Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?
Patients with Crohn's Disease (or IBD) can develop features of large vessel vasculitis or even other forms of vasculitis. The first consideration in a young patient would be determining the type of vasculitis--whether there is a distribution and clinical picture suggestive of TAK. It is important to...
What diet do you recommend for patients with inflammatory bowel disease?
This is a good question and very commonly comes up. The first step is really understanding what the expectations and goals are. If the goal is to achieve remission in people with inflammation who are symptomatic and want to use diet as monotherapy or in conjunction with meds, I discuss various thera...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
How do you adjust medications for patients with eosinophilic esophagitis who responded to budesonide or PPI, and when do you repeat EGD?
Repeat EGD after BID PPI is normal- do you decrease to once-a-day PPI? When to repeat EGD if ever? I try to decrease to once daily in the morning, but if so, I repeat an endoscopy 3 months later to make sure histologic remission is still maintained. After response to Budesonide, continue life-lo...
What are your preferred treatment options for patients with chronic non-healing leg ulcers?
In addition to all the typical things (decreasing edema with meds, compression, etc + treating superinfection, critical colonization, or debriding eschars), there is some evidence for pentoxifylline 400 mg TID or 800 BID in ulcerations of any etiology. There is also newer evidence for using topical ...
What are your preferred treatment options for patients with chronic non-healing leg ulcers?
In addition to all the typical things (decreasing edema with meds, compression, etc + treating superinfection, critical colonization, or debriding eschars), there is some evidence for pentoxifylline 400 mg TID or 800 BID in ulcerations of any etiology. There is also newer evidence for using topical ...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...
Would you consider anti-fibrinolytics for heavy menses in patients with a history of VTE?
A recent review article provided reassuring evidence about the combined use of antifibrinolytics and estrogen in women with heavy menstrual bleeding (Meschino et al., PMID 40680937); however, it did not specifically provide data in women with a prior history of VTE. In this case, I would first ensur...
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...