I've been sending email updates to my family in parallel with my reddit posts, obviously with more detail (and gifs), and decided to share one of those emails with you guys. I'm sure there will be someone out there staring down the barrel of BEPx3 and wondering what the hell to expect.
There are lots of posts here with bulleted lists of tips (all extremely helpful), but thought I'd provide something a bit different: a sort of day-by-day, play-by-play of my treatment for the first week or so.
To retain some semblance of anonymity, I will change/remove the names, but otherwise it's the same. For reference, the 21-day cycle for BEPx3 generally goes something like this:

bleomycin: days 1, 8 and 15 etoposide: days 1-5 cisplatin: days 1-5

My team gave me the bleo on day 2, but otherwise are keeping to the NCCN schedule. Today (1/19) is cycle 1, day 10 for me.
Brief background: stage 2A pure seminoma, left orchiectomy 6.5 cm, max RP lymph node side of 2 cm.
Hope this helps someone!
Hi all,
Sorry for the delay, I know it's been a minute since my last update. Turns out that "chemo brain" is a very real thing. Tasks as simple as reading turned out to take way more effort than I had anticipated.
Despite this, I somehow managed to keep a sort of chemo diary to pluck details out over the course of the week, and managed to set up a few calls with people (with help from my wife-- and thank you to those who called). It is from that diary that I will pull a few of the juicier play by plays from my week inpatient.
Strap in! This is a long one. :)

Week One

Monday (1/10)

Sunday night had me in some of the worst back pain of my life, even worse than the Thursday prior (see last update), so I decided not to screw around with the oxy. Woke up at 4 to take one, then woke up at 6 in a pool of sweat from the pain, so took another 2 and a Zofran. "Not fucking around this time," I wrote. "Lots of movement today." Took another oxy at 8 with plans to take another at 10.
At around 8:30 I finally had my lung function test, which sort of sets the baseline for how my lungs should be doing before the bleomycin has its way with them. This is the phone booth they shoved me in for the test. Lots of breathing, panting, sucking, and blowing into that white contraption while wearing nose clips.
Had a brief follow-up with my oncologist and his cohorts before learning that we already got ourselves a room upstairs for admission, sooner than expected. We met my nurse, who was very sweet, and I weighed in at 91.0 kg. Pretty hefty, but about where I've been for the last few weeks. She allowed us to record her accessing my brand new port from last week.
While doing all this, the pain was creeping back in again-- it was now well past 10a, and they didn't want me taking any outside meds at this point. It got to the point of begging, with me writhing in the bed. Not a pretty sight. The hospitalist took pity on me and gave me a bolus of 2 mg Dilaudid through the port, which once it was flushed through, radiated through every vein at once (catheter goes straight to my right atrium), and I immediately started crying from the relief. I didn't even realize how bad the pain was until it was all taken away at once.
The chemo pre-flush-- the fluids they need to have on board before pushing the drugs themselves-- was meant to start at 1, but I was struggling to get out a urine sample. Turns out I'm hella pee-shy. When you've got me in a patient bathroom with my dick in a portable urinal and 2-3 people waiting on the other side of the door waiting for something to happen... it ain't gonna happen. But it eventually did and I got my pre-flush. They also pushed something called fosaprepitant, which is a sort of wombo-combo bag of antiemetic goodies. They also gave me dexamethasone and Zofran to keep the nausea down during the infusion. They capped it off with one more bolus of Dilaudid, with a promise of Ativan or some other anxiolytic to come.
Around this time, my wife noticed that the whites of my eyes had turned inexplicably blue around each iris. Still haven't figured out the cause. I guess that's this week's problem. Fortunately, the color intensity appears to have gone down some. The docs and nurses had no clue. Supposedly they reached out to an opthamologist on my behalf, but I have yet to hear from them. Following up tomorrow.
(The spice must flow.)
At about 3:15p, the cisplatin infusion started. It didn't burn going in, though it was a bit intimidating having a bag of something that couldn't even be exposed to light going into my port. It had its own shroud.
By the end of the first bag, I felt... maybe a bit heavy. Like I had this general sluggishness starting to settle in. This fatigue would get stronger with each subsequent infusion the rest of the week.
The etoposide infusion started right after the cisplatin finished, and that one wrapped up at 5:30p. I could tell that it was already having an impact, because I was able to skip my evening dose of Dilaudid, which meant it was shrinking the tumors in my RP space. Having that tangible sense of progress was very uplifting.
It was hampered a bit by the fact that it was like 80 degrees in my room and I was sweating ball just lying there in a gown, boxers, and nothing else. The techs seemed to only be able to adjust the temps in increments of 10 degrees. Well, at least it felt like that, because jesus h crackers.
Later that night, I experienced the first direct side effect of the chemo: sore throat. It would be thankfully short lived and easy to treat, unlike the side effect I was about to have unleashed upon me by the bleomycin. I also learned that the cycle for my chemo would be every 21 hours, meaning each day's infusion would start 3 hours earlier than the previous day's. It wasn't exact, but it was designed (I think) to ensure that I could be discharged by a reasonable time on Friday.

