Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you prescribe fluocinolone in peanut oil in patients with peanut allergies?
Yes. Paller et al., PMID 12664021
Do you treat non-albicans strains of Candida on sputum culture or BAL in patients who are immunosuppressed?
I agree with these answers and do not treat either without biopsy.
How do you approach balancing the treatment of urinary incontinence with anticholinergic medications with the use of cholinesterase inhibitors in dementia?
This is a great question and speaks to the importance of shared decision-making and understanding the context of individual patients. Ultimately, it would be best to avoid anticholinergic medications in our patients living with dementia. Medications with anticholinergic properties increase the risk ...
What other considerations for hyperlipidemia management would you have for a patient with multiple prior PCIs whose LDL remains above goal on high intensity statin, ezetimibe, and evolocumab, assuming the patient is compliant with medications?
There are a few options, most of which depend on insurance coverage and patient preferences. But first, would do a chart biopsy to assess the efficacy of each of the therapies to better understand the reason for persistent LDL elevation. Perhaps they have a dysfunctional LDL receptor, so upregulatio...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
Outside of their use in performance anxiety, have you tried or found benefit with a daily beta blocker for generalized anxiety?
In concert with a psychiatrist, I've used beta blockers for patients with a history of trauma and/or somatoform disorder to reduce sympathetic stimulation and bodily sensations that worsen anxiety. In one particularly challenging case, the near-immediate relief after taking propranolol was helpful i...
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
Do you ever favor cefazolin over ceftriaxone for bacteremia with susceptible E. coli?
No
How do you interpret small joint effusions seen on ultrasound without power doppler signal in the setting of compatible inflammatory symptoms (i.e morning stiffness)?
It certainly increases probability of Inflammatory arthritis, if aligns with clinical symptoms. I would check inflammatory markers, autoimmune serologies, infectious work up and all to determine type of arthritis and consider prednisone trial and likely consider immune suppressive regimen based on r...
For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?
Leukopenia most often as lymphocytopenia, of course, is not unusual in lupus. Total WBC less than 4000 is an ACR classification criteria for the disease as is ALC less than 1500 on two occasions. SLICC disease classification requires ALC less than 1000. Total WBC < 3000 generates SLEDAI points. On t...