Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you prescribe linezolid to patients who are concomitantly on an SSRI?
Yes, cautiously, especially when LZD is the best or only option. Recent Eur J Clin Pharmacol July 2023 meta-analysis involving 84 publications found an observed rate of < .01%; another study Shi et al., PMID 37301313 found a similar rate (1/1743 persons, 0.06%). Holding an SSRI for a day or two prio...
Would you consider transitioning patients older than 75 years of age with coronary disease from statins and/or other lipid-lowering agents to PCSK9 inhibitors given concerns for polypharmacy, provided their LDL levels remain at or below goal?
We do not have any data to suggest PCSK9i are better than statins, and all of the PCSK9i outcomes data are on top of statins. Data show generally that lower is better, and there isn’t a “floor” to benefit. That said, if I have someone on statin + ezetimibe who then gets LDL-C very low on a PCSK9i, I...
Do you recommend to exchange nephrostomy tubes when a patient is diagnosed with a urinary tract infection in the absence of any overt signs of infection at the exit site?
This patient has asymptomatic bacteriuria by definition - apparently with occasional symptomatic UTI. I would not change the tube because of the ASB like I would not change a urethral catheter in the setting of ASB. And as noted the patient has already demonstrated continued ASB after changing the t...
Would you consider giving hormone replacement therapy to a patient with atypical ductal hyperplasia with no alternative options to manage postmenopausal symptoms?
After careful counseling about the possible risks and symptomatic benefits of hormone replacement therapy (HRT), I do prescribe these supplements when requested by my patients with ADH and DCIS. This is particularly true for women who have had hysterectomy, where the progestational component of HRT ...
How do you manage a patient with sickle cell disease during pregnancy?
I refer all pregnant women with SCD to maternofetal medicine/high risk pregnancy clinic for more frequent monitoring. I recommend a baby aspirin for preeclampsia prevention (see UK guidelines). I recommend folic acid 4 mg. If they do have iron overload, I do not recommend iron supplementation. For a...
What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?
My approach to electrolyte monitoring and repletion emphasizes a patient-specific risk assessment rather than adherence to arbitrary numeric thresholds. The routine, reflexive repletion of potassium, magnesium, and phosphorus in unselected medical inpatients is an overused practice with limited supp...
What therapies do you recommend for patients with limited life expectancy (<3 months) but whose depression is significantly reducing their quality of life?
I agree with Dr. @Dr. First Last that the first thing we need to do is to make sure that the patient actually meets the criteria for depression rather than demotivation or demoralization. If the patient is depressed, using Ritalin may have an effect in a very short amount of time, although there isn...
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...