Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to using stimulants in treating children with both ADHD and autism?
I think the most important thing to understand is that stimulants can be helpful but perhaps less frequently helpful and often with more side effects than in children with ADHD only. So low expectations with awareness of and preparation for the potential of significant worsening is key. A few other ...
Would you refer a patient for parathyroidectomy if they have normal calcium levels, mild hyperparathyroidism, and evidence of osteopenia?
It is important to be certain the patient has primary hyperparathyroidism by demonstrating by ultrasound or sestamibi scan the presence of an adenoma. Often patients with an elevated PTH and a normal calcium are also vitamin D deficient and have parathyroid hyperplasia. It is also important to rule ...
What are your recommendations for managing perivascular dermatitis with eosinophils unresponsive to high-dose antihistamines, a prednisone taper, and topical steroids?
I would check and treat for scabies.
What is your treatment algorithm for excoriation disorder?
Neurotic excoriation, also known as skin-picking disorder or excoriation disorder, is part of the obsessive–compulsive spectrum. There is no FDA-approved pharmacological treatment. The gold standard, evidence-based therapy is Habit Reversal Therapy (HRT), a form of cognitive behavioral therapy that ...
How frequently do you obtain lipoprotein (a) levels on asymptomatic patients without a prior history of CAD?
Recent recommendations are considering that the entire population ought to be tested at least once in their lifetime given the estimated prevalence in the general population of some degree of elevation in as many as 20% of the population. That said I certainly check in most people with a family hist...
What is your approach to patients who insist on testosterone replacement therapy despite normal testosterone levels on repeated labs?
I explain that with a normal testosterone level there is no indication for testosterone replacement. Hormone replacement is always about evaluating risks and benefits. With a normal testosterone level the risks outweigh the benefit. I offer to evaluate causes for patient’s symptoms such as sleep apn...
Do you adhere to the standard 5-day minimum treatment duration for community-acquired pneumonia, or have you used shorter courses for certain low-risk patients?
This is a question addressing a shorter duration of antibiotic therapy than the current IDSA guidelines for community-acquired pneumonia (CAP) recommend. It has been the topic of several studies, for example, 3-day treatment (Richard T. Ellison III, MD, reviewing Dinh et al., PMID 33773631; Niederma...
Do you recommend osteoporosis medication in postmenopausal females on anastrozole with very low Vitamin D (4.5)?
A vitamin D level of 4 is very low and should be corrected before any osteoporosis therapy is considered. Severe low D is associated with decreased Ca absorption and sometimes low serum Ca. Giving an anti-resorptive could result in hypocalcemia. Sometimes D levels that low are associated with muscul...
Are there any potentially successful pharmacologic interventions (instead of CBT or behavioral interventions alone) for Schizoid personality disorder?
This is a tricky question to answer in part because people with schizoid personality disorder do not typically present for treatment. If they do, it is often due to co-morbid symptoms such as mood or anxiety symptoms. Therefore, these symptoms are often what are targeted pharmacologically. People wi...
For patients with hypertension who have normal filling pressures following right cardiac catheterization, can hypertension still be attributed to volume overload?
I do not think of chronic hypertension as a disease of volume overload. Loop diuretics are indeed very poor antihypertensive agents. I agree that cardiac loading conditions are dynamic, but in a patient with normal filling pressures and hypertension, I would think of inappropriately increased periph...