Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How do you distinguish cannabinoid hyperemesis syndrome from cyclic vomiting syndrome?
When you are seeing a patient with intractable vomiting, this is a good time to slow down and take a thorough history. Often, patients can provide key pieces of information that help you distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS). CHS typically occurs in y...
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
How do you suggest transitioning someone from methadone to buprenorphine for the purpose of pain management?
Hello! I have had to do this on a number of occasions as a Palliative Care physician and hospitalist. To my knowledge, there are a couple of approaches that can be taken, but no singular validated consensus approach in the literature.I have generally utilized a low-dose buprenorphine initiation to t...
How do you suggest transitioning someone from methadone to buprenorphine for the purpose of pain management?
Hello! I have had to do this on a number of occasions as a Palliative Care physician and hospitalist. To my knowledge, there are a couple of approaches that can be taken, but no singular validated consensus approach in the literature.I have generally utilized a low-dose buprenorphine initiation to t...
What is your approach when a female patient does not want a male MA/scribe present in the exam room but other staff are unavailable?
I think we need to respect a patient’s request for same sex providers. Some patients are shy. For some, it is religion-based. I would ask the scribe to stand behind the curtain while I am seeing the patient. Regarding the MA, I would ask the MA to leave the room during my full-body skin exam. If I n...
How do you recommend incorporating B-lines on lung POCUS as part of evaluating a patient's volume status?
Great question! As you allude to in your question, it is important to address this problem holistically in the context of the patient's history, exam, labs, and other imaging. I find that this happens all of the time, and here is how I typically break them down when applying lung ultrasound. 1) 1-2 ...
How do you recommend incorporating B-lines on lung POCUS as part of evaluating a patient's volume status?
Great question! As you allude to in your question, it is important to address this problem holistically in the context of the patient's history, exam, labs, and other imaging. I find that this happens all of the time, and here is how I typically break them down when applying lung ultrasound. 1) 1-2 ...
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...