General Hospital Medicine&nbsp;&nbsp;&nbsp;

In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?

Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?

What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?

Do you involve additional specialists, such as ENT, to further evaluate? Is there a particular algorithm followed by your institution, or is it just d...

How do you typically manage a patient with a single positive blood culture from two sets growing Candida species in a stable patient without prosthetic devices or material?

5 Answers available

Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?

How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?

How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?

For example, anticoagulation for recent, significant PE or dual antiplatelet therapy for recent MI, but requiring urgent procedures such as biopsy of ...

Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?

What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?

How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?

For example, do you consider "cautious" IV fluids or otherwise consider early vasopressors?

5 Answers available

How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?

What is your approach to the management of unprovoked distal DVTs?

Given the unprovoked nature, do you favor indefinite anticoagulation? Would a presentation with bilateral distal DVTs or other concerns for thrombophi...

Do you recommend that your patients with COPD avoid gabapentin or pregabalin entirely, given the increased rate of exacerbations noted in patients on these medications?

Rahman et al., PMID 38224592

Do you routinely use cefdinir for the treatment of common infections diagnosed in the outpatient setting such as CAP, uncomplicated UTIs?

How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?

Do you have to extend treatment for acute Lyme disease if a patient is on high dose steroids for another indication?

How can I incorporate neuromuscular ultrasound into my practice with limited prior experience?

How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?

What is your approach to iron supplementation in patients with an active infection?

Are there situations in which you still feel comfortable giving IV iron? If not, do you consider PO iron?

What is your approach to electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?

For example, do you target K >4 and Mg >2?

How soon after a fracture would it be safe to start anti-resorptive therapy?

What are your thoughts on the results of the ALONE-AF trial and the safety profile of discontinuing anticoagulation post-ablation, provided there is no atrial arrhythmia recurrence?

If it's reasonable to stop anticoagulation, how frequently should patients be monitored for AFib/atrial arrhythmia recurrence?

When do you consider using disulfiram in patients with alcohol use disorder?

In what patient populations would you consider using disulfiram (Antabuse) instead of, or in addition to, acamprosate or naltrexone? In your experienc...

6 Answers available

How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?

Would you use oral cefixime as an alternative treatment for early syphilis in cases of benzathine penicillin G shortages?

Klementova et al., PMID 40795115

Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?

Rogers & Rice, PMID 38018162

What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?

Does your approach change depending on whether and how long the patient has been anticoagulated?

Is there a role for functional medicine approaches in psychiatric treatment?

How do you critically assess the evidence base for functional medicine approaches? How do you respond when patients specifically request functional me...

How do you manage symptomatic ascites in a patient with SBP?

At what point do you feel comfortable using diuretics or performing a therapeutic paracentesis?

Do you routinely adjust your interpretation of SLUMS and/or MOCA tests in patients depending on their level of education?

What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?

Assume QTc is not prolonged, electrolytes are reasonably normal, and the patient is not already on heavy psychotropic polypharmacy.

What additional workup would you perform to evaluate a new onset of spontaneous hemarthrosis?

Young adult male previously without bleeding diathesis and no family history. Platelet count, PT, and PTT are normal. Also normal factor 8, 9, 12, 7, ...

How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?

If placed for this indication, how do you decide when to remove?

When do you consider scheduled antiemetics in hospitalized patients experiencing severe nausea?

How do you monitor for prolonged QTc in this situation (i.e., telemetry, serial EKGs, etc.)?

When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?

In other words, are there benefits to identifying URI pathogens that do not necessarily have targeted therapies (e.g., rhinovirus, non-COVID-19 Corona...

Do you routinely recommend transition to dual PO antibiotic coverage for strep species and MRSA, for patients with purulent cellulitis and in the absence of culture data?

What factors influence your decision to start salt tablets, urea, or a vaptan first in the management of a patient diagnosed with SIADH?

For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?

If they have been on IV heparin for 3 days, for example, would you subtract those days from the recommended loading dose time?

5 Answers available

Do you recommend initiating treatment with an SGLT2 inhibitor or semaglutide first for a patient with obesity and heart failure with preserved ejection fraction?

Would you initiate both medications at the same time?

How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?

What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?

For example, what do you do when someone requests aggressive, life-prolonging treatments but then is not receptive to elements of day-to-day care in t...

How do you consider sending fungal studies in a patient with pneumonia?

When do you have consider sending them as part of your initial workup?

How do you decide which IV opioid to use for symptom relief at the end of life?

How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?

7 Answers available

How do you decide which patients with upper GI bleeds should be monitored on telemetry?

Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?

When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?

If the patient does not have underlying diabetes, do the benefits of an insulin drip for this indication outweigh the risks?

How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?

What is your approach to IV fluid resuscitation during a sickle cell vaso-occlusive crisis?

