Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you work up a mildly neutropenic patient (ANC >800) with family history of neutropenia and personal history of occasional mouth sore?
The first question is whether to evaluate the neutropenia at all. With ANCs >800 and only occasional mouth sores, is a diagnosis necessary, and should the term “neutropenia” be used at all? If the family’s origin is in a part of the world where the Duffy null phenotype is common (e.g. Africa, parts ...
Would you pursue a colonoscopy for a patient in their 20s with constipation and rectal bleeding if they had a first-degree relative who died young from a "carcinoid tumor"?
Carcinoid tumor is relatively uncommon in someone who is relatively healthy and young. I would make sure to consider all the more common diagnoses and workup before considering carcinoid tumor. Moreover, carcinoid tumor is associated with diarrhea rather than constipation. Neuroendocrine tumor of th...
Would you pursue a colonoscopy for a patient in their 20s with constipation and rectal bleeding if they had a first-degree relative who died young from a "carcinoid tumor"?
Carcinoid tumor is relatively uncommon in someone who is relatively healthy and young. I would make sure to consider all the more common diagnoses and workup before considering carcinoid tumor. Moreover, carcinoid tumor is associated with diarrhea rather than constipation. Neuroendocrine tumor of th...
In patients with an acute gout flare who have stage 3–4 CKD or are on anticoagulation, what is your preferred first-line treatment?
This is a challenge. Intra-articular steroids may be the best option. Colchicine is an extremely complicated issue. A single dose of colchicine at 0.3 or 0.15 mg might be considered. Systemic steroids probably should be avoided because they reduce resistance to infection in an already compromised in...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Do you diagnose MCAS if a patient is concurrently on drugs known to cause non-specific mast cell degranulation?
Yes, MCAS may be diagnosed if a patient is on drugs known to cause non-specific mast cell activation.The reason for this answer requires a better understanding of MCAS criteria and etiology. In 2022, an expert consortium proposed revisions to the classification of mast cell activation disorders. (Va...
How do you manage patients desiring home hospice but with severe thrombocytopenia and/or anemia due to advanced malignancy?
As a pediatric hematologist/oncologist and pediatric palliative care physician, I can only speak to our approach with children, which may be quite different than the adult world. In our community, we are not able to provide blood or platelet transfusions in the home. For children who are profoundly ...
How do you approach using fecal microbiota therapy for recurrent Clostridioides difficile infection in immunocompromised patients?
We generally do not do the single donor FMT via colonoscopy, that was popular 5-10 years ago. We do offer both the oral and enema-based products, with a slight preference for the oral-based product due to ease of use.
When incidental microscopic hematuria is found on routine urinalysis, how do you decide on further workup versus repeat testing?
How would you approach counseling an older patient with significant hearing loss and nonadherence to use of hearing aids?
Using my own grandmother as an example, hearing aides were an affront to her vanity, and she perceived them as a sign of weakness in aging…and she probably felt as if they were thrust upon her by the family—so, in the end, she was stuck in silence within her own world—which was a sad and lonely and ...