Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
Do you perform pap smears as part of the surveillance of patients with a history of cervical or vaginal cancers who had radiation as part of their treatment?
I personally do not routinely perform pap testing for patients with a prior history of cervical or vaginal cancer who have had prior radiation. The main driver for me in this decision is that the results we receive from Pap testing often show abnormalities that are not reflective of recurrence or de...
How do you approach the treatment of microscopic colitis?
If there is a temporal association between starting a drug like NSAIDs, PPI, SSRI, statin in the onset of diarrhea deny would stop the medication before beginning pharmacological therapy for microscopic colitis. If there is no potential drug trigger, and I stratify my treatment based on severity of ...
What factors should guide the choice between fosfomycin and nitrofurantoin for uncomplicated cystitis, given the reduced efficacy of fosfomycin?
I agree with the authors you reference that, though fosfomycin is listed as a first-line option in the 2011 IDSA UTI guidelines for uncomplicated cystitis, our assessment of its efficacy has changed somewhat since then.We now have two larger randomized controlled trials that demonstrate that women r...
How do you approach the use of GLP-1 receptor agonists for the management of patients with metabolically healthy obesity?
I want to define my understanding of the term “metabolically healthy obesity”. Generally, this is meant to describe patients with a BMI in the obese range but without hypertension, dysglycemia or dyslipidemia. Obesity is associated with a wide range of medical conditions beyond those three such as o...
In patients with resolved LV thrombus post-MI after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
A common and sometimes challenging scenario. If there is persistent LV dysfunction (EF <40%) with apical akinesis /aneurysm, I maintain anticoagulation regardless of thrombus resolution. Recurrence of thrombus, even after echo imaging evidence of resolution in this state has been observed. There is ...
What scenarios do you utilize CT venography in the workup of suspected DVT?
There are likely a limited number of scenarios in which a CT venogram should be ordered. My own approach is as follows: Bilateral deep venous thrombosis: to exclude IVC obstruction. Anecdotally, in the younger patients, we have made a diagnosis of IVC atresia. Suspected May-Thurner syndrome: typica...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
Should patients starting cyclophosphamide be screened routinely for latent tuberculosis (TB)?
Yes, I think patients starting Cyclophosphamide should be screened routinely for latent TB since CYC is a strong immunosuppressant and increases the risk of TB reactivation. The issue is that CYC is often being considered for life or organ-threatening situations, for which it may not be ideal to wai...
How do you manage sleep disturbances in patients with Alzheimer’s disease without relying heavily on deliriogenic medications?
Sleep disturbances are common in older people and in those with Alzheimer’s disease (AD) in particular, and there are often multiple etiologies. Whether sleep disturbances increase the risk for AD, or are a result, metanalyses have suggested that the magnitude of sleep impairment correlates with the...