Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...
What suggestions for environmental modifications do you find most helpful to reduce the risk of falls in the geriatric population?
Great question! The following recommendations encompass those that have been deemed cost-effective for fall prevention. The CDC STEADI program is also useful for reviewing these things. First, I would usually order home health PT/OT to do an assessment if the person has Medicare, and they will often...
What are your typical recommendations for when a patient can return to work following a cardiac arrest, considering the variation in neurological recovery and the potential ramifications based on the type of job?
Impossible to answer categorically. As the question implies, there are so many variables, including the nature of the job, physical demands, patient age, co-morbidities, and extent of neurological and psychological recovery. The latter may be the most important since return to work may be helpful or...
Do you counsel a mother to avoid certain food in her diet if she is still breast feeding and her child has confirmed IgE mediated food allergies?
Wangberg et al., PMID 33636342 surveyed a total of 133 breastfeeding mothers with allergic children. A total of 47.4% of mothers reported their healthcare provider encouraged them to continue breastfeeding without dietary restrictions, 17.3% were advised to continue breastfeeding but avoid eating th...
Do you routinely hold anticoagulation (including pharmacologic VTE prophylaxis) for bedside procedures such as paracentesis, thoracentesis, and central venous catheter placement?
We do not hold anticoagulation of any kind for paracentesis. I also do not hold anticoagulation of any kind of thoracentesis, though some places will still ask things like Plavix or DOAC to be held. We do hold ppx and anticoagulation for LP due to the risk of epidural hematoma. I do not hold for the...
Do you recommend the use of albumin-adjusted calcium measurement formulas to accurately assess calcium levels?
It is a reasonable approach to correct serum calcium using albumin when hypocalcemia is present, especially in a hospital setting. I believe it is less useful for evaluating hypercalcemia.Although it is reasonable to use albumin to correct serum calcium in patients with hypocalcemia it may be worthw...
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...
What topical therapies have you found most effective for managing scalp psoriasis?
For tough scalp psoriasis, I use an old regimen. 10% LCD 2% Sal acid in olive oil applied tiw x 1 hour under a shower cap. This is then washed out with a zinc-based shampoo followed by the application of a potent topical steroid. This is labor intensive but can be incredibly effective and sometimes ...