Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your treatment algorithm for actinic cheilitis?
Great question. We prefer to use efudex for broad involvement or liquid nitrogen for more localized AK. Some people do use CO2 laser as another modality for treatment. You can also pre-prescribe valacyclovir to help prevent cold sore recurrence during treatment with laser.
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What is your approach for patients with recurrent nephrolithiasis who require daily use of acetazolamide for management of an unrelated chronic condition?
Acetazolamide, or other carbonic anhydrase inhibitors, typically increase urine pH into the low 7s. Normally, it is approximately 6.0. A mildly alkaline urine favors the formation of brushite and hydroxyapatite kidney stones. My first step is to contact the provider who prescribed the carbonic anhyd...
What are the clinical indications and major limitations of lipoprotein apheresis?
LDL apheresis is a procedure that selectively removes apo B-containing lipoproteins (so primarily LDL particles) from the circulation. Very simply - venous blood is withdrawn via IV, plasma separated by the machine (liposorber, FDA approved in the US), passed through a column which binds the apo B c...
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...
How do you approach transaminase elevations with use of allopurinol in gout?
This is quite rare in my practice of the use of allopurinol. That may be because I discourage NSAID concomitant use in people with gout, given their concomitant hypertension, and NSAID-associated GI, renal, and liver toxicity. 1. If mild transaminitis happens, I would approach it as I do for any pat...
What sort of telehealth approaches do you pursue for a newly diagnosed end stage kidney disease patient starting peritoneal dialysis or home hemodialysis?
All new patients to home dialysis should be seen in person for at least three months. The first three months of home dialysis is a time by which you can make sure that the patient is stable. The patients are always adjusting to home dialysis both physically but also emotionally. After the first thre...
What is your approach to management of persistent painless salivary gland swelling/sialadenitis in patients with Sjogren's?
This is a common problem in this patient population, and we had Rheumatologist send to worry about physical findings that we are having trouble explaining. In this particular situation, the printable concern would be for sites of damage. Unfortunately, there are no known immunologic interventions th...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
What are the reasons for SLE specific labs to turn negative?
I agree and appreciate the answers by Dr @Dr. First Last and Dr @Dr. First Last. My answer may be stating the obvious, but I think it is important to mention that lupus is not infrequently over-diagnosed and overtreated. Serologies are sometimes over-interpreted with low-titer antibodies labeled as ...