Background: As part of the ABIM Foundation’s Choosing Wisely campaign the Society of Hospital Medicine recommended providers avoid performing repetitive CBC and chemistry testing in the face of clinical and lab stability. In 2014 as part of an EMR upgrade our institution removed the “daily labs” order. A 1-year post change audit showed no change [...]

Background: Cirrhosis is the permanent fibrosis of the liver and carries a prevalence of 600,000 cases per year. Hospitalizations due to cirrhosis have doubled from 2001 to 2011 with an average hospitalization cost of $15,000. Hospital readmissions for cirrhosis are frequent and have been noted to be up to 3 readmissions per year. Given the [...]

Background: Rising healthcare costs have driven both the government and the private sector to seek cost-saving innovations in health care delivery. The Center for Medicare and Medicaid Innovation (CMMI) is leading this charge from a federal level, with burgeoning efforts coming from universities and private foundations. The Stanford Clinical Excellence Research Center (CERC) was established [...]

Case Presentation: A 62 year-old man presented to the emergency room with recurrent, colicky generalized abdominal pain. He had presented with similar abdominal pain in the preceding 6 weeks, requiring two hospital admissions. Admissions were accompanied by asymmetric lower limb swelling and pain on one admission, and swelling of lips on this admission. Six weeks [...]

Case Presentation: Sump syndrome is a rare complication of side-to-side choledochoduodenostomy (CDD). CDD used to be a common surgical procedure done in the era before endoscopic retrograde cholangiopancreatography (ERCP). After side-to-side CDD, the CBD between the anastomosis and the ampulla of Vater becomes a potential sump (a recess or reservoir serving a drain for liquids). [...]

Case Presentation: 42 year old male with history of alcoholism and chronic tophaceous gout on allopurinol, presented with acute left elbow pain and swelling. Exam showed synovitis of left wrist and elbow, distal interphalangeal joint (DIJ) and right knee and tophi  on left DIJ.  Arthrocentesis of left elbow revealed purulent fluid with leukocytosis (5000,000/mm3) and [...]

Case Presentation: A 56-year-old man presented with one day of high fevers to 104°F, myalgias, and non-productive cough. His past medical history is significant for polycystic liver disease leading to liver transplant, and metastatic neuroendocrine tumor managed with intravenous somatostatin. Two weeks prior to admission, he began a taper of his immunosuppressive medication. On the [...]

Case Presentation: An 80 year-old man presented with one day of confusion, worsened cough, and subjective fevers. He had a productive cough since emigrating from Mexico six months ago, but no complaints of dyspnea. He had a history of diabetes and stable angina for the past year. On presentation, he was tachycardic with a temperature [...]

Case Presentation: A 29 year old male with HIV/AIDS only intermittently taking antiretroviral therapy (ART), Pneumocystis jirovecii (PJP) pneumonia actively being treated with trimethoprim-sulfamethoxazole (TMP-SMX) and prednisone, and cutaneous Kaposi sarcoma all diagnosed one month ago at an outside clinic presented to the hospital with worsening cough and shortness of breath. Initial vitals were notable [...]

Case Presentation: A 73 year-old female with a history of recurrent DVT’s on Warfarin, microscopic polyangiitis and ulcerative colitis status post total colectomy initially presented with altered mental status. Lab workup revealed acute renal failure for which she underwent intermittent hemodialysis. Due to a suspicion for microscopic polyangiitis relapse, the patient was started on steroids. [...]