Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend starting with oral or intramuscular B12 supplementation in patients with newly diagnosed deficiency?
Good question - the answer has some nuances. When making this decision, I think about two things: 1) The severity of the deficiency/urgency of repletion and 2) the likely etiology of the deficiency. Regarding #1, if a patient has symptomatic anemia or neuropsychiatric symptoms, regardless of etiolog...
What treatment modalities have you had success with for treating extensive molluscum in the pediatric population?
I've had very good success with the use of oral cimetidine, 400 mg PO tid in children. Usually, they remain on this tx for 4-6 weeks with sig clearing beginning by the 1st 2-3 weeks. I also use tretinoin gel 0.1% qd-bid to the more stubborn lesions if necessary.
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
Do you start more than one medication for alcohol use disorder simultaneously (e.g., disulfram with gabapentin, acamprosate, or naltrexone) or do you start one agent at a time?
Depends on the patient and what medication they are opting to start. If they're having any post-acute withdrawal symptoms, one of my favorite combos is naltrexone + gabapentin, which is probably the situation I am most often starting multiple meds right off the bat. Otherwise, I generally try to avo...
How effective have you found acupuncture for treatment of chronic migraine?
I would prefer to educate a patient interested in acupuncture for severe headaches about all the other treatments that are available. However, if they would still like to pursue acupuncture, I would support them, just like Dr. @Dr. First Last would say. Some patients can get better, although it is n...
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
How do you approach the use and titration of Cobenfy in patients with treatment refractory schizophrenia not responding to clozapine?
It depends on what medications they are on. If they are on clozapine and you want to cross-titrate, then it will depend on the dose of clozapine and how fast you want to take it off, as we do not want cholinergic rebound. Let's say they are on clozapine 300 mg po qhs, then you can start Cobenfy at t...
Can rapid weight loss following GLP1 R agonist therapy lead to postprandial hypoglycemia and if so, what are the treatment options outside of dietary modifications?
This is a very interesting question but I am not sure that there is a clear published answer. Of course, we know that this class of medications can contribute to hypoglycemia in patients on insulin or SUs and in that situation the management would involve cutting back on the insulin or SU or decreas...
How do you approach incidental image findings with unclear clinical significance?
I approach them as findings, regardless of how they were acquired they need to be managed. In primary care one of the biggest drivers of malpractice cases is failure to act on a finding, just because it wasn't something you were directly looking for does not protect you. So manage the finding. Work ...
How do you approach incidental image findings with unclear clinical significance?
I approach them as findings, regardless of how they were acquired they need to be managed. In primary care one of the biggest drivers of malpractice cases is failure to act on a finding, just because it wasn't something you were directly looking for does not protect you. So manage the finding. Work ...