Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you choose among SSRIs and dosing strategies for the management of behavioral and psychological symptoms of dementia?
The best supported SSRI for BPSD generally is citalopram. Much of this came out of the CitAD trials [1]. This primarily showed citalopram may be useful for hyperactive behaviors, irritation, but also for depression and anxiety [1, 2]. The effect and response to citalopram, though, may be affected by...
How would you recommend using POCUS to evaluate jugular venous pressure?
I use it in essentially the exact same way I do with visualizing the JVP; put the patient at a 30-45 degree angle, and measure how far up the neck it goes. If you are able to easily visually estimate JVP, POCUS doesn't add much. However, in someone whose venous pulse is hard to see, POCUS has been h...
How would you recommend using POCUS to evaluate jugular venous pressure?
I use it in essentially the exact same way I do with visualizing the JVP; put the patient at a 30-45 degree angle, and measure how far up the neck it goes. If you are able to easily visually estimate JVP, POCUS doesn't add much. However, in someone whose venous pulse is hard to see, POCUS has been h...
How do you reassure families that no allergy testing is needed for urticaria?
I explain to them that it is an immunologic phenomenon (inside job) and not allergic (outside job).
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
How do you counsel patients about the potential benefits of laxatives when they are experiencing overflow diarrhea and are concerned about it getting worse with these medications?
I'll preface this by saying I rarely see this, and I will approach this answer as if this patient were in palliative care. But I think I would start with education on the mechanism of this type of diarrhea and the rationale for using laxatives to improve the situation. I would also discuss that, aft...
What therapies have you found most effective for JAK-induced/associated acne (JAKcne)?
Doxy will work quickly and is pretty safe. If all goes well, you can taper the dose of the oral antibiotic and use topical agents.