The Clinical Problem Solvers Episode 430: WDx #39: Clinical Unknown with Drs. Kuchal Agadi and Ann Marie Kumfer
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Nov 13, 2025 Dr. Ann Marie Kumfer, a North Carolina hospitalist, and Dr. Kuchal Agadi, an internal medicine resident, delve into a complex case of a ventilated young man suffering from fever and empyema. Ann Marie shares insights on assessing infection sources in nonverbal patients, while Kuchal presents alarming lab results such as severe anemia and loculated effusion. The duo discusses the challenges of antibiotic stewardship and the importance of timely drainage in empyema management, revealing final microbiology findings like Achromobacter and Pseudomonas.
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Separate Signal From Noise
- Systematically separate signal from noise when a patient cannot give history and has many prior data points.
- Call the sending facility and review baseline labs to focus on relevant changes before acting.
Look For Hardware And Hidden Skin Sources
- Check all lines, tubes, tracheostomy and urinary catheters as likely infection sources in healthcare-exposed patients.
- Perform a thorough skin exam for hidden pressure ulcers or IV exit-site infections.
Approach Acute Severe Anemia
- For acute hemoglobin drop, prioritize distinguishing blood loss from hemolysis and compare to recent baseline Hgb values.
- Check stool, urine, and hidden spaces (thighs, retroperitoneum) and get reticulocyte count to assess marrow response.