Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What strategy do you find most effective for outpatient induction of buprenorphine in opioid use disorder?
The method for induction of Buprenorphine for OUD needs to be tailored for the specific patient and the environment. The standard induction was introduced during the time when heroin was the most common opioid being used on the streets, as well as diverted prescription narcotics. Also it was mainly ...
What strategy do you find most effective for outpatient induction of buprenorphine in opioid use disorder?
The method for induction of Buprenorphine for OUD needs to be tailored for the specific patient and the environment. The standard induction was introduced during the time when heroin was the most common opioid being used on the streets, as well as diverted prescription narcotics. Also it was mainly ...
How do you approach requests from facilities requesting a urinalysis (either on demand or PRN) for "behavioral changes"?
First, I would do a happy dance (discreetly, of course) because rather than asking me to prescribe a psychoactive medication, the facility thought about the possibility that a behavior change has an underlying medical cause. And before getting too distracted by the request for a UA, I would get more...
Would you consider using steroids in patients with respiratory failure caused by aspiration pneumonitis?
For aspiration pneumonitis alone, typically no. If there are other indications for steroids, for example, acute COPD or asthma exacerbation, then I would. I would also focus on addressing the aspiration to prevent future events. I have also seen providers use antibiotics if aspiration pneumonia vers...
Do you routinely prescribe oral antifungals for seborrheic dermatitis?
The most common indication when I have prescribed an oral anti fungal is when the seborrheic dermatitis extends beyond the scalp, such as on the sternum and/or face (petaloid), and has failed topicals. With that much widespread distribution, adequate application of topical treatments can be very cha...
Do you routinely hold OCPs to assess menopausal status, and if so, for how long?
This is a good question. Obviously, OCPs will mask a woman's menstrual cycle. In order to see if someone is truly menopausal, you will need to stop OCPs. It is unclear for how long, though. In my practice, it depends on whether the woman has pregnancy potential. If no, you can just stop the OCPs and...
Do you routinely check PSA before starting finasteride?
I tend to grab a PSA prior to starting higher doses of finasteride for BPH treatment, given these patients are older and may have a different risk profile for prostate cancer. I am less inclined to grab a PSA prior to starting it for younger patients using lower doses of finasteride for male pattern...
How do you treat patients with stroke thought to be secondary to Lambl excrescence?
Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
Do you use lactulose in acute liver failure, particularly in patients on continuous renal replacement therapy (CRRT) for ammonia or toxin clearance?
Generally lactulose should be avoided in the situation given limited benefit as well a tendency for ileus in ALF and potential for lactulose to cause bowel distention.