How do you reconcile the potential risks and benefits of IV fluids in this patient population? Do you have a preferred type of fluid, as was suggested...

Do you recommend fluid restriction in addition to other management strategies for patients with hyponatremia due to SIADH?

6 Answers available

How do you manage catheter-associated, upper extremity superficial venous thrombosis?

Do you prefer anticoagulation? Is there a role for aspirin? How strongly do you recommend line removal?

How do you decide whether to include a basal rate when initiating a PCA?

How do you subsequently titrate it?

Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?

Do you recommend providing supplemental oxygen for patients with a pneumothorax in the absence of hypoxemia?

What are your thoughts on trending beta-hydroxybutyrate once a diagnosis of DKA is already established?

Do you find it helpful to monitor for treatment response, resolution, and/or recurrence?

How do you decide whether or not to pursue inpatient workup of an incidental liver mass?

What clinical, system, and/or social factors play into this decision?

How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?

How does your approach vary by indication (critical illness, acute renal failure, hyponatremia, diuresis, etc.)?

How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?

How do factors like the presence of varices, severity of coagulopathy, etc., play into your decision?

What is your stepwise approach to treating constipation in a patient with symptoms such as abdominal pain, nausea, decreased appetite, etc?

What do you start initially, and how do you go about escalating the regimen if constipation persists?

What is your approach to discharge planning for a patient with chronic SIADH who is admitted with asymptomatic acute-on-chronic hyponatremia?

How do you establish an acceptable baseline serum sodium? How do you decide between non-pharmacological interventions, such as fluid restriction vs th...

When do you consider using phenobarbital over symptom-driven alcohol withdrawal protocols for patients at low-to-moderate risk of withdrawal complications?

How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?

Does your approach change with venous vs arterial contrast?

What is your approach to VTE prophylaxis in hospitalized patients who are already on DAPT?

Particularly with prolonged hospitalizations, do you have any concerns about exposing patients to bleeding risks associated with "triple therapy" even...

How do you recommend incorporating B-lines on lung POCUS as part of evaluating a patient's volume status?

In particular, how do you reconcile situations where lung POCUS findings contradict other components of volume assessment (e.g. JVD, peripheral edema,...

Do you routinely prescribe naloxone at discharge for patients with a known history of opioid use disorder?

How do you manage gram-negative bacteremia in a patient with an aortic bypass graft, for whom there is low clinical suspicion for active graft infection?

Tabaja et al., PMID 38635420

What is your process for considering alternative imaging modalities for cardiac imaging when POCUS is limited by patient conditions, such as emphysema or body habitus?

How do you decide whether to place an NGT or PEG tube in patients with dysphagia precluding adequate PO nutritional intake?

Do you commonly use prognostic tools such as PRESS to aid in your decision?

What is your approach to managing post-operative dysphagia following C-spine surgery?

What is your approach to optimizing pre-operative hemoglobin in patients with sickle cell disease?

How do you decide between simple transfusion and red cell exchange?While the 2020 ASH Guidelines provide some conditional guidance on transfusion supp...

What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?

Are there situations in which you would continue the possible offending agent with close monitoring?

Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?

For patients admitted with acute decompensated heart failure, do you wait until the patient is euvolemic before ordering a TTE?

If yes, what is the rationale?

Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?

Would you start octreotide in a patient with suspected sulfonyurea overdose but without frank hypoglycemia?

How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?

Is it clinically necessary to provide supplemental oxygen to patients with mild, asymptomatic hypoxemia only during activity while they are recovering from an acute respiratory illness?

What is your approach to checking preoperative cardiac biomarkers such as troponin and BNP?

Do you find them more helpful as predictors of perioperative risk or as a baseline to detect post-operative adverse cardiac events?

When do you consider using a paramedian approach for a lumbar puncture?

What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?

How do you consider prn antihypertensives while admitted and/or adjusting a home antihypertensive regimen?

How do you recommend counseling patients on the prognosis of advanced cancer as a generalist who is not highly specialized in cancer literature or cancer-directed therapies?

What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?

For example, do you find trending WBC, procalcitonin, CRP, etc., more or less helpful?

At what point should you consider deactivating ICDs or implanted pacemakers in patients nearing the end of life but not imminently dying?

Should we consider this as a unique point during goal of care discussions, separate from code status, comfort measures only, etc.?

Do you always stop dexamethasone at discharge for patients admitted with COVID requiring respiratory support (as done in the RECOVERY trial), or are there situations in which you will prescribe it to complete a 10-day course?

What situations prompt you to prescribe dexamethasone to complete a 10-day course at discharge?

What is your typical approach to the use of beta blockers in the setting of recent cocaine use amongst patients presenting with cocaine-related MI, arrhythmias, or new-onset heart failure?

