Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
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.
How do you counsel patients with epilepsy who are interested in purchasing a seizure dog?
I recommend getting a dog because it can enhance their quality of life, similar to enjoying a glass of wine or relaxing in a Jacuzzi :-). However, I do not consider it as a medical treatment so it should be at their expense.
How do you recommend incorporating B-lines on lung POCUS as part of evaluating a patient's volume status?
Great question! As you allude to in your question, it is important to address this problem holistically in the context of the patient's history, exam, labs, and other imaging. I find that this happens all of the time, and here is how I typically break them down when applying lung ultrasound. 1) 1-2 ...
What is your approach to deciding when to stop therapy for cutaneous Mycobacterium chelonae infections?
I have an ongoing case of M abscessus cutaneous infection, possibly acquired from a pedicure. This is a similar bug to M chelonea, but even harder to treat. Our approach was to gather the opinion of several experts through email communication. The conclusion was to treat for 6-12 months, and follow ...
Do you recommend increased screening for hypercortisolism in older patients given recent evidence that older patients do not commonly display hallmark symptoms of Cushing's Disease?
Well, the study you are referring reports that "younger patients were more likely to present with abdominal striae, acne, facial rounding, hirsutism, menstrual irregularities, and weight gain". Obviously, menstrual irregularities cannot be seen in postmenopausal women. As for the rest, I am not sure...
Is there a role for empiric scabies treatment in itchy patients without clear clinical signs of scabies?
I have seen many astute clinicians miss scabies or consider it after months of treating for AD with biologics and other systemics (including myself). Though this is very rare my personal rule of thumb is to treat with oral ivermectin if at any point patient is not responding the way I expect to trea...
What additional therapies can be helpful for vaginal dryness causing dyspareunia in premenopausal woman already using lubrication?
Not a lot of evidence for this particular situation. Can always try a daily moisturizer (Peplens) + lubricant. Anecdotally, many of my patients find coconut oil a good lubricant, superior to K-Y jelly.
How have you integrated the new HPV self-swab collection into your routine cervical cancer screening, particularly in those with prior abnormal results?
Unfortunately, the new HPV self-swab collection is not currently available in my institution, but I would definitely incorporate this into my routine cervical cancer screening if it were an option! I think the HPV self-swab option is ideal for patients who are either not amenable to a pelvic exam or...