly needed, as in obese patients, where landmarks are difficult to palpate. Got...
What are some TTE findings that suggest worsening function of a bioprosthetic AVR that would require further surveillance or diagnostic imaging?
Doppler findings of an increasing transaortic gradient; 2D findings of decreased valve excursion and increased cusp calcification.
When evaluating an older adult patient for cognitive concerns, what is your process for deciding whether or not to refer them for neuropsychological testing?
When I'm deciding whether to pursue neuropsychological testing, this can come down to 2 questions: Will the results change management and/or prognosis? Can the person do the testing? 1) Will the results change management and/or prognosis?Many different aspects can inform this question. F.e., Is this...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
Do you start bisphosphonates after tapering off menopausal hormone therapy to prevent the rapid decline of bone mineral density?
Women lose one T-score unit (10-12%) of bone mass on average during menopause. Estrogen, as a part of menopausal hormone therapy (MHT), is approved by the FDA to prevent osteoporosis, but not for its treatment. Upon MHT discontinuation, women will experience a period of rapid bone loss, for which st...
Do you start bisphosphonates after tapering off menopausal hormone therapy to prevent the rapid decline of bone mineral density?
Women lose one T-score unit (10-12%) of bone mass on average during menopause. Estrogen, as a part of menopausal hormone therapy (MHT), is approved by the FDA to prevent osteoporosis, but not for its treatment. Upon MHT discontinuation, women will experience a period of rapid bone loss, for which st...
Do you pursue a malignancy workup beyond age-appropriate malignancy screening in patients with antibody negative necrotizing myopathy?
This is a great question that speaks to the nuanced (and still-being-elucidated) association between malignancy and the increasingly better sub-divided different autoimmune myositis subtypes:While anti-SRP and anti-HMGCR are the two myositis-specific antibodies (MSA) most closely associated with imm...