Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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 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...
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 ...
How do you approach the use of stimulants in patients with ADHD with previous or current substance use disorders?
I agree with Dr. @Dr. First Last about the use of non stimulants as an important intervention with these patients with the added caveat that Wellbutrin XL is highly abused by crushing it up and snorting it. Even this strategy has its limitations in addressing the issue of ADHD and Substance Use Diso...
How do you engage and approach a patient presenting with psychotic symptoms who has demonstrated a pattern of malingering and also has polysubstance use disorder?
This is a nice general summary of some basics, non-judgemental, supportive approach, quiet/low stimulation environment: Mental Health First Aid Guidelines. With regards to malingering and how to approach it, try to determine the real want/need (housing or food insecurity?) and if it is something tha...
How do you manage patients with alcohol use disorder who express interest in moderation rather than full abstinence?
In the past, I would try to engage these patients in complete recovery—AA, etc. Today, having read the literature on harm reduction and perhaps being more experienced and tolerant with age, I engage the patient in healthcare activities like exercise, sleep, and diet, and discuss recovery from alcoho...
How do you approach weaning patients off of buprenorphine?
I have found using injectable extended release buprenorphine (XR-BUP) as a good way to help patients taper off SL buprenorphine in a means much more tolerable than trying to taper SL buprenorphine. We published a case series on this approach (Ritvo et al., PMID 32925232) and subsequently another cas...
Have you incorporated National Acupuncture Detoxification Association (NADA) ear acupuncture into the treatment of substance use disorders?
No, not necessarily. Perhaps on a case-by-case basis, and with patient request, this option is considered. Don’t have evidence-based data to support its use.
What factors influence your decision to start salt tablets, urea, or a vaptan first in the management of a patient diagnosed with SIADH?
In patients with SIADH, free water intake has to be less than the urinary electrolyte-free water clearance in order for the serum sodium level to increase, assuming no significant extra-renal fluid losses. Therefore, if urinary electrolyte-free water clearance is very low, then free fluid restrictio...