Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
With the rise in home monitoring devices, how should we approach asymptomatic NSVT detected in healthy individuals with no prior cardiac history and with low risk cardiac profile?
With home monitoring devices, we are finding a lot of arrhythmias that would have previously remained unidentified. If episodes of NSVT are being found on home monitoring devices, the patient should receive a formal monitor to confirm NSVT. The formal monitor should be a Holter monitor that is able ...
How do you approach a referral for findings of intestinal metaplasia on a biopsy of an irregular z-line?
It is true that intestinal metaplasia of the GEJ is not Barrett's esophagus but it increases the risk of cancer like it is in the stomach. In the last 5-10 years, it has attracted more attention. Now, pathologists are starting to describe complete vs incomplete intestinal metaplasia. A good study wi...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...
How do you counsel patients struggling to decide if they wish to pursue an invasive diagnostic procedure to confirm a severe illness with poor prognosis and/or limited treatment options?
First, I would reassure them that there is no right answer to this question. What we're trying to do is to come up with an answer that the patient can be psychologically at peace with. Second, I would begin to inquire about what we will do with the information, or, to put it differently, how the inf...
How do you counsel patients struggling to decide if they wish to pursue an invasive diagnostic procedure to confirm a severe illness with poor prognosis and/or limited treatment options?
First, I would reassure them that there is no right answer to this question. What we're trying to do is to come up with an answer that the patient can be psychologically at peace with. Second, I would begin to inquire about what we will do with the information, or, to put it differently, how the inf...
What treatments have you found to be most effective in treating oral lichen planus?
Agree, have had good response with oral tacrolimus solution. Patients can work in nystatin mouthwash or clotrimazole troches +/- chlorhexidine gluconate oral rinse 0.12%. Dexamethasone solution may be rotated with the tacrolimus if desired (I've just used the lower strength 0.5mg/5mL, dose: 10cc, sw...
Do you favor 24 hour urinary metabolites over random urine collection when screening for MCAS?
In my practice, I currently use 24-hour urine metabolites. The 24-hour urine collection has been extensively validated and its use is supported by the literature (see review: Butterfield et al, PMID 35346887).That being said, a spot urine collection is now available and this is far more convenient f...
What therapies have you found most effective for JAK-induced/associated acne (JAKcne)?
Doxy will work quickly and is pretty safe. If all goes well, you can taper the dose of the oral antibiotic and use topical agents.