If these patients were already prescribed non-selective beta blockers outpatient, do you recommend withholding these medications in the acute phase?&n...

How would you approach the management of a patient who develops an accelerated junctional rhythm who exhibits no symptoms and has no prior history of cardiac issues, aside from consulting a cardiologist?

What additional assessments and considerations would you suggest to comprehensively evaluate the underlying cause of the rhythm disturbance and ensure...

Do you maintain a strict platelet threshold of >50k when performing a lumbar puncture, or are there situations in which you feel comfortable with a lower threshold?

While many US guidelines have supported a threshold of > 50k, there does not appear to be robust data to support it. Notably, the 2025 AABB and ICT...

Do you ever favor cefazolin over ceftriaxone for bacteremia with susceptible E. coli?

What techniques do you find most helpful to optimize image acquisition for cardiac POCUS in patients with poor acoustic windows?

What is the role of anticoagulation in patients with septic thrombophlebitis?

Would you be comfortable with the use of DOACs?

What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?

Should long-acting subcutaneous insulin be started upfront in addition to regular insulin infusion for patients with diabetic ketoacidosis?

Is there any benefit from oral vs topical steroids in herpes zoster opthalmicus?

Would the management change if there were complications with optic neuritis?

How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?

How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?

Do you prefer scopolamine patches, glycopyrrolate, or other treatment regimens to manage oropharyngeal secretions at the end of life?

What is your preferred first-line agent for VTE prophylaxis in hospitalized medical patients with adequate renal function?

Do you prefer heparin, enoxaparin, DOAC, or aspirin?

What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?

How do you rule out empyema in a small pleural effusion that is not amenable to thoracentesis?

How would you decide on the duration of antibiotics in this case?

Would you consider using steroids in patients with respiratory failure caused by aspiration pneumonitis?

How do you decide when, if ever, to defer pharmacologic venous thromboembolism prophylaxis for hospitalized patients?

Do you use prophylaxis universally or based on risk scores?

When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?

How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?

What is your approach to duration of fidaxomicin in a patient receiving treatment for first C difficile infection while also receiving concurrent antibiotics for an infection?

Do you extend the course of fidaxomicin past initial 10 days to at least 3-7 days after completion of antibiotics?

When do you consider using aspirin 81 mg PO BID for VTE prophylaxis over other agents in patients with a fracture, considering recent trial data?

O'Toole et al., PMID 36652352

What adjunctive therapies beyond an antisecretory agent (e.g., PPI, H2RA, etc.) do you find most helpful in managing the acute symptoms of PUD?

For example, do you routinely supplement with calcium carbonate, magnesium hydroxide, aluminum hydroxide, simethicone, sucralfate, etc.?

How do you decide if patients without contraindications should receive IV fluids during the pre-operative period if they are undergoing surgery during their hospitalization?

In other words, do you consider administering pre-operative IV fluids routinely or only under specific circumstances?

Under what circumstances do you recommend POCUS guidance for lumbar puncture?

How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?

Do you use the traditional strict limit of 1.5 L, or do you consider removing more volume if a patient appears to tolerate it?

What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?

For example, would you consider alternatives to paracentesis (Denver shunt placement, CART therapy, or permanent tunneled catheters) that might better...

How do you decide whether to use lung POCUS versus CT as the next step when a chest X-ray is equivocal for pneumonia?

How do you think about deferring VTE prophylaxis versus implementing non-pharmacologic methods when chemical prophylaxis is contraindicated?

For example, do you think the benefits of sequential compression devices outweigh the risk of falls, delirium, etc.?

In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?

What is your risk/benefit analysis when deciding on the appropriateness and timing for discontinuation of systemic anticoagulation in patients who underwent ablation for paroxysmal atrial fibrillation with CHADS2VASc score >2?

How do you use cardiac POCUS to potentially defer formal echocardiogram in patients presenting with an acute pulmonary embolism?

What is your approach to secondary prophylaxis for C difficile infection during concomitant antibiotic use in a patient with a history of C difficile infection?

What duration of antibiotic therapy do you use for a loculated parapneumonic effusion that does not meet criteria for empyema?

6 Answers available

Do you recommend routinely monitoring pancreatic markers such as amylase and lipase while receiving GLP1 R agonist or dual agonist therapies to determine their risk of pancreatitis?

Would you supplement iron for low iron studies in absence of anemia?

Primary care providers often check iron studies during workup for fatigue, even if anemia is not present.

How do you approach the work-up for a patient with iron deficiency anemia who is not responding to oral iron therapy?

Presuming good medication adherence.

How do you approach the management of a patient with symptomatic iron deficiency anemia who is intolerant of iron?

Such as a patient who cannot tolerate oral iron and has had a anaphylaxis to intravenous iron