Jack Stephens, M.D.

Essentially yes. Most hospitalist go through Internal Medicine residency programs and become a hospitalist thereafter. There are a select few who go through a family medicine residency program and become hospitalists as well. Both backgrounds have hospitalist practice as a PCP for patients while in a residency program but the internal medicine background is more focused on hospitalized patient's and their acute issues, whereas the family medicine program is more outpatient problem oriented.

Hope this helps and good luck with your upcoming hospital stay,

Jack Stephens, MD

I always continue antidepressants for my patients. There are very few circumstances when antidepressants are not continued. That being said, a majority of antidepressants have a very long half life, meaning it takes a long time for them to leave your system. This is the same reason it takes so long to get therapeutic on antidepressants. A couple days off of your medication shouldn't be a big deal if you happened to have a circumstance in which your medication needed to be held.

Hope this helps,
Jack Stephens, MD

This is somewhat confusing, I know. The new hospital system emphasizes safety of patients by ensuring all medical issues are properly cared for. Surgery is great at performing their respected procedure and dealing with the issues regarding that procedure respectively. All of the patients other medical problems not related to the surgery are typically overseen by a hospitalist. Often times a hospitalist will be consulted or even be the primary physician caring for a surgical patient to oversee all medical problems not related to the surgery.

Hope this helps,

Jack Stephens, MD

Good question. High blood sugars have a significant impact on your entire body, including your heart. improved with good blood sugar control but not eliminated. The major damage from persistently high blood sugars is caused by deposition of the sugar in your microvasculature, your blood cells and your kidney filtration system. Your eyes and extremities take a major hit with uncontrolled blood sugars which leads to death of or peripheral nervous system causing blindness, cataracts, peripheral nerve pain, foot deformities and frequently amputations. Your kidneys become no longer capable of filtering your blood effectively leading to a large amount of protein loss and kidney failure which is a common cause of dialysis. Your blood cells lose function and are no longer capable of fighting infections and your blood vessels are no longer capable of delivering blood products or antibiotics to damaged areas of the body leading to serious infection and amputation. The main cause of heart attacks comes from plaque deposition in your vessels which is worse with uncontrolled blood sugar but larger vessel disease causing heart attacks hasn't been directly correlated to poor blood sugar control. I can go on forever on this topic, but needless to say, it is extremely important to control your diabetes by practicing a good complex carbohydrate diet and being compliant with the medications required to maintain a blood sugar typically ranging from 100-140. If you already have significant medical issues your blood sugar control doesn't need to be as tight because of your increased 10 year mortality.

Hope this helps,

Jack Stephens

This is a touchy subject. Simply put, blood transfusions are typically given more frequently than they should be and we are currently trying to turn this around in medical practices around the nation. With that being said there may sometimes be over emphasis on not transfusing patients. You can ask ten doctors and get multiple preferences in regards to when to transfuse a patient but this is a rough guideline that I like to use. #1: Transfuse for hemoglobin less that 7.0. There are some patients with chronic anemia in the setting of cancer treatments that may be asymtomatic even when less than 7.0 and could have a lower threshold for transfusion. #2: Transfuse for acute blood loss causing symptoms (dizziness, weakness, palpitations) even with hemoglobin above 7. #3: Transfuse for patients with coronary artery disease for Hemoglobin <8.0-9.0 depending on circumstances. Transfusion typically won't improve mortality in most other situations and is not risk free. Patients with chronic anemia can benefit by treating the cause of their anemia be it vitamin deficiency, iron deficiency, or blood loss. Often times patients with advanced kidney disease require replacement of the enzyme which stimulates the bone marrow to make red blood cells called erythropoetin. A nephrologist will typically give these patients epogen and intravenous iron replacement therapy to achieve a goal hemoglobin >10.0. This treatment may cause increased mortality if given to a patient with hemoglobin >11. There is another group of patients with anemia of chronic disease which deprives the body of iron by storing it in the liver and requires treatment of the underlining chronic medical issues. There are obviously many more circumstances to consider but these are the most frequent things to consider.
To answer your question more specifically, I would assess how much improvement your mother has following a transfusion, specifically in her energy levels and consider therapeutic transfusions only if her underlining cause of anemia can be corrected. If her underlining cause of anemia is unable to be corrected I think it is an indication that your mother may be chronically ill and her body is simply not able to function sufficiently anymore. Typically these patients will have other indicators such as loss of appetite, trouble swallowing, weight loss and even multigrain dysfunction.

