Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are there any concerns with live vaccine innoculation and patients who are on denosumab?
This is a complicated question because while denosumab is a biologic therapeutic that has immunomodulatory effects on innate and adaptive immunity its association with serious infections complications appears modest. An increased rate of background infections and some increase in serious infections ...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
Are there scenarios in which you would advise using benzodiazepines for the treatment of hyperactive delirium?
The only situation that comes to mind is in patients who have active alcohol or benzodiazepine withdrawal as the etiology of their delirium. Outside of that, I do not use benzodiazepine therapy for delirium due to the risk of adverse effects (including prolonging the delirium) and lack of any data I...
How do you counsel patients with CKD who are on a PPI given a prior observational study showing an association between PPI use and incident CKD?
I am a little conflicted about this topic and have changed my practice in the last 4-5 years.There are multiple observational studies that suggest an association between PPI and CKD but residual confounding remains a concern in these studies. A nice commentary on this topic was published last year i...
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
For patients with Hashimoto's thyroiditis, is there a commercially available blood test for detecting abnormalities in the type 1 deiodinase enzyme in order to identify patients who would potentially benefit from T4 and T3 combination therapy?
Most clinicians decide to use combination therapy based on a weak response to levothyroxine, with patients still complaining of symptoms related to hypothyroidism. The TSH should not be low before selecting dual replacement.
Do you recommend obtaining one or two 24-hour urine stone risk profile(s) when evaluating patients with nephrolithiasis?
I would say that two is optimal, and ideally 1 of these on a work day and 1 on a non-work day. However, the practice setting and clinical situation with the given patient might also determine how hard this is to do in practice, and if you would do this in every patient or set things up differently. ...
When (if ever) do you recommend taping a patient off of buprenorphine after sustained remission?
I rarely recommend tapering off buprenorphine after sustained remission for opioid use disorder (OUD) because typically, buprenorphine is well-tolerated, risks are minimal, tapering can be challenging, and the risk of overdose after tapering off MOUD is high.Instances when I would consider a taper a...
When (if ever) do you recommend taping a patient off of buprenorphine after sustained remission?
I rarely recommend tapering off buprenorphine after sustained remission for opioid use disorder (OUD) because typically, buprenorphine is well-tolerated, risks are minimal, tapering can be challenging, and the risk of overdose after tapering off MOUD is high.Instances when I would consider a taper a...
What is your preferred, first-line class of anti-anginals for MINOCA with proven epicardial coronary vasospasm?
We typically start with long-acting nitrates such as isosorbide mono or dinitrate, but often patients will have adverse effects to nitrates that make long-term use challenging. We have had good results with non-dihydropyridine calcium channel blockers, particularly diltiazem, both as short and long-...