Tuesday

Despite some battling with throat sprays in the middle of the night (lemme tell ya, there aren't too many things more gross than coating your tongue in phenol instead of your throat), Tuesday started out OK. My nurse woke me with vitals, and noted just how cold it was-- A/C was blasting. I eventually asked them to just set the temp to 70 and be done with the flip-flopping.
The hospitalist continued to be a bit dismissive of my eye concerns, and I was awoken by a Typhoid Mary of a clergyman (who reminded me of Guillermo) from Jimmy Kimmel), hopping from room to room-- even the COVID-positive rooms-- to offer spiritual guidance. Look, I get that there are those who really need it, but please don't wake me up from what little sleep I had been getting to badger me about god after just leaving a COVID patient's room. You crossed several lines, there, Guillermo.
Today's infusion started around noon. Every day, 3 hours earlier. From my diary: "Around 1407, etoposide almost done, I started feeling uncomfortable. Not nauseous, I don't think. Not pain. Just my brain felt out of it. Couldn't focus on one thing. Maybe this is the chemo brain people talk about."
Around 4p was the bleomycin push. This is a 10 mL infusion pushed directly into the port over 10 minutes, then flushed. Walked a few laps around the wing with my wife-- something we'd start doing with a bit more frequency-- and ate dinner. Also finally showered. Diary: "At 1721 I started hiccuping after a series of sneezes, both of which are not things that have happened frequently since being admitted." I continued hiccupping for the rest of the hour. This is the worst side effect so far of the treatment, largely courtesy of the bleo. They treated it with baclofen, which did help. I was later prescribed some for home, as well.

Wednesday

Diary: "The fatigue is real." It certainly was. They pushed the drugs around 9 on Wednesday, and I was in and out of consciousness through the ordeal. They weighed me at 11:30 after noting some poofy ankles and discovered that I had put on 16 lbs in 2 days, all fluid retention. They pushed Lasix that afternoon, and god damn, that stuff works. I peed a full liter in one go. I didn't even know the bladder could stretch that much.
My oncologist came to check on me shortly before my wife arrived for the afternoon. I think he was largely curious about the eyes. Diary: "He asked me if I had any family history of bone disease. I asked him, 'Like osteogenesis imperfecta?' He laughed, because I think at this point he's becoming amused with my homework. I told him no. He said I would be seeing an ophthalmologist, either inpatient or outpatient."
I'm going to try to describe the fatigue... Imagine your worst morning. You got barely a wink of sleep, you need to sign into work in 15 minutes, and you are firing on maybe 1 or 2 cylinders at most. Now imagine that no matter what you do-- coffee, tea, energy drink-- nothing will make you feel like you're fully awake. On top of that, no amount of time passing since you woke up will make you feel more awake, either. Now, on top of all of that, imagine that you can't actually get back to sleep. That's the fatigue I've been feeling, and it peaked that afternoon.
I finally felt ready to take a couple calls that evening, and got to speak to a bunch of you (thank you). It was difficult saying bye to my wife at 6p, so being able to talk to people helped a lot.
I also started to write a bit less in the diary, as it was getting a bit harder to get the thoughts out, but I pressed on anyway.

