u/Scared_Problem8041

5 years out of residency, i still can’t figure this out: why do patients with particularly bad cold symptoms almost always get prescribed azithromycin rather than a different antibiotic? I understand the poor antibiotic stewardship aspect of it, that most of these are viral to begin with. But if you are going to assume bacterial, would it not be some type of amoxicillin for sinusitis (or cephalosporin for penicillin allergy)?
The best i can come up with is that azithromycin has anti-inflammatory properties…Can someone make it make sense?

Maybe I have a unique echo chamber, but i am constantly seeing ads or hearing from patients how traditional medicine fails in treating hypothyroidism correctly. I also have several patients who ask for free T3, free T4, rT3, autoantibodies…
All i do is order a TSH w/reflex and then treat with levothyroxine for TSH>10 or lower TSH levels depending on age and symptoms. Is it really that simple or am I part of the problem?
The complaints just seem so ubiquitous that it’s hard to think my simple solution is the right one. If I am doing it right, then is it all just gaming people for money?

How far down the algorithm of osteoporosis treatment are we going? I am comfortable doing any type of bisphosphonate but tend to feel a bit unsure when it comes to treatments like denosumab, romosozumab, teriperatide, etc. On UTD it doesn’t indicate specialist referral for any of these treatments. I am wondering how many PCPs are ordering these medications, especially the anabolic therapy!

What are we keying in on most as far as family history ?
- Cancer (especially breast, ovarian, pancreatic, prostate, colorectal)
- Single gene diseases (sickle cell, hemochromatosis, CF, polycystic kidney disease, huntington, etc)
- Premature CAD
What else would you add to this list ?
How close of attention do you spend to second degree relatives health?

Full disclosure: i have a patient with pancreatic cancer determined to have an ATM gene mutation. I did not do genetic screening as i only inquired regarding his first degree relatives, to which his mother had breast cancer at age 60. He did inform me today though that his maternal grandmother had pancreatic cancer. Just wish I would have done genetic testing 4 years ago when he first established care with me!

Thought I would ask if anyone else has seen patients taking retatrutide from off the internet who are having biliary colic. I have a 48 yo female whose been on it for six weeks and all of a sudden had textbook biliary colic. Only problem is that the initial ultrasound shows no stone disease, sludge or wall thickening! Wasn’t sure if anyone else has seen this?

As it has been 5 years out of residency I thought I would make a post about what things I didn’t see much or get much instruction on in residency that have been very common as an attending:
- How to manage severe hypertension (formerly hypertensive urgency). We gave these patients either captopril or clonidine and then sent them to the ER if it didn’t get better. Now I assess them physically and start them on bp meds with office follow up thereafter. No more asymptomatic high blood pressure patients in the ER.
- Vertigo vs dizziness and how common BPPV is and treatable with the Epley maneuver
- Hidradenitis Suppurativa is super common and symptomatic lesions can be treated in office
- Biopsies of obvious basal and squamous cell cancers is very easy and satisfying
- Seems like medication side effects are at least partially to blame for so many of patient visits (especially SSRI, swelling from amlodipine, cramping from thiazide diuretics, diarrhea from metformin)
- The most intellectually challenging appointments are new complaints (ie not follow ups or physicals) because the more i learn the differential just gets bigger and for some reason the stakes seem to feel even higher!
- There’s still so much to learn. Doing CME and reading AAFP articles really seems to enhance my day to day skills and actually helps prevent burnout.
- Once a year someone walks in with an abnormal mass they are concerned about but it just happens to be their xiphoid process!

What did I miss?

I know I am delving into an area outside of USPSTF or any established medical body recommendations. Would you ever order something like ca 19-9 or any other blood test for a patient who is asymptomatic, aware of the false positive risks but still wants this type of “cancer screening” done?
maybe I am just hurting over the two healthy, sixty year-olds on my panel who complained of light abdominal pain, and went on to have stage four pancreatic cancer, but I just wonder what could’ve been different. I know ca 19-9 is not reasonable to do across large asymptomatic populations… but let’s see someone specifically request That test, would you order it?

When are we adding ACEi/ARB, Glp-1, sglt-2, finerenone to patients? At what ratio? I used to use 300 but now up to date seems to say 30. I glanced over the KDIGO guidelines and it seems like they recommend 200.
Often patients are already on one or two of the aforementioned agents but still have elevated ratios. Did you start adding additional medications to try to further lower the ratio?
Thanks!

45 yo male with T2IDDM with a1c<7% who dropped a 45 lb kettle bell on his second toe 9 days ago. Went to the ER with normal x-rays and diagnosed with toe abrasion and started on keflex. He sends me photos from home the next day and the wound is open with minimal erythema (wound looks unchanged from the ER visit). He asks if he needs an appointment to see me and that he is afraid he may lose his toe. I tell him that he should keep the wound covered and continue the antibiotic and that all will be well. Five days later he contacts us and says it’s getting worse, did not send a picture. I check the EMR and see that the ER has been trying to call him for the last two days as wound culture showed MRSA sensitive to doxycycline. So i go ahead and send him doxycycline and refer to wound care. Yesterday i get a note from wound care that he has wet gangrene and see he is scheduled for toe amputation tomorrow.
I am shocked and start combing the chart. I realize that I documented DP pulses only detected by doppler on his last foot exam and also review all the images from the ER and realize he had a tiny foot ulcer on the tip of his toe, likely since before sustaining the kettle bell injury. So he probably has peripheral vascular disease driving the gangrene!
Obviously I wish I had him come in for an in person follow up originally (would have caught the foot ulcer/PVD and probably sent him to wound care right away) and I wish I had requested photos or another visit when it got worse five days later (could have recommended hospital admission for IV antibiotics). So I made mistakes. I know the current situation is out of my control. Assuming he doesn’t fire me, which is a real possibility, how would you apologize? How do you minimize future errors? How do you forgive yourself but also hold yourself to a higher standard? All i can think about is how mad he must be and how I wish I could go back in time! I wish i had been more humble and taken his concerns more seriously…

I have typically treated patients with a B12 less than 200 or even 300. However, I see a lot of local doctors and neurologists starting people on B12 if they are 500 or less. Is that just non-evidence based practice? Or is it beneficial?

I am just having so much trouble with chlorthalidone and HCTZ in my geriatric patients. Seems like 50% of patients who start them either get some type of significant electrolyte derangement or an AKI. I find myself reaching for them a lot though as there are a lot of uncontrolled hypertensives already on two drugs or those on one ARB/ACEi but with peripheral edema due to CCB (which is also fairly common). I guess I want to know if anyone else out there has this much of a headache treating hypertensive geriatrics!