Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach treatment of latent TB for patients who cannot tolerate rifamycins or isoniazid due to allergy, intolerance, or drug-drug interactions?
Levofloxacin or moxifloxacin. Duration is 6-9 months.
For patients with acute renal failure and possible urinary retention, do you obtain a bedside bladder POCUS exam before ordering renal imaging or placing a Foley catheter?
Bedside Bladder Ultrasound has a strong role in the evaluation of acute urinary retention (AUR) as a possible cause for acute renal failure. Practice varies, as does the evidence base, but most POCUS experts recommend ultrasounding both the bladder (to assess for post-void residual volume) and both ...
Are there any special considerations when treating patients with recurrent nephrolithiasis who also have medullary sponge kidney?
Sponge kidney patients present a very challenging therapeutic situation. Anatomically speaking, a sponge kidney is often a congenital, although occasionally acquired, dilation of the renal collecting ducts, which in turn causes the inability to acidify urine. Urine pH is typically unusually alkaline...
Do you integrate firearm violence prevention into your annual wellness visits?
What factors should be considered when deciding whether to omit radiation in pediatric/AYA patients receiving N+AVD, particularly regarding long-term outcomes and second malignancy risks?
Based on the early data from S1826, it appears that radiation can be omitted if end-of-therapy scans (after 6 cycles of therapy) show metabolic remission of disease. The ability to limit RT to 1% of patients is encouraging for potential reduction in late effects such as cardiovascular disease and SM...
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
With the rise in home monitoring devices, how should we approach asymptomatic NSVT detected in healthy individuals with no prior cardiac history and with low risk cardiac profile?
With home monitoring devices, we are finding a lot of arrhythmias that would have previously remained unidentified. If episodes of NSVT are being found on home monitoring devices, the patient should receive a formal monitor to confirm NSVT. The formal monitor should be a Holter monitor that is able ...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...