Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
What topical regimens do you recommend for redness related to rosacea in patients who defer laser treatments?
Naturally, laser is the most ideal and best solution. Green-tinted makeup is also a great adjunct. Aside from the usual routine counseling (avoidance of sun, food triggers, etc.), one product that I have found remarkable results with is the compounded SkinMedicinals ET-Rosacea Cream, which contains ...
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I will assess how long I am treating the person/infection, and go from there in terms of how likely I am to induce the AmpC based on the duration of treatment. For example, if it's a 7-day course for UTI or GN bacteremia, I may risk the penicillin/cephalosporin (based on susceptibilities, of course)...
How do you approach Pityriasis rubra pilaris that is retinoid resistant?
I find most PRPs to respond, at best, incompletely to retinoids - they are not my first line. Any TNF-alpha or IL-12/23 inhibitor is reasonable to try, and there are no head-to-head trials to my knowledge to endorse one other. Mtx may need to be added. IL-17s likely work too for some patients. Depen...
Do you prescribe bronchodilators to patients with radiographic emphysema and respiratory symptoms, but no spirometric obstruction?
Yes, I will sometimes offer a therapeutic trial of bronchodilators to symptomatic patients with radiographic emphysema, but no obstruction on spirometry. Patients with CT evidence of emphysema were not specifically studied in the RETHINC trial.
What is your approach to monitoring blood parasite smears in an immunocompetent patient with babesiosis?
In an immunocompetent person the response rate to the treatment of acute babesiosis is extremely high and if a person is clinically improving follow-up smears are probably unnecessary. However, I generally check one at 48 hours to confirm a decrease in parasite burden. If that is favorable and the p...