Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
What nutritional supplements do you recommend for patients with hair loss?
Protein 30-40 grams a day. These skinny dieters who only eat fish aren't getting enough. I do check iron and ferritin and get ferritin to at least 50, even 60-70 for shedding hair. I really like untangled by foundation skincare.
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
Has the recent large observational data suggesting that continuing metformin during hospitalization is associated with lower post-discharge mortality and hypoglycemia changed your approach to holding it on admission in stable, non-critically ill patients with T2DM?
I really like this paper, but I don't think it is plausible that a 5-day difference in receipt of metformin (the median length of stay was 5 days) could really affect 90-day mortality.The study question is a good one because the evidence that metformin causes lactic acidosis is extremely limited. In...
What resources or interventions do you provide to older adults who are experiencing financial mistreatment/scams?
The intervention I recommend depends on the type of mistreatment. If there is suspicion of elder financial abuse (e.g., a family member is taking money away from the patient without the patient's permission/knowledge), then you may be obligated to report this suspected abuse to appropriate authoriti...
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?
Large volume paracentesis (LVP) can lead to complications such as post paracentesis circulatory dysfunction. In patients who have ongoing acute renal failure, patients with borderline low blood pressure, or in patients who have a history of hyponatremia, LVP should be limited to 5L.
What therapies have you most effective in managing the pruritus associated with lichen amyloid?
Lichen amyloidosis itch would respond extremely well to Nemolizumab. See the report by Talias group. Makes sense as we found that IL31R and OSM are key factors in pathogenesis.Gabriela Soto-Canetti et al., JAAD Case Reports 2025If Nemo is not available, MTX works.Methotrexate for the Treatment of Re...
What is your approach to the management of pressure ulcers in bedbound older adults who are community-dwelling?
Management of pressure ulcers in bedbound community-dwelling older adults centers on three pillars: Pressure off-loading, nutritional optimization, and stage-appropriate wound care, supported by an interdisciplinary approach that includes caregiver education. Pressure Off-Loading This is the single ...