Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you pursue any additional testing in your patients with chronic kidney disease who are found to have "small hypodensities too small to characterize" on renal ultrasound?
Renal cell carcinoma in dialysis patients and to a lesser degree in patient with CKD is not uncommon. As such, I would like to re-image these patients after 6 months or so. Usually, these cancers grow slowly and don't cause major disease but it is variable.
What is your approach to a toddler-aged patient with speech apraxia without other autistic features?
Evaluate for a hearing issue, broader developmental concerns, and dysarthria/bulbar symptoms. The diagnosis and management of childhood speech apraxia can be made by pediatric SLP.
Is there a role for Vitamin D supplementation in the treatment of Hashimoto’s thyroiditis?
Although there is some evidence that vitamin D may play a role in immune function, there is no credible evidence that vitamin D has a role in the management of autoimmune thyroid disease including Hashimoto's and Graves's disease.
Do you periodically check a urine culture for patients without dysuria but who have a history of struvite kidney stones and urinary tract infections with urease producing organisms?
Struvite nephrolithiasis is caused by a high urine pH (usually>7.0). Typically, a urine this alkaline requires urinary infection with a bacterium that produces urease, (Proteus, Providencia, Klebsiella) which in turn splits naturally occurring urea into ammonium, driving the pH to supraphysiologic l...
What biologics have you found to be most effective in treating hidradenitis suppurativa?
I'll answer the easy part of the question first. For insurance coverage, the HS Foundation website has wonderful prior auth letter templates for biologics, laser therapy, and other treatments. I have had a lot of successes in getting off-label biologics covered with them. It doesn't always work, but...
In what clinical scenarios should we use the 2-day 2mg DST instead of the 1mg overnight DST for screening of Cushing syndrome?
The 2-day low-dose DST may be of some value in patients suspected to have nonneoplastic hypercortisolism (normal cortisol <1.4-1.8 ug/dL). The Dex/CRH test performs better in such patients, but the CRH is not available.
Do you routinely perform in-office urine microscopy for your patients with recurrent nephrolithiasis?
Yes and no. We have a dedicated laboratory at Mayo Clinic that specializes in urinalysis and is expert in recognizing crystals. I do not do office microscopy myself. I think it is important for my stone patients to have a urinalysis when I see them. I am looking for hematuria suggesting surgical sto...
What are some considerations to make when managing patients with recurrent nephrolithiasis who are found to have nephrocalcinosis on imaging?
Nephrocalcinosis is generally defined as calcification of the renal parenchyma, especially the medulla and papillary tips, as opposed to nephrolithiasis which refers to calcification in the urinary space. The two often coexist. Nephrocalcinosis, and its accompanying nephrolithiasis, are typically pr...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...
What is your preferred therapy to raise urinary citrate in a patient with recurrent calcium based stone disease and hypocitraturia?
I prefer potassium citrate tablets. For those who have trouble swallowing tablets, it also comes in liquid form. There used to be a powder packet that you could tear open and mix in liquid, but it is my understanding that is no longer available. These products require a prescription. For those on a ...