My heart goes out to you, I know it is frustrating to see a loved one in such circumstances.

Sincerely,

Jack Stephens, MD

Jaundice is a symptom of elevated bilirubin, typically when >3.0. There are many things that can cause elevated bilirubin which are typically caused by loss of synthetic function of the liver in cases of cirrhosis, lysis of red blood cells typically from autoimmune diseases or obstruction of the biliary tract by gallstones or tumors.

I'm not sure what you were diagnosed with and are currently being treated for. If you have advanced liver failure you may never be able to improve your bilirubin enough to the point where you are no longer jaundiced. Some reversible causes can occur in successful treatment of hepatitis C or liver dysfunction related to ETOH use, but this is case by case and depends on the extent of cirrhosis before treatment. Other issues can improve with immune system modulating medications or surgical correction of underlying cause.

Good luck with everything,

Jack Stephens, MD

Often times a patient can develop fever related to cancer or treatment of cancer. The important thing to consider is if they are neutropenic(low white blood cell count) and if they are experiencing any other symptoms. Patients who are neutropenic are unable to manifest the typical immune response required to fight infection and often times don't have symptoms related to an underlying infection. These patients should at least report to the emergency department and be screened for pneumonia, urinary tract infection, abdominal infection(colitis), and bacteremia(blood cultures). a lot of time they will be started on an antibiotic called cefepime while they are being worked up. If all tests come back negative the patient can go home but typically they should have improvement in their white blood count level first which can be aided with a medication called neupogen in select circumstances. If the patient has normal white blood cell count and the initial sceen for infection is negative often time they will be released from the emergency department home.

Hope this helps,

Jack Stephens, MD

This is a good question. Most cases of bacterial pneumonia have low probability of being spread to caregivers. The types of bacterial pneumonia that do spread easily are typically identifies and people in close contact with these individuals are contacted by infection control agencies who are automatically notified for such cases. Viral pneumonia can typically spread easily to people in close contact but don't typically have as big of an impact on those without chronic medical disease and strong immune systems.

Jack Stephens, MD

Osteopenia is a precursor to osteoporosis. The most important thing you can do is perform resistant exercises to improve the density of your bones. Resistance will cause your body to build bone mass and no resistance will cause your body to breakdown bone because it is efficient like that. Simply put, if you don't use it you lose it. The other thing you can do is take daily vitamin D(at least 800 IU) and calcium only if you have low calcium. Your doctors have likely checked for underlying diseases contributing to this including hyperthyroidism or hyperparathyroidism.

Jack Stephens, MD

It depends on the type of pneumonia, but typically washing your hands is the best thing you can do to prevent any type of infection. If your father has airborne or droplet precautions you should consider wearing a facemark, but this is usually related to viral pneumonia. I'm around patients with pneumonia all the time and have never had a problem.

Jack Stephens, MD

This is a legitimate concern. Typically there are a number of medications which can help break down secretions or reduce secretions but they usually don't impact mortality or reduce complications significantly. The most important thing to help mobilize his secretions. If he has a strong cough and is getting mucus to come out on his own he should be fine. In the hospital we use chest physiotherapy to help patients with a weak cough mobilize their secretions.

Jack Stephens, MD

Catheters very frequently cause UTIs. We usually only place catheters in the hospital if there is a good reason such as urinary obstruction or in select cases a need to have accurate urine output. If there is no clear indication for a catheter in your father it should absolutely be removed and he should have a urinalysis to screen for a UTI.

