July 2nd, 2015

Two consults for fevers without clear source!

One end up with toe infection!

Another surgical wound infection on his back !!

Rminded me about the FUO with severe nasty pressure ulcer !

Vancomycin toxicity

June 13th, 2015

I always worry about Vancomycin toxicity. As soon as you make the mistake to trust this drug, you end up with troubles.

I sent a patient home on IV Vanc, leves only 12. One week later level 40, Cr up to 4.2!

Lesson either not use Vanc IV as outpatient or Get a Vancomycin trough twice weekly.


January 7th, 2015

I was called for Leukocytosis on a patient I was following and I noticed abdominal distention and tenderness - placed a foley cath and got 1500 cc

another patient with fever and enterococcus bacteremia of unclear etiology, end up having peg site abscess !

fever after hernia repair and abdominal surgery

December 13th, 2014

the answer is CT Abddomen-pelvis

I had a case a patient after some panniculcectomy, spiked a fever, I gave some empirical abx and he responded but I never got a clear picture on what surgery has been done and  he had some drains not sure what they were draining.

Anyway, we stopped abx after a week, then he end up having fevers, and found to have his mesh infected with proteus.

He was getting treated for prolonged periods of time, again still has drain not sure what is it draining, and despie having no fevers, no chills, no leukocytosis - CT abdomen showed an abscess.

So  - I forgot that as ID physician - we have to fix the surgeones mess.

I should have from the first consult, got a CT Chest, abdomen and pelvis and get culture of the drain materials.

The second time, I should have questioned these drains

Persistent leukocytosis

October 29th, 2014

Diarrhea starts after couple of weeks!  C diff


October 29th, 2014

rash - redness all over the body, concentrating on the folds, hands etc…

erythema multiforme

October 29th, 2014

rash mostly hands, symmetric - also some vesicles that may reflect herpes…

Erythema multiforme - target lesions.

Need to look closely and think target lesions.

Fever due to drugs

October 2nd, 2014

another case of drug fevers.

placed on risperdal for psych issues, started to have fevers, headaches, full work up negative, no response to IV abx.

We discuss with psychiatry, we added parlodel and the patient completely better!

Drug fever from risperdal.

Acute cholecystitis again

June 24th, 2014

pt with no definite source of infection.

We accused picc line but cultures are negative, we grew some bacteria from trach but chest xray is clear, urine is negative, changes of abx etc…

Patient with normal LFTS, and no abdominal pain, but vomiting triggered GI consult, and HIDA Scan was positive!!

Again, if something is not making sense, let us go back and think it through from scratch as new consult….

US Gallbladder with stones should be taken seriously

gram neg bacteremia

June 24th, 2014

Patient with Enterobacter pneumonia and bacteremia.

Pneumonia rarely causes bacteremia, you shoud look for line infection.

In addition, persistent leukocytosis should make us look for persistent bacteremia, then persistent bacteremia should trigger the search for septic thrombophlebitis.

PCP end up repeating the blood cultures to find persistent bacteremia, and then I searched for DVT — consequence needs trt with anti-coagulation.

Fever of unclear etiology

June 5th, 2014

I got a patient with relapsed fever and leukocytosis.

Demented, with seems painful abdomen, simple test without CT shows acute cholecystitis ! Do not buy diagnosis of recurrent aspiration without hypoxia.

Remember causes of fevers: Acute  cholecystitis - sinusitis in addition to drug fever, non infectious etiology:DVT, PE, gout attacks…

Severe C diff

April 21st, 2014

I got a patient with C. diff, he was getting worse, abd pain and distention despite IVV metro, po Vanc and vanc enemas  and removing any abx with gram neg effect.

What got him better is placing him NPO!

Can not miss - Can not assume

April 12th, 2014

When you are concerned about a young patient with high liability barometer.

You MUST review every small tiny details.

The main disaster in young people involve one issue that is very evident at the time of reviewing the chart.

Can not work in a hurry, you must take a detailed long history, even when patient do not comply, physical exam very meticulous, and reviewing the vitals, labs, and imaging, surgical reports very cautiously.

You have to be READY for the REVIEW, QUESTIONS, READY for pointing fingers, NOT MISS ANY SINGLE WORD.

Failure of Cefepime

April 12th, 2014

Again, pt having fevers, on Cefepime, and you have no cultures growing, you have to go back from the start, and you need to escalate spectrum of abx!

Change to Carbapenem, cosnider adding vanc , anti-fungals, Steno, MDR, aypials that needs quinolones, doxy, azithro, bactrim, Amabisome.

Look for C. diff, TB, ricketsia,

Sometimes it doesn’t make any sense, but it is the best thing to do until the patient better then worry about de-escalation and discharge.

Break the pattern of thinking

April 12th, 2014

If you face a diagnostic dilemma or fevers and something doesn’t look right, then it is likely not right, now u should be able to find solution for any issues, with internet and simply by breaking the pattern of thinking.

Go back from the start, review everything again!

Look into a different angle.

Protected: Persistent fevers and leukocytosis

April 12th, 2014

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Protected: Severe UE pain

March 31st, 2014

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March 31st, 2014

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March 28th, 2014

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Osteomyelitis vs Charcot foot

February 25th, 2014

It is intresting that MRI are not useful in this case.

Consider ESR and cRP simple tests!