Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there a role for suppressive antibiotic therapy when it comes to chronic femoral/tibial osteomyelitis?
Suppressive antibiotic therapy would be considered if there is felt to be a nidus that cannot be removed. For example, if a patient has hardware in place that is infected with associated osteomyelitis, but is not a candidate for surgery due to advanced age perhaps. This patient can be considered for...
How do you decide when and how often to reach out to patients with serious mental illness who are disengaging from care due to psychosocial stressors?
Outreach is always determined on a case-by-case basis, so it's difficult to give a definitive answer on this. Important factors to consider are the person's functional status, potential risk for harm without care, their decision-making ability, and the intensity of stressors. Obviously, those who ar...
What is your approach for de-escalation of antiarrhythmics for patients with a history of ventricular arrhythmias?
This is an important question. The answer depends on several factors including the type of arrhythmia being treated, the patient's underlying condition, drug intolerance and expense, and patients' expectations. Unfortunately, there is very little published information on this topic but as a general ...
How do you select between antipsychotics in the treatment of delirium refractory to nonpharmacological management in hospitalized older adults with dementia?
I have learned that antipsychotic selection is very institution-based/variable.Traditionally, at the Brigham, we have preferred Seroquel because it is titratable and avoids issues if the patient has underlying Parkinson's. However, now that Zyprexa is available in IV form, house staff often prefer t...
What work-up and treatment do you recommend for exertional headaches?
Primary Exercise Headache Diagnostic Criteria per ICHD-3: At least two headache episodes fulfill criteria B and C Brought on by and occurring only during or after strenuous physical exercise Lasting <48 hours Not better accounted for by another ICHD-3 diagnosis Caveats: Migraine headache worsened o...
How do you approach new-onset idiopathic intracranial hypertension (IIH) with someone who has history of systemic lupus erythematosus?
Since there is not a clinical recurrence of lupus, let's assume the disease is quiescent. The patient may have a clotting tendency so extra care should be taken in MRV interpretation. Does the MRV show the smooth-walled flow-related stenoses of intracranial hypertension or is it more consistent with...
How do you approach patient requests for medical time away from work or other accommodations (such as disability paperwork) when the patients have mild-moderate symptoms being managed in the outpatient setting?
This is a very important question as clinicians are often requested to provide certain assertions based on their role as the medical provider. In reviewing this, there are several areas to keep in mind: First, if you are the provider and are the one with the knowledge, then you should provide the r...
How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?
There is a potential benefit of adding additional immunosuppression for an RA patient with a UIP pattern on HRCT. My go-to-drugs are either abatacept or rituximab. While MMF is a standard first-line medication for many forms of ARD-ILD, it was tried for RA joint disease many years ago and the study ...
Does Dupixent interfere with patch testing?
Dupilumab suppresses Th2 skewed responses such as those associated with systemic contact dermatitis (e.g. propylene glycol, compositae mix, carmine, etc.) so testing while on dupilumab results in incomplete results. Responses to Th1 skewed allergens (e.g. epoxy or methylchloroisothiazolinone) may be...
How would you manage an ESKD patient who complains of severe fatigue after hemodialysis, but does not experience intradialytic or post-dialysis hypotension and has not responded to dry weight adjustments?
Difficult but unfortunately not uncommon situation. My theory is that more frequent dialysis would be beneficial to avoid dramatic electrolyte and fluid shifts that occur with intermittent hemodialysis. Would see if peritoneal dialysis or home hemodialysis would be an option. If not, maybe 4 days pe...