Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How does trimethoprim-sulfamethoxazole's efficacy against S. pyogenes influence your empirical treatment of skin infections in regions with high resistance rates?
Recommendations against using trimethoprim-sulfamethoxazole (TMP/SMX) for group A strep (GAS) skin and soft tissue infections (SSTIs) likely stemmed from a misconception that GAS is inherently resistant to the drug. Older studies reporting resistance used media containing a high thymidine concentrat...
For iron deficiency anemia due to heavy menstrual bleeding, what is your preferred method of controlling heavy menses?
I definitely loop in my GYN friends for this one! According to ACOG: "Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life." The consequences of HMB are substantial and multifaceted, and, as we f...
Do you obtain routine blood cultures in a non-immunocompromised patient with community-acquired pneumonia who does not meet criteria for severe CAP?
Fabre et al., PMID 31942949, categorizes "non-severe community-acquired pneumonia" as low yield for bacteremia and therefore less critical and potentially wasteful/poor stewardship to obtain blood cultures, however do note that severe community-acquired pneumonia (CAP) falls into a moderate pre-test...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?
This test indicates that this patient has fairly good urinary concentrating ability, but does not meet most criteria for "normal" since the osmoles did not go over 600. Since diabetes insipidus is a spectrum disorder, this result does not completely rule out the possibility of very mild diabetes ins...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
How do you advise families about the risks and benefits of long-term SSRI use for children who being treated at a very early age (e.g., early elementary school)?
Sorry, but I usually reframe this question when I get it. There is no good data as there is no way to study patients long-term. So to get an idea of what would be required, it would be to randomize a clinical population (anxiety, depression, OCD) to drug and placebo for an extended period to be abl...
Would you start ASA and/or statin therapy on an asymptomatic patient noted to have incidental pathologic Q waves on EKG, assuming no prior history of ischemic heart disease?
I would start with a thorough H and P and comprehensive risk evaluation with necessary screening including blood work, at least a stress echocardiogram if not a full echocardiogram in addition, and also offer Calcium scoring. Given more details are not given regarding the patient's age and functiona...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
What is your approach to treatment in a patient with radiographic UIP but pathologic evidence of both fibrotic NSIP and UIP?
Depends on the underlying etiology and progression. I will most likely use antifibrotics, particularly for IPF or progressive fibrosis, but include immune suppression for autoimmune-related ILD.