Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How long do you wait for a patient to be seizure-free before you clear them with regard to operating heavy machinery (i.e., for work)?
I would use the driving laws in the state where the patient resides as the guide for this. After all, if the patient can drive a car, it would be hard to tell them they can’t operate other heavy machinery. In my state, this would mean 6-12 months (we have a variable restriction on driving privileges...
What further work up do you recommend for patients with a chronic high anion gap metabolic acidosis with normal eGFR who have been ruled out for lactic acidosis, ketosis, toxic alcohols, and other usual culprits of high anion gap metabolic acidosis?
I take a good history for Tylenol for pyroglutamic acid, as that may not be a test you can do. If there is ANY GI history of a D-lactate level. Might as well get a salicylate level, it can be hidden in wintergreen oil and a few other things. Make sure it isn't pseudohypobicarbonatemia, seen with hy...
Do you advise Kegels/pelvic floor physical therapy to minimize urinary incontinence when irradiating the prostatic fossa?
I have not recommended Kegels/pelvic floor PT in asymptomatic patients, but if patients are symptomatic either before, during, or after RT, I will make this recommendation. My preference is to refer the patient to a Physical Therapist or pelvic rehab team with special expertise in this field, but if...
What is your approach to further workup and treatment of abdominal aortitis found on imaging in asymptomatic individuals with elevated inflammatory markers?
The differential diagnosis of abdominal aortitis would include giant cell arteritis (we do not know the age of this patient), Takayasu arteritis, IgG4-related disease, Behcet's disease or other systemic rheumatic diseases (RA, SLE, ANCA-associated vasculitis - although less likely since this individ...
What strategies have you used to help patients with advanced kidney disease who are asymptomatic understand the severity of their condition?
It is not unusual for patients with advanced kidney disease (stage 4, for example) to be asymptomatic or for the symptoms to be so insidious that the patient doesn't notice them or denies them. That's why it's very useful for such patients to be seen with a significant other or relative who can prov...
What is your blood pressure threshold to hold an ESA for patients with ESKD, anemia, and hypertension?
I will hold ESA for BP 170 or higher.
How long do you wait before reassessing a 24 hour urine calcium level in patients with recurrent nephrolithiasis, hypercalciuria, and osteoporosis who are initiated on bisphosphonate therapy?
Thank you for your excellent question. This is a relatively common concern, and yet I am aware of very little hard data. Opinions will differ; here is mine: In this scenario, it is my practice to have the patient visit with our Stone Clinic dietitian regarding dietary recommendations for calcium, so...
How do you decide between CT and ultrasound imaging tests for surveillance imaging for patients with recurrent nephrolithiasis?
I much prefer non-contrast renal CT scanning compared to ultrasound to determine metabolic stone activity (an increase in size or number of stones from previous imaging). Although more expensive, radiation exposure is low and sensitivity is high. Determining metabolic activity is important; if activ...
What approaches do you take for your patients with nephrolithiasis who undergo intermittent fasting for cultural, religious, or personal reasons?
Assuming "fasting" does not prohibit the intake of water, I encourage my patients to continue drinking water frequently, ideally at least 2 L daily, as that is the minimum amount shown in previous studies to decrease kidney stone passage. If fasting is intermittent and includes all fluids, I encoura...
What instances will you start outpatient steroids in patients with nephrotic syndrome of unknown etiology prior to obtaining a kidney biopsy?
It is Friday, your patient presents with classic acute nephrotic syndrome, your biopsy Friday won't have results (if not longer if you need EMs which you need for MCD) until Tuesday. I never think a few days of steroids is a big deal, so I can see doing it.