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

Do you routinely observe inpatients for 24 hours after transitioning from IV empiric antibiotics to an oral regimen prior to discharge when the source of infection is unclear?

How do you decide when to treat hypocalcemia in hospitalized patients?

When do you consider a trial of steroids for acute hypoxemic respiratory failure when there are no other clear indications for its use (i.e., COVID, COPD, organizing pneumonia, etc.)?

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

Would you perform a diagnostic paracentesis for first-time ascites in a patient with established CHF or pulmonary hypertension, but without apparent liver or other intra-abdominal disease?

What is your approach to treating hypercalcemia secondary to immobilization?

Do you set specific goals related to mobility, volume management, and vitamin D levels? When do you consider medications such as bisphosphonates, calc...

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?

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 use IVC caliber and collapsibility to guide decisions about diuresis?

4 Answers available

How do you advise using Mycoplasma antibody testing to guide antibiotic selection in patients with pneumonia?

How do you think about using contraction alkalosis as a mark of achieving goal diuresis?

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

Considering the recent article in CHEST that describes the increasing incidence of fungal pneumonia Azar. Chest 2024

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?

Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?

Leem et al., PMID 37713527Smith et al., PMID 40961256

Have you used Karius to work up fevers in the hospital when the source remains unknown?

Do you consider holding PPIs in patients hospitalized with infections like pneumonia or C. diff colitis?

Would you consider empiric anticoagulation in patients with an acute stroke for whom you have high suspicion for cardioembolic source, but have not yet confirmed LV thrombus, atrial fibrillation, etc.?

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?

Do you commonly observe acute erythrocytosis in patients with ILD flares being treated with supplemental oxygen and high-dose corticosteroids?

If so, do you recommend any specific workup, monitoring, or intervention?

What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?

What is your approach to volume resuscitation in patients who are third spacing fluids?

Do you always rely on albumin, or do you ever consider running crystalloid fluids at a high rate to increase intravascular half-time?

How do you evaluate the etiology of hyponatremia in a patient with ESRD and baseline oliguria/anuria?

How do you subsequently monitor treatment response without the ability to monitor urine studies, urine output, etc.?

What is your approach to scheduling and then weaning nebulizers in patients admitted with acutely exacerbated asthma or COPD?

What are some practical steps physicians can take to optimize mobility and reduce falls in hospitalized patients?

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

How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?

Do you prescribe it universally or based on specific risk factors?

At what initial sodium level do you recommend strict avoidance of overcorrection (e.g., no more than 6 mEq/L in 24 hours) in patients with hyponatremia?

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

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 manage symptomatic ascites in a patient with SBP?

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

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

What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?

Is there an advantage between saline and LR?

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

How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?

How do you evaluate for an ascending UTI in a patient with a urostomy?

Do you still find urinalysis helpful in this situation, or do you rely on more specific culture data, imaging studies, etc.?

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 electrolyte repletion for patients hospitalized with cardiac and non-cardiac conditions?

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

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?

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.

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...

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?

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

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

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

How do you subsequently titrate it?

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 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 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?

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?

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

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 approach to isolated alkaline phosphatase without other laboratory abnormalities?

What are your next diagnostic steps/tests?

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?

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...

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?

4 Answers available

Has your management of severe hyponatremia changed after a recent observational study described higher in-hospital mortality for sodium correction of <6 mEq/L compared to 6-10 mEq/L in the first 24 hours?

Seethapathy et al., PMID 38320180

5 Answers available

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?

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?

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?

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.?

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 is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?