Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you discuss the importance of ongoing lifestyle-based interventions when starting a GLP-1 agonist for medically relevant obesity (i.e., with comorbid conditions)?
I discuss the importance of ongoing lifestyle interventions by going back to the primary research for the corresponding GLPs. I point out the fact that in many of the trials, both the control group and the experimental groups would have some form of therapeutic lifestyle change (usually a mix of edu...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
What is your preferred treatment for actinic cheilitis?
PDT is effective as well as an ablative laser for long-term control. Efudex or imiquimod for multiple weeks is good for localized or milder disease. Consider getting a biopsy if you’re concerned for invasive SCC. Encourage them to use sunscreen too.
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...
Do you recommend boric acid for patients with recurrent candida vulvovaginitis?
Yes, this will be effective at 600 mg bid for 2-4 weeks. However, with recurrence, it is important to obtain a fungal culture to document species and susceptibility.
What additional workup would you perform to evaluate a new onset of spontaneous hemarthrosis?
The workup that you've outlined is essentially complete. Would rule out any possible medication/supplement effects, Would consider the possibility of a vascular fragility syndrome (EDS) or other connective tissue disease, Would rule out vitamin C deficiency, If there is other bleeding that clinical...
Do you still consider propranolol first-line for sinus tachycardia in thyroid storm, or have newer perspectives on beta-blocker risks altered your management?
Yes, but...Propranolol remains the first-line option for thyroid storm, but recent evidence supports that beta-1 selective agents (metoprolol, atenolol) are equally effective and may be preferred in certain clinical contexts. The choice between propranolol and cardioselective beta-blockers should be...
How do you manage/treat acute radiation-induced enteritis?
I have no problem with the excellent comments already made. However, I think it is important to add some comments. First - one needs to be sure that the patient truly has radiation enteritis. Many patients receiving abdominal radiation therapy have other issues that need to be explored first. For ex...