Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
Do you routinely hold anticoagulation (including pharmacologic VTE prophylaxis) for bedside procedures such as paracentesis, thoracentesis, and central venous catheter placement?
We do not hold anticoagulation of any kind for paracentesis. I also do not hold anticoagulation of any kind of thoracentesis, though some places will still ask things like Plavix or DOAC to be held. We do hold ppx and anticoagulation for LP due to the risk of epidural hematoma. I do not hold for the...
Do you ever use POCUS to evaluate for fecal impaction or stool burden in a patient with abdominal pain?
I have used POCUS in the evaluation of abdominal pain suspected of being constipation. I generally find it easiest to assess this in the right upper quadrant near the gallbladder, where you can often get a decent view of the ascending/transverse colon. If there is significant stool in the colon at t...
Do you ever use POCUS to evaluate for fecal impaction or stool burden in a patient with abdominal pain?
I have used POCUS in the evaluation of abdominal pain suspected of being constipation. I generally find it easiest to assess this in the right upper quadrant near the gallbladder, where you can often get a decent view of the ascending/transverse colon. If there is significant stool in the colon at t...
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
What is your approach to isolated alkaline phosphatase without other laboratory abnormalities?
Assuming none of the other LFTs are abnormal, I would get a GGT. If GGT is elevated --> likely a hepatobiliary issue. Would consider age, medical history, and risk factors. If persistently elevated, could consider RUQ US + MRCP. Conditions like PSC or PBC are frequently discovered due to asymptomati...
What is your approach to symptom management in patients with infectious diarrhea?
When it comes to infectious diarrhea, I would consider a short course of loperamide for symptomatic relief, provided that my suspicion for C. diff colitis and/or dysentery is low. Antimotility agents in the setting of toxin-producing infectious diarrhea can increase the risk of toxic megacolon (in C...
What is your approach to symptom management in patients with infectious diarrhea?
When it comes to infectious diarrhea, I would consider a short course of loperamide for symptomatic relief, provided that my suspicion for C. diff colitis and/or dysentery is low. Antimotility agents in the setting of toxin-producing infectious diarrhea can increase the risk of toxic megacolon (in C...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...