Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you ever consider oral doxycycline for treatment of either gram-negative or gram-positive uncomplicated bacteremia?
I would not consider this a first or even second-line option due to the poor serum levels that are achieved. I supposed that this could be used for "mop up" therapy, but in such cases, it's almost as if you are using the doxy to treat yourself rather than the patient.
Do you recommend genetic testing for patients with a family history of polycystic kidney disease and who meet the imaging criteria, but the specific genetic variant in the family is unknown?
This is an interesting and evolving area. I think this is somewhat dependent on a patient's own interest after discussing the following things: In some cases, even with family history and imaging criteria, a genetic diagnosis may not be available from testing (due to inability to detect or perhaps i...
How does your approach to subsegmental PE differ from segmental PE both diagnostically and therapeutically?
My approach to subsegmental PE and segmental PE generally tends to be very similar. I am aware of the CHEST guidelines which indicate patients can safely be observed with subsegmental PE, but like a recent study showed (Rouleau et al., PMID 37531107), uptake of these guidelines is slow and many pati...
How do you manage patients with ice-pick headaches?
Ice-pick headaches, previously known as jabs & jolts and now often referred to as stabbing headaches, also manifest as stabbing face pain, which can be mistaken for trigeminal neuralgia due to lack of awareness. They can strike the head or the face suddenly, resembling lightning bolts. While common ...
Do you restrict topical diclofenac use in your patients with chronic kidney disease?
It is a great question. I normally don't but I always do it with a touch of hesitation. I believe the absorption is minimal but it also depends of the degree of use. At this time, when narcotics are in restricted use and oral NSAIDs are not a good option in patients with CKD, topical NSAIDs may be t...
Do you evaluate patients for low health literacy prior to discussing treatment options?
To answer this question - I do not routinely evaluate for low health literacy in my patients. This may not be the correct approach, but here is my rationale. I assume low health literacy and work up from there during each consultation. Even patients who are highly educated and/or have a background i...
In patients presenting with classical findings of primary hyperparathyroidism (i.e mild hypercalcemia, high 24hr urine calcium, elevated 1,25 Vit D but normal PTH), can spontaneous normalization of calcium be explained by episodic hypersecretion of PTH?
PTH secretion is always about 70% basal, related to the mass of parathyroid tissue, and about 30% episodic. Patients with primary hyperparathyroidism can have superimposed secondary hyperparathyroidism. High urinary calcium suggests a negative calcium balance. PTH is not "normal" if calcium levels a...
For how long would you treat Klebsiella aerogenes folliculitis of the face manifesting as a cystic lesion?
This is an unusual clinical presentation in an immunocompetent patient. Most reported cases of facial gram-negative folliculitis are due to pseudomonas or proteus. Draining a lesion large enough to be called an abscess is indicated, the benefit of unroofing the smaller lesions is less certain. I wou...
When would you consider treatment with steroids in patients with diabetic radiculoplexus neuropathy?
Steroids (pulse IV methylprednisolone) are the only treatment for diabetic amyotrophy supported by randomized placebo controlled trial (Dyck PJB et al., Neurology 2006; 66(5, Suppl 2):A191.) The soonest the treatment is started after onset of symptoms, the best. I will treat most patients presenting...
Do you recommend adjusted adult cancer screening for patients who have been on long term biologics and/or tsDMARDs since childhood?
I recommend routine adult cancer screening with the exception that I suggest annual dermatology evaluation for patients who are taking chronic immunosuppression.