Jack Stephens, MD

This is something we call fever of unknown origin. Typically this can only be diagnosed if typical causes of infection are ruled out including pneumonia, urinary tract infections and abdominal infections. The other common causes of low grade fever involve more indolent processes such as fungal infections(geographic), helmith infection, viral infection, autoimmune diseases and cancer. The tests that should be consider are typically selected for the background of each patient specifically. A lot of times we are unable to identify a source and the patient is then labeled as having fever of unknown origin.

I'm not sure what medication you are referring to which helps with the fevers but that could indicate the underlying issue. Sometimes antibiotics help with symptoms but don't resolve the problem if there is an underlying infection of a foreign object or fluid collection such as an abscess or pleural(lung) fluid collection. Some patients suffer from an inherited condition called familial mediterranean fever which is typically one of the last resort screening tests ordered.

Hope this helps,

Jack Stephens, MD

This is a question for her hepatologist. Typically a liver transplant can provide around 20 years in my experience but it is extremely variable depending on how the patient takes care of themselves following the transplant and the condition requiring the transplant in the first place. Some patients are unfortunate and have complications related to graft vs host disease which can occur days to years after the transplant and is why it is extremely important to be compliant with the immune modulating drugs prescribed after a transplant.

Jack Stephens, MD

Infections are typically caused by a process which creates the conditions that allows bacteria to thrive. In the case of UTIs, it could be because urinary obstruction is preventing emptying of the bladder and static urine allows for bacterial growth. Urinary catheters or foreign objects in general commonly cause infections. Underlying lung disease can predispose to pneumonia, especially in the setting of large amounts of mucus production or damage to bronchials preventing mobilization of secretions and allowing for breading grounds to bacteria. Hospitalized patients in general are predisposed to infections given lack of ambulation and reconditioning of lungs causing collapse of the bases to their lungs called atelectasis. In general, if medical problems are stable we try to discharge patients as soon as possible to prevent infections from being in the hospital. Less often patients get infected hardware from previous joint surgeries or infected heart valves.

Jack Stephens, MD

This question is depends on the circumstances surrounding the diarrhea. Some patients with high potassium or liver failure have diarrhea because of the medications we give them. Others have diarrhea because of infectious processes which typically aren't treated with antibiotics or drugs such as loperamide, because of complications associated with both. chronic diarrhea can be treated with the "BRAT diet", loperamide or increased fiber intake. Diarrhea from C. Diff infection typically caused by destruction of good gut bacteria from antibiotics should be treated with an oral antibiotic called vancomycin. Diarrhea from inflammatory bowel disease can be treated by immune modulating agents.

Jack Stephens, MD

I believe air beds would be able to distribute the body weight better. The most important thing is to perform frequent turns every two hours to prevent ulcers from developing.

Jack Stephens, MD

Feeding tubes aren't sterile. It is important to flush feeding tubes with water to prevent them from being clogged but you shouldn't worry excessively about bacteria growing in them because that is unavoidable. If you think about it our gut is full of bacteria and it is able to protect itself because the good bacteria are well colonized making it difficult for bad bacteria to establish growth. Bacteria are vital to our health and nutrition and putting things in a feeding tube to kill off bacteria would likely have the opposite effect than you would be looking for.

Jack Stephens, MD

This was likely a type two NSTEMI from demand ischemia. This means your father likely has obstruction of his coronary arteries at baseline which doesn't prevent his heart from receiving the necessary blood supply but when his body is under stress from infection or medications used to keep his blood pressure elevated his heart muscle needs more flow than his partially obstructed arteries can supply causing his heart to leak a protein called troponin which is a marker for heart muscle stress. This happens all the time in sick patients and typically resolves with treatment of the underlining stressor and without any intervention. He should consider having a nuclear medicine stress test or cardiac catheterization when he is more stable to possibly fix underlying disease.

Jack Stephens, MD

Typically this is in the realm of Orthopedic surgery. There are support groups with good information regarding this and foundations such as the fibrous dysplasia foundation that can recommend physicians specializing in this rare disease.

Hope this helps,

Jack Stephens, MD