Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider recommending parathyroidectomy for primary hyperparathyroidism patients with high calcium and PTH levels, even without traditional criteria, based on recent studies showing reduced anxiety and depression?
It depends on several factors. If the patient is suitable for surgery without any major significant risk factors then I would definitely proceed especially with a surgeon who has a lot of experience with parathyroidectomy.
How do you define treatment-resistant depression in your practice?
Well, technically, treatment-resistant depression is defined as no meaningful response after at least two trials of antidepressants at therapeutic doses and durations (≥8 weeks). The first step is to rule out inadequate dosing (try to reach the max dose), poor adherence, and medical comorbidities th...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
How do you suggest incorporating POCUS into the evaluation of SSTIs, and do you use this as a means to guide initial antibiotic selection?
I routinely incorporate POCUS into my SSTI evaluation because it reliably distinguishes simple cellulitis from purulent infection, which directly guides my initial management. A quick bedside scan allows me to rule out a drainable abscess. If the scan shows only cobblestoning without a fluid collect...
Do you recommend starting with oral or intramuscular B12 supplementation in patients with newly diagnosed deficiency?
Good question - the answer has some nuances. When making this decision, I think about two things: 1) The severity of the deficiency/urgency of repletion and 2) the likely etiology of the deficiency. Regarding #1, if a patient has symptomatic anemia or neuropsychiatric symptoms, regardless of etiolog...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
Do you start more than one medication for alcohol use disorder simultaneously (e.g., disulfram with gabapentin, acamprosate, or naltrexone) or do you start one agent at a time?
Depends on the patient and what medication they are opting to start. If they're having any post-acute withdrawal symptoms, one of my favorite combos is naltrexone + gabapentin, which is probably the situation I am most often starting multiple meds right off the bat. Otherwise, I generally try to avo...
How do you approach the use and titration of Cobenfy in patients with treatment refractory schizophrenia not responding to clozapine?
It depends on what medications they are on. If they are on clozapine and you want to cross-titrate, then it will depend on the dose of clozapine and how fast you want to take it off, as we do not want cholinergic rebound. Let's say they are on clozapine 300 mg po qhs, then you can start Cobenfy at t...
Can rapid weight loss following GLP1 R agonist therapy lead to postprandial hypoglycemia and if so, what are the treatment options outside of dietary modifications?
This is a very interesting question but I am not sure that there is a clear published answer. Of course, we know that this class of medications can contribute to hypoglycemia in patients on insulin or SUs and in that situation the management would involve cutting back on the insulin or SU or decreas...
How do you approach incidental image findings with unclear clinical significance?
I approach them as findings, regardless of how they were acquired they need to be managed. In primary care one of the biggest drivers of malpractice cases is failure to act on a finding, just because it wasn't something you were directly looking for does not protect you. So manage the finding. Work ...