Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What screening tools or signs do you use to predict if a cancer patient is near end-of-life?
For most of us, long-time practicing oncologists, all we have to do to determine that one of our patients is at the end of their life is to be in the same room with them. No special computer programs or calculators are needed. Just look closely at the patient's current weight, their level of conscio...
How do you decide when to initiate buprenorphine for chronic pain?
Typically, I initiate buprenorphine for chronic pain in two scenarios: The patient's providers are no longer willing to prescribe full-agonist opioids. This typically happens when there is concern about misuse. Buprenorphine is a good option for these patients because of its partial agonism, making...
What is the optimal number of days to hold apixaban prior to a kidney biopsy or tunneled dialysis catheter placement?
If the patient has normal or mild renal impairment (≥30 mL/min), I will hold apixaban for 2 days prior to the procedure. If the patient has moderate to severe renal impairment (<30 mL/min), I will hold apixaban for 3 to 4 days prior to the procedure.
Do you consider testing and treating IDA in unexplained thrombocytopenia?
Iron deficiency often causes thrombocytosis, and in fact, probably is the most common cause of reactive thrombocytosis encountered in clinical practice. With very severe iron deficiency, thrombocytopenia can be seen. I have seen it in rare patients presenting with hemoglobin levels about 3 gm/dL or ...
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.
What is your approach to genetic counseling prior to obtaining genetic testing in young asymptomatic patients suspected of having autosomal dominant polycystic kidney disease?
If you feel comfortable, a nephrologist who sees a lot of PKD patients is usually capable of doing the counseling. For me, I discuss the pros and cons and alternatives to genetics testing such as imaging, which has limitations at young ages, and considering blood pressure monitoring and other genera...
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?
There is little systematically collected information in this area on which to base judgments. A case series of 5 post-bariatric surgical patients treated empirically with liraglutide described reduction of hypoglycemic events based on patient history. In an experimental study comparing several treat...
Would you consider opting for beta blocker withdrawal to improve exercise capacity in patients with heart failure with preserved ejection fraction and chronotropic incompetence?
The short version of my answer is Yes, however, I will provide more insight into this: When considering beta-blocker withdrawal to improve exercise capacity in patients with HFpEF and chronotropic incompetence, the evidence and guidelines are nuanced. A prospective, randomized, controlled trial "Pre...
Do you routinely check an ECG in the ambulatory setting in patients without a cardiac history when starting a medication that can potentially prolong QTC?
I do not. Typically, the drugs I use that could be QTc-prolonging are short-term medications and are low dose. However, if there is a potential for longer use (>2-4 weeks) or dosages that are not typical, I will typically err on the side of caution and check an ECG prior to committing them to extend...