Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
What specific criteria or patient conditions would make you hesitant to use fluoroquinolones early in the treatment course for managing MSSA joint infections with oral antibiotics?
For MSSA joint infections, I have moved away from using FQ to using high-dose cephalosporins as a step-down therapy, particularly cefadroxil 1 g twice daily, given less frequent dosing/increased adherence. Considering the risk-benefit analysis, I prefer using FQ as an oral option in polymicrobial an...
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
Do you consider use of oral antibiotics for complicated polymicrobial intra-abdominal infections?
Depends on how you're defining "complicated" IAI. Source control is key (I like this review: Source Control and Antibiotics in Intra-Abdominal Infections), especially if there's a fistula or anastomotic leak; but once an abscess is <5cm, if I have oral options that the patient can tolerate/dosed app...
How do you counsel your patients with diabetes that tighter glycemic control could be harmful as they age when they've been committed to a goal A1c% <7.0-7.5 for many years?
I counsel my elderly patients and their families that at a certain age, the risk of developing long-term sequela of diabetes (eye disease, kidney disease) becomes lower because those things take many years to develop. However, elderly people are more vulnerable to medication side effects, so we adju...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
What is your treatment algorithm for dissecting cellulitis of scalp?
I view dissecting cellulitis as a variant of HS (and we know it's a component of the follicular tetrad along with acne conglobata and pilonidal cysts). Anti-TNFa inhibitors and isotretinoin are preferred therapies for this condition with a high level of efficacy.
What is your approach to anticoagulation in patients with hypertrophic cardiomyopathy and an apical aneurysm?
Patients with hypertrophic cardiomyopathy and an apical aneurysm are at higher risk for sudden cardiac death (hence the 2a guideline recommendation for primary prevention ICD) and thromboembolism. Rowin et al., PMID 29122139 previously noted that non-anticoagulated HCM patients with apical aneurysms...
How do you recommend counseling patients on the prognosis of advanced cancer as a generalist who is not highly specialized in cancer literature or cancer-directed therapies?
Generalists can accurately prognosticate on the order of days to short months without specialized knowledge when caring for people with advanced cancer because the prognosis is often clinically obvious, and because most cancer-directed therapies take weeks to months to work (a patient may not live l...