Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What strategies have you found helpful to manage SSRI associated night sweats?
Reduced dose to the lowest effective dose. Gabapentin can be used off-label for hyperhidrosis and vasomotor symptoms of menopause. I had one patient on an SSRI for GAD and found the gabapentin helpful enough for anxiety that he tapered off the SSRI. If it is just night sweats, you can do a nightly ...
In a woman with bipolar disorder with a menstrual component would lamotrigine itself worsen the condition given that it interacts with prescribed estrogen?
Very unlikely. Estrogen can cause a lowering of the Lamictal serum levels and not vice versa. So, if a patient on Lamictal is put on an estrogen product, there may be a need to increase the dose of Lamictal.
How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?
Great question and one that comes up all the time for me. As the patient has more signs of true infection, such as those you mention with fever, leukocytosis, and respiratory distress, I am much more likely to start antibiotics. If the patient just has chest radiograph findings of opacities and some...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
In the absence of clear guidelines, when would be a reasonable threshold to refer patients with resistant hypertension for renal denervation?
Recommendations surrounding renal denervation have now been added to the AHA 2025 guidelines.
What type of DES should you opt for if a patient has or is concerned about possible nickel allergy?
For a coronary stent, I would lean toward a Medtronic DES. There are published recommendations for nitinol with a durable polymer. That said, I cannot remember more than one case in 25 years where I thought that a metal allergy may have played a role in a patient receiving a stent and that was prior...
How do you typically manage a patient with a single positive blood culture from two sets growing Candida species in a stable patient without prosthetic devices or material?
Candidemia is defined as the presence of Candida species in the blood, and even a single positive blood culture specimen is considered significant and warrants treatment as candidemia. Initial management should include: Initiating antifungal therapy with an echinochandin (micafungin, capsofungin, o...
With OpenBiome no longer in operation, what is your current approach for obtaining FMT for inpatients with acute severe/fulminant C. difficile infection unresponsive to antibiotics?
Consider Rebyota by enema or flex sig, similar to what you had done with standard FMT.
What are the best practices for optimizing transitions from hospital to skilled nursing facilities for older adult patients, with specific regard to adapting hospital medication regimens to the skilled nursing facility setting?
Medication errors and discrepancies are well known to lead to adverse drug events during transitions of care, as well as rehospitalization. The standard of care that has emerged over the last twenty years or so is rigorous medication reconciliation. Medication reconciliation is defined as comparing ...
Do you switch from 0.15 mg to 0.3 mg epinephrine at 55lbs or 66lbs?
Dr. @Dr. First Last, thank you for posting this question. I see variances in practice among both allergy and primary care practices on when a patient is prescribed the 0.3mg dose of epinephrine. Our practice is to switch patients to 0.3mg when they are 25 kg to prevent underdosing and inadequate res...