Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your typical approach to the use of beta blockers in the setting of recent cocaine use amongst patients presenting with cocaine-related MI, arrhythmias, or new-onset heart failure?
I favor using or continuing non-selective beta-blockers in patients presenting with acute cardiac manifestations of recent cocaine use. My preferred agent in this setting is carvedilol.
What is the youngest age and dose that you would consider for oral minoxidil?
I would consider prescribing oral minoxidil for children as young as 2 years old, but only if the condition is severe and does not respond to topical therapy.
What is your go-to strategy for non-opioid management of chronic low back pain in patients with limited access to physical therapy or behavioral health?
The short answer is that if pain fails to improve after three months of conservative management, patients should be referred to a board-certified pain physician for further evaluation and treatment. The long answer is that chronic pain management is a highly complex, multidisciplinary field that can...
What is your go-to strategy for non-opioid management of chronic low back pain in patients with limited access to physical therapy or behavioral health?
The short answer is that if pain fails to improve after three months of conservative management, patients should be referred to a board-certified pain physician for further evaluation and treatment. The long answer is that chronic pain management is a highly complex, multidisciplinary field that can...
Do normal methylmalonic acid levels absolutely rule out vitamin B12 deficiency?
An elevated MMA is a good indicator of B-12 deficiency but a normal level does not argue strongly against B-12 deficiency. Normal MMA levels have been reported in 10-25% of patients with known B-12 deficiency (B-12 levels below 100). Testing for an elevated homocysteine level might help but this tes...
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...
How do you manage pregnant individuals with newly diagnosed idiopathic intracranial hypertension?
Pregnancy in IIH is managed the same as if the patient did not have IIH with one caveat. IIH patients should stay within the recommended weight gain their obstetrician targets. Pregnancy is not a cause of IIH, but the excessive weight gain that can occur can trigger or worsen IIH. Labor and delivery...
How do you counsel parents of children with atopic dermatitis about preventing recurrent Staph infections?
For recurrent Staph infections, I recommend bathing daily, as well as giving a bleach bath 2-3 nights per week. If they are struggling with multiple or recurrent abscesses, and/or other family members are also having recurrent Staph infections, that is when I recommend intranasal mupirocin. I typica...
How long are you comfortable with keeping pediatric patients on oral antibiotics for acne?
I start all acne patients on a topical retinoid and if they need an oral antibiotic, I will prescribe that with a follow-up at 3 months. It takes about that long for a topical retinoid to kick in. If they need a couple of months longer, that's okay, but I might add topical or oral spironolactone to ...