Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you lead a goals of care discussion in terms of prognosis/survival likelihood for patients with inotropic dependent HFrEF with CRT-D on maximally tolerated GDMT?
I usually start by reviewing the prognosis with inotrope-dependent HF, quote data from DT VAD trials (REMATCH). I assess the eligibility for DT VAD and transplantation and review the shared decision-making pathways (IDECIDE LVAD) if the patient is eligible for DT VAD. If the patient is not a candida...
Is there a role for cefpodoxime for treatment of acute cystitis caused by an Enterobacterales isolate with resistance to cefazolin, but susceptibility to ceftriaxone?
Yes – “sort of”. This is a much more complex question than it initially seems. First some background. CLSI has established a surrogate cefazolin breakpoint to predict susceptibility of urine isolates of Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis causing uncomplicated infection to...
How do you manage proteinuria in a patient with type 1 diabetes mellitus who has orthostatic hypotension and is unable to tolerate ACEi/ARBs?
I do agree with Dr. @Dr. First Last that orthostatic hypotension should be evaluated. This could include a 24-hour ABPM and/or careful home BPs + weight monitoring. If dysautonomia is suspected, then seeing a specialist for dysautonomia could be beneficial.Surprisingly, orthostasis symptoms improved...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...
In a patient with isolated HLA B27+ anterior uveitis, how long would you continue immunosuppressive therapy?
Although the majority of patients with Human Leukocyte Antigen B27 (HLA B27)-associated recurrent, acute anterior uveitis have some evidence of spondyloarthropathy, this disease does occur sometimes with clinical disease only in the eye. The disease is not usually chronic (i.e., lasting longer than ...
How would you manage an elderly patient with type 3 achalasia who previously underwent POEM and has recurrent dysphagia, high Eckardt score, and dilated esophagus concerning for blown-out myotomy on esophagram?
This is a complex clinical scenario which requires a multi-disciplinary approach at an expert center. One of the main goals is to decipher why the patient is still having symptoms. Is the patient is having symptoms due to persistent achalasia or due to the blown out myotomy. You can make this distin...
Do you ever delay starting levodopa in patients with Parkinson's disease?
With LEAP and the 5-year follow-up study, we can feel comfortable deciding to start patients early on levodopa to maximize quality of life via motor symptom control. In this study, there were no differences in UPDRS scores, the prevalence of wearing off, or levodopa equivalent daily dose between the...
Is there any utility to trending Histoplasma serology titers to guide duration of therapy or treatment response for pulmonary histoplasmosis with negative urine antigen?
Serology unfortunately is not useful to monitor response to therapy as the fall in titers is often very slow. In immunocompetent individuals, titers will often take a few years to show a significant drop in the antibody titer after successful treatment. The treatment duration should be guided by the...
Does a low serofast RPR titer (such as 1:1 or 1:2) in the setting of a remote history of appropriately treated latent syphilis in a patient with now uveitis of yet unknown etiology referred from ophthalmology for possible ocular syphilis make a diagnosis of ocular syphilis less likely?
I err on the side of offering empiric treatment. As syphilis rates have risen over the past 20 years, so has the incidence of syphilitic uveitis (Mir et al., PMID 37991790), and the question posed, therefore, represents a not uncommonly encountered conundrum for infectious disease consultants. Syphi...
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...