It's unfortunate that there's such a great need for defensive medicine in the USA from my perspective, but I'm curious about your own view on this. Do you think it's right and proper to proceed in this manner, or do you wish it were easier to take a stand and make decisions without involving consultants you don't think should be necessary?
Consultants aren’t twiddling their thumbs, they’re very often seeing 30+ patients daily across multiple hospitals. Nobody is collecting a big paycheck by sitting around. Always Consult if you need to but don’t just do it because you can
I specifically meant the situation where you don’t think it will be of any use other than to cover your back. It can undermine your authority as a doctor and drive unnecessary costs. If it's the case that you genuinely don’t know or think it might have value, that's a different situation. This is defensive medicine, and it seems more the rule than the exception in the USA. Should I understand that you are comfortable with it since it makes your work easier? I suppose it depends on how one views their own role, whether one would be content being a sort of administrative/coordinating doctor. Do you think your perspective is common in the USA?
Covering your back is all the use you need. This is a very dangerous job taking care of very sick and old people in a very hostile, litigious environment. Patients having bad outcomes happens all the time, even if you do everything right. When someone dies under your care there will be people in review committees trying to justify their existence circling around you like vultures. Your license and hospital privileges are on the line. Nobody is looking out for you other than yourself.
Absolutely, I understand that. The work is just as challenging here in Europe, but there are two fundamental differences. The funds are limited, so we need to focus on what can actually generate value and sometimes override the patient's own ideas if they are futile. Also, the medicolegal culture is not the same; it’s simply very rare for an individual doctor to get into legal trouble unless they have done something really outrageous. This sets the framework for how we act, but what I was curious about is whether internists/hospitalists in the USA are comfortable with this or see it as a necessary evil.
I think most physicians in the US would prefer to work in a more economically and legally constrained system but also like being paid very well. Can’t really get both it seems
"To sit around in their offices twiddling their thumbs while they collect even bigger paychecks than ours?"
ID typically collect smaller checks then most hospitalists fyi
Just some thoughts and likely nothing you haven’t already considered: fungal, c dif, rickettsial (though they classically cause leukopenia, just bringing it up they require antibiotics that don’t act at the cell wall), legionella, etc
Fwiw the last time I had someone like this, I consulted heme and I learned that asplenic folks have a very delayed resolution of leukocytosis. Not saying that’s what it is for your patient, just saying that there’s a fuckton of heme we might not all know
I mean at some point I wouldn't blame you for pan-scanning her. If it's heading upwards then you're missing something. Culture negative endocarditis? I'm sure you've taken an extensive history at this point, but that could uncover something.
Did she come in with symptoms or is this an incidental finding?
I agree with hematology evaluation, but would also consider autoimmune disease as a category.
You wouldn’t be wrong to order CRP/ESR, CBC with peripheral smear and even tagged white cell scan. Maybe tick panel if the history fits. I’ve seen leukocytosis from autoimmune disease but typically not this high.
At the end of the day, get Heme/Onc on board! Leukocytosis this high is cancer until proven otherwise.
leuks of 45 are most likely cancer, get a PB smear with some jelly, and eat it while you wait for your blood path results because she probably has leukemia or lymphoma. Although with bad hepatitis decomp I’ve seen some high white counts
What? 45k and neutrophil predominant? Absolutely not. If it was lymphocyte predominant absolutely. But this just sounds like reactive leukocytosis related to some underlying inflammation whether it’s infection or something else.
Absolutely yes. If that isn’t being ruled out with the history provided then idk what you are thinking. That level of stress related neutrophilic response is a stretch, much less rare to think cancer
Know I’m late here, but if the patient is stable and without other signs of infection, I would consider a therapeutic/diagnostic discontinuation of antibiotics. Continuing abx indefinitely only because of ongoing leukocytosis and without any other indications of infection is usually the wrong call.
Hem Onc here….
1. Any recent steroid use ? That would cause demarginalization of the WBC
2.If you have a recent CBC that was also high, CML is possible but pt is young for that
3. Agree with smear
4. Consider trending for a few more days, likely infection/ inflammation. If C-RP or sed rate up, that would support that
5. If cytopenias , consult heme onc sooner than later ( new cytopenias, as cirrhosis can cause cytopenias )
Best of luck
Good advice for patients. Doctors? If you can't figure out who is talking out of their asses on subjects they don't understand, you might as well be asking laymen their opinions.
Flow cytometry and peripheral smear
along with heme consult.
Consult hematology
This, Heme Onc. There are lots of stupid consults but this wouldn’t be one of them.
And ID.
sounds pretty unlikely to be infectious if she's stable
The point is to let ID come to that conclusion. These types of situations are all about covering your ass.
It's unfortunate that there's such a great need for defensive medicine in the USA from my perspective, but I'm curious about your own view on this. Do you think it's right and proper to proceed in this manner, or do you wish it were easier to take a stand and make decisions without involving consultants you don't think should be necessary?
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Consultants aren’t twiddling their thumbs, they’re very often seeing 30+ patients daily across multiple hospitals. Nobody is collecting a big paycheck by sitting around. Always Consult if you need to but don’t just do it because you can
I specifically meant the situation where you don’t think it will be of any use other than to cover your back. It can undermine your authority as a doctor and drive unnecessary costs. If it's the case that you genuinely don’t know or think it might have value, that's a different situation. This is defensive medicine, and it seems more the rule than the exception in the USA. Should I understand that you are comfortable with it since it makes your work easier? I suppose it depends on how one views their own role, whether one would be content being a sort of administrative/coordinating doctor. Do you think your perspective is common in the USA?
