Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there a serum potassium level for when you would recommend discontinuing potassium citrate in a patient with recurrent nephrolithiasis, hypocitraturia, and hyperkalemia?
I take hyperkalemia seriously, as cardiac effects do not correlate closely with serum levels. If evaluation does not reveal a correctable cause, I would decrease potassium citrate dosage to keep serum potassium below 5.0. Stephen B. Erickson, MD
How would you approach surveillance imaging for men with early-stage, hormone receptor-positive breast cancer after unilateral mastectomy?
As always, appreciate others' input. If you're referring to systemic imaging, I do not obtain surveillance systemic imaging as part of surveillance for any patient with early-stage hormone-positive breast cancer (male or female) unless there are symptoms or initial labs that suggest possible metasta...
How would you approach surveillance imaging for men with early-stage, hormone receptor-positive breast cancer after unilateral mastectomy?
As always, appreciate others' input. If you're referring to systemic imaging, I do not obtain surveillance systemic imaging as part of surveillance for any patient with early-stage hormone-positive breast cancer (male or female) unless there are symptoms or initial labs that suggest possible metasta...
How do you approach the medical evaluation of new onset psychosis in elderly patients?
The medical evaluation of new-onset psychosis begins with a thorough history (medical, neurologic, and psychiatric history), including a history of the present illness, medications, as well as the use of alcohol and recreational drugs. Obtaining information from family or others who know the patient...
When do you send for genetic testing (e.g., SPINK1, PRSS1, CFTR) in a patient with recurrent or chronic pancreatitis without an obvious etiology and how does it impact your management?
I offer and discuss getting genetic testing in patients with idiopathic recurrent acute pancreatitis or chronic pancreatitis, more frequently in younger patients. Impact of testing can help identify undiagnosed CFTR patients, for whom further CF evaluation and management including options to try new...
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...
Would you use febuxostat for an African-American patient with gout and previous cardiovascular events (stroke, MI) who tested positive for HLA-B*5801?
Well, I would certainly avoid using allopurinol. The initial CARES trial raised concerns about the safety of febuxostat, using a median dose of 40 mg. The subsequent study FAST did not show any signals of CV disease using a median dose of 80 mg. The internal validity of the study was greater in the ...
Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?
There is little systematically collected information in this area on which to base judgments. A case series of 5 post-bariatric surgical patients treated empirically with liraglutide described reduction of hypoglycemic events based on patient history. In an experimental study comparing several treat...
What is your approach to a newly diagnosed LBBB in individuals >70 years old who are free of any signs or symptoms of heart disease and without other significant ASCVD risk factors besides age?
The presence of BBB; whether IVCD or RBBB or LBBB, signifies infranodal conduction delay from a myopathy. That myopathy may be hypertensive (LVH) or ischemic (LAD disease) or something less common (inflammatory etc). The ideal test would evaluate anterior septal LV thickness and vascular flow; it’s ...
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...