Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you evaluate exercise induced hematuria that persists after one week of cessation of exercise?
Exercise-induced hematuria typically resolves within a week. If the hematuria persists after one week of cessation of exercise, further work-up of the hematuria is warranted. First, hematuria should be confirmed by excluding myoglobinuria and march hemoglobinuria. If hematuria is confirmed, then one...
Do you use combination therapy for persistent MSSA bacteremia?
I don’t think I’ve ever come across a situation where the problem wasn’t source control…
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
Do you recommend starting a statin in patients above 75 years old with diabetes but no known ASCVD?
The time to benefit (TTB) for statins in primary prevention of cardiovascular events is generally about 1.5 to 3 years. This means that adults aged 50 to 75 years typically need to take statins for at least 2.5 years to achieve a meaningful reduction in major adverse cardiovascular events (MACE), su...
Where does dronedarone fall in your list of antiarrhythmics drugs to use in terms of efficacy and patient selection in contemporary management of atrial fibrillation?
Dronedarone tends to be my last choice for treatment of AF to maintain sinus rhythm of all currently available oral antiarrhythmic meds available in the US - least effective and very expensive drug. I may use it in patients that I believe would be better served with catheter ablation- treatment with...
Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?
I advocate for the use of LMWH. I see a surprising number of patients on unfractionated heparin with PTTs indicating either homeopathic (<35s) or supratherapeutic (>120s) levels of anticoagulation. The 2025 ACC/AHA Guideline for the Management of Patients With Acute Coronary Syndromes summarizes cli...
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
Do you prescribe bronchodilators to patients with radiographic emphysema and respiratory symptoms, but no spirometric obstruction?
Yes, I will sometimes offer a therapeutic trial of bronchodilators to symptomatic patients with radiographic emphysema, but no obstruction on spirometry. Patients with CT evidence of emphysema were not specifically studied in the RETHINC trial.
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...