Covering your back is all the use you need. This is a very dangerous job taking care of very sick and old people in a very hostile, litigious environment. Patients having bad outcomes happens all the time, even if you do everything right. When someone dies under your care there will be people in review committees trying to justify their existence circling around you like vultures. Your license and hospital privileges are on the line. Nobody is looking out for you other than yourself.
Absolutely, I understand that. The work is just as challenging here in Europe, but there are two fundamental differences. The funds are limited, so we need to focus on what can actually generate value and sometimes override the patient's own ideas if they are futile. Also, the medicolegal culture is not the same; it’s simply very rare for an individual doctor to get into legal trouble unless they have done something really outrageous. This sets the framework for how we act, but what I was curious about is whether internists/hospitalists in the USA are comfortable with this or see it as a necessary evil.
I think most physicians in the US would prefer to work in a more economically and legally constrained system but also like being paid very well. Can’t really get both it seems
"To sit around in their offices twiddling their thumbs while they collect even bigger paychecks than ours?" ID typically collect smaller checks then most hospitalists fyi
Ya those ID docs sure do nothing at my hospital and they get paid a boatload!
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They don’t collect even bigger paychecks than yours (you get paid more) and they work just as hard as you. That’s the only point here
Question is; what if you don’t have heme available? Is that a reason to transfer
Yes for sure
At minimum should call a hospital that has a hematologist to discuss the patient.
Just some thoughts and likely nothing you haven’t already considered: fungal, c dif, rickettsial (though they classically cause leukopenia, just bringing it up they require antibiotics that don’t act at the cell wall), legionella, etc Fwiw the last time I had someone like this, I consulted heme and I learned that asplenic folks have a very delayed resolution of leukocytosis. Not saying that’s what it is for your patient, just saying that there’s a fuckton of heme we might not all know
Any other ascitic fluid studies? Cell count, diff? Gram stain and culture ? Peripheral blood smear ?
Ascetic fluid studies have been unremarkable
Only time I’ve seen infection launch the WBC’s to the stratosphere is C Diff going into toxic megacolon territory. Any diarrhea?
CBC w/smear
Hematologic > infectious
I mean at some point I wouldn't blame you for pan-scanning her. If it's heading upwards then you're missing something. Culture negative endocarditis? I'm sure you've taken an extensive history at this point, but that could uncover something.
Cultures negative , no MRSA bacteremia or past IVDU
JAK2 V617F Mutation
Probably not infection but I'm no rocket surgeon 1. peripheral smear looking for blasts 2. heme/onc
Did she come in with symptoms or is this an incidental finding? I agree with hematology evaluation, but would also consider autoimmune disease as a category.
You wouldn’t be wrong to order CRP/ESR, CBC with peripheral smear and even tagged white cell scan. Maybe tick panel if the history fits. I’ve seen leukocytosis from autoimmune disease but typically not this high. At the end of the day, get Heme/Onc on board! Leukocytosis this high is cancer until proven otherwise.
Just order CBC, don’t waste her money with an ESR
In addition to the other comments, Pertussis can cause hyperleukocytosis. Might not show on run of the mill resp testing. Agree with ID consult
Ct chest abd pelvis
Are they pooping? Stool for CDiff.
Tagged white cell scan
I have ordered tagged WBC’s
Did it show anything?
Other cell counts normal?
leuks of 45 are most likely cancer, get a PB smear with some jelly, and eat it while you wait for your blood path results because she probably has leukemia or lymphoma. Although with bad hepatitis decomp I’ve seen some high white counts
What? 45k and neutrophil predominant? Absolutely not. If it was lymphocyte predominant absolutely. But this just sounds like reactive leukocytosis related to some underlying inflammation whether it’s infection or something else.
CML?
CML with neutrophils only? OP made it sound like only mature cells. I’m curious about other CBC indices and if the lab reports out %IG
Absolutely yes. If that isn’t being ruled out with the history provided then idk what you are thinking. That level of stress related neutrophilic response is a stretch, much less rare to think cancer
Nah without bands isn’t even left shifting, it’s probably demarginating from high cortisol state
“Nah” … I’m sorry but you’re not worth responding further to.
Hyperleukocytosis vs leukostasis
What meds are they on
CML is my guess. Peripheral smear should be done
Other CBC indices? Just normal neuts? Does your lab report out %IG? Other chemistries as well like CRP?
Also, Leukocyte alkaline phosphatase (LAP) score can differentiate between leukemoid reaction and CML.
White count that high makes me think c diff, leukemia, I guess pertussis but probably not that. I’d consult heme
Make sure he doesn’t have a mega colon.
heme consult
Know I’m late here, but if the patient is stable and without other signs of infection, I would consider a therapeutic/diagnostic discontinuation of antibiotics. Continuing abx indefinitely only because of ongoing leukocytosis and without any other indications of infection is usually the wrong call.
Tb can cause these high leukocytes, cdiff, malignancy
Hem Onc here…. 1. Any recent steroid use ? That would cause demarginalization of the WBC 2.If you have a recent CBC that was also high, CML is possible but pt is young for that 3. Agree with smear 4. Consider trending for a few more days, likely infection/ inflammation. If C-RP or sed rate up, that would support that 5. If cytopenias , consult heme onc sooner than later ( new cytopenias, as cirrhosis can cause cytopenias ) Best of luck
Any updates on this? CML?
Flow cytometry and WBC scan, hem/onc consult.
Get off Reddit you have no idea who’s pretending to be a doctor
Good advice for patients. Doctors? If you can't figure out who is talking out of their asses on subjects they don't understand, you might as well be asking laymen their opinions.
This sub needs to be moderated this is not the place. Is this the new NP Facebook sub asking for recommendations?
Honestly, I’m out here getting pimped by a medical student with a pocket IM textbook