Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...
How often and in what way do you monitor patients who are receiving teprotumumab (Tepezza) for thyroid eye disease?
A week or two after completion unless having an issue.
In an older adult hospitalized with recurrent falls, weight loss, without clear injuries, but with an inconsistent or difficult-to-reach caregiver, what findings would make you formally report suspected elder neglect and/or abuse?
I'm so glad that you're thinking about the possibility of abuse/neglect in this scenario! It's important to have it on our differential, or we'll always miss this diagnosis. First, it would be good to see if the patient can explain what is happening and provide contextual information that veers us a...
What is the goal oxygen saturation for patients with COPD and pulmonary hypertension?
Although an oxygen saturation target of 88–92% is commonly used in patients with COPD to reduce the risk of oxygen-induced hypercapnia, a higher saturation goal is appropriate in patients with pulmonary hypertension associated with COPD. In this population, we generally aim for an oxygen saturation ...
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
What key principles of consultative/peri-operative medicine would you emphasize for early-career internists/hospitalists serving in this role without much prior experience?
For completing a preoperative risk assessment: Take a systematic approach, hitting the high-yield systems/topics: Cardiac, pulmonary, DVT/PE prophylaxis, delirium, Diabetes/endocrine, Anticoagulants/antiplatelet agents, medications, clinical frailty, and other applicable to your patient (e.g., live...
How would you manage superficial thrombophlebitis of the great saphenous vein involving the knee and calf?
I would point you to an excellent algorithm created by Sherry Scovell on UpToDate, "Superficial Vein Thrombosis and Phlebitis of the Lower Extremity Veins" which has informed my practice. The highlights of the approach utilized are to perform imaging with Doppler ultrasound to determine the length o...
How do you decide between obtaining routine, outpatient ETT versus stress TTE when screening for CAD, especially given insurance company preference on ETTs?
Before getting into the opinion on the above question, it has to be said that the practice of utilizing any stress test to "screen" for coronary artery disease is currently frowned upon, and it is recommended that proceeding with a diagnostic workup should be based on the patient being both at risk ...
Is there a role for 24 hour urine stone risk profiles in your patients with known recurrent struvite kidney stones?
It depends. Pure struvite stones are not a metabolic abnormality; they are the consequence of a urease-producing urinary infection that splits urea to ammonium, raising the urine pH into the high 7-8 range, which in turn precipitates magnesium ammonium phosphate, otherwise known as struvite. Pure st...
How do you discuss the benefits and potential risks of anticoagulation for a strong indication (e.g., atrial fibrillation with high CHA2DS2-Vasc score) with older adult patients with frequent falls?
Current guidelines from AHA/ACC emphasize that oral anticoagulants should not be withheld simply because a patient is at risk of falling.Instead, I try to manage involving shared decision-making with the patient or DPOA that weighs stroke risk against modifiable bleeding and fall risk factors( with ...