Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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 ever favor cefazolin over ceftriaxone for bacteremia with susceptible E. coli?
We do cefazolin often unless h/o ESBL or complicated infection or procedural history. It is our preferred abx for pyelo or intra-abdominal infection (we add Flagyl for intra-abdominal) and is driven by our local susceptibility data.
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...
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...
What suggestions for environmental modifications do you find most helpful to reduce the risk of falls in the geriatric population?
Great question! The following recommendations encompass those that have been deemed cost-effective for fall prevention. The CDC STEADI program is also useful for reviewing these things. First, I would usually order home health PT/OT to do an assessment if the person has Medicare, and they will often...