Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
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.
How do you evaluate for an ascending UTI in a patient with a urostomy?
Evaluating for ascending UTI in a patient with a urostomy UA Generally low value; chronic pyuria/mucus makes results unreliable. Urine culture Essential; must be collected from a clean stoma catheterization or a fresh pouch, and not from the urostomy bag. Imaging (CT abdomen and pelvis wit...
How do you evaluate for an ascending UTI in a patient with a urostomy?
Evaluating for ascending UTI in a patient with a urostomy UA Generally low value; chronic pyuria/mucus makes results unreliable. Urine culture Essential; must be collected from a clean stoma catheterization or a fresh pouch, and not from the urostomy bag. Imaging (CT abdomen and pelvis wit...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
Are there scenarios that new visits/consults with patients can be done virtually amidst the COVID-19 outbreak?
Starting 3/16, we began offering lower-complexity / lower-risk patients the option of having a Tele-medicine consult vs re-scheduling to a later date. This offer has been extended broadly to all new consults at our facility when the provider indicates that s/he can extend comparable service virtuall...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
Do you require an ECG to assess the QTc interval before administering ondansetron to a hospitalized patient without a known cardiac history or QT-prolonging medications?
There is a nice "Things We Do For No Reason" article in Journal of Hospital Medicine on this: "Hospitalists need not order an initial and subsequent ECGs when administering standard doses of intravenous ondansetron for patients without significant risk factors for QTc prolongation. To assess risk fa...
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...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...