Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What patient factors are most important when considering who needs a broader workup for osteoporosis prior to starting therapy?
A workup to rule out secondary causes must be done prior to starting therapy for osteoporosis. A good history and exam are recommended to look for any clues for modifiable factors. At a minimum, one should do CMP, 25-OH vitamin D, TSH, and a 24-hour urinary calcium or calcium/creatinine ratio should...
How do you counsel patients with osteoporosis and cervical spine osteoarthritis who are considering chiropractic cervical manipulation or traction?
I am concerned with the risks of actually causing a fracture or nerve impingement/damage. So, I would recommend against.
What clinical tools and/or thresholds do you use to determine driving risk among older patients with mild cognitive impairment?
I like to use the Clinical Assessment of Driver-Related Skills (CADReS). It reminds me to assess multiple domains, and reminds me which part of the MOCA is more pertinent to driving-related skills. If I have concerns, depending on the extent of my concern, I will either then file a concern with the ...
How do you approach recurrent, elevated PMN on wet prep in an asymptomatic patient that has negative STI testing and negative wet prep?
This is a great question and it would really depend on the situation. Firstly, why was a wet prep done in an asymptomatic patient? If it was just for STI screening, then I probably would not do anything unless the patient became symptomatic. For someone with bothersome discharge, I would consider al...
How do you approach and manage anorexia and appetite loss in people with advanced cancer?
Anorexia/cachexia is often distressing to patients and families and it is this distress that is the target of many of the interventions for this syndrome as there are, in general, no effective therapies. Patients and families are routinely battling over the lack of eating as this causes further disc...
Do you typically give GI prophylaxis when providing patients with steroid taper for status migrainosus?
I usually do a 3-6 day taper with prednisone, dexamethasone, or medrol dose pack for status migrainous. Occasionally, I have done a 12-day taper if the status migrainous is prolonged. I have not used GI prophylaxis.
What recommendations do you provide to patients on isotretinoin about timing of tattoos?
No specific recommendations due to the absence of robust data
Should there be a role for sacubitril-valsartan in the management of patients with heart failure with preserved ejection fraction?
When it comes to HFpEF, we don't have a lot of effective therapies in our armamentarium. SGLT2 inhibitors have known cardiovascular benefits and were shown primarily to reduce hospitalization in EMPEROR-Preserved and DELIVER. Arguably, spironolactone can be included here despite a trial (TOPCAT) tha...
Do you routinely order karius in evaluation of culture negative prosthetic valve endocarditis?
Don’t “routinely” order Karius test. Rarely, in culture-negative suspected endocarditis, especially if a prosthetic valve is present. Once for suspected culture-negative aortic graft infection. 3x for culture-negative meningitis. Likely to become more frequent but adoption very dependent on cost an...
Should GLP-1 agonists be held during chemotherapy?
I think there are several aspects to this question. First, is there evidence that as a class GLP-1 RAs increase the risk of cancer or worsen prognosis during cancer? I could find nothing to raise concerns about outcomes. One recent report even showed a decreased risk of some cancers with GLP-1 RA co...