Thursday

Thursday was more of the same. Infusion around 7a, and the fatigue set in quickly. That afternoon I felt like I could do a bit more, so my wife and I walked around the wing again, played some Mario Kart, some Battleship, etc. She's amazing, and my rock. I wouldn't get through this without her.
That evening I talked with a few more folks (thank you), dreading the early wake up call for the chemo. Friday's infusion was to start at 3 a.m. Yikes.

Friday

Several Xanax later, I finally got a tiny bit of shuteye in the wee hours of Friday morning before my nurse started the last round of EP (around 4a). Tragically, while watching an episode of The Simpsons to try and level-set myself, it happened to be the moment at Martin's party where everyone got sick and Milhouse yelled "I gotta barf!" Talk about sympathetic nausea. I instantly became nauseous. Thankfully, they were able to push compazine pretty quickly and the urge subsided. I slept the rest of the morning.
By 11:30 I was finally discharged. While I was able to process my surroundings, operate door handles, generally function as a human... I still felt very off. There was this intense sense of foreboding, like I couldn't relax for even a moment. Everything had me on edge. My wife thankfully identified it pretty quickly as extreme anxiety and ran me a bath with epsom salts and bubbles to soothe my nerves (worked wonders-- I should take more baths). The prescribed Xanax eventually kicked in, along with a THC gummy, and I was out for the evening. I seriously was not expecting the anxiety to be a side effect of the chemo.

Saturday

Day 6, Saturday, was a bit rough. This was the first day with no infusions, and all I had to do was drink water and continue to let the rest of the drugs exit my system. Still, another new side effect presented itself: stomach pain. So far I had to deal with fatigue, nausea, hiccups, and anxiety-- and now we're back where we started with the pain. At least it's not in my back, I guess? I already have GERD, so it seems the chemo is exacerbating it.
I tried, and failed, to eat a normal diet. At 4 a.m., I mistook the stomach pains for hunger and tried a small bowl of cereal. Didn't settle it. A few hours later, I tried a full one. Still not feeling quite right. Had a strange hankering for breakfast sandwiches, so my wife and I made some bacon, egg, and cheese bagels. They were delicious, but probably not the smartest choice in hindsight.
I spent that evening hugging a bucket, desperately staving off the nausea while watching the Bills pummel the Patriots. By this point, it became clear that my diet was an issue, and I had nothing but toast the rest of the night.

Sunday

Turns out that Saturday was just the warmup. The pain lasted well into the evening and beyond the Bills game, and continued into the night and morning. By 4a, I had given up, and woken up my wife. It felt like my stomach lining was being slowly peeled back, then wrung like a washcloth. I was in agony.
We called the cancer center, who suggested I take some of the pain pills I had been prescribed. Unfortunately, shortly after attempting to get up, I vomited from the pain, and it became clear that oral drugs were a no-go. We went in.
At the center, they gave me 2L of fluids, Protonix, Tylenol, and took some labs. When the labs suggested that I had pancreatitis-- goody-- they pushed Dilaudid. Fortunately, the CT they later took turned up negative and I did not in fact have pancreatitis. Unfortunately, though, they have no idea what caused my plasma lipase levels to shoot through the roof (4x normal). The answer we got seemed to be the equivalent of: "*shrug* ... Chemo."
After giving me an oxy, we headed home, with a plan to basically treat my new gut as the fragile, chemo-ravaged thing that it is. My wife went shopping for BRAT-diet-like things that would be easy on the digestion, and I loaded up on pain and nausea meds the rest of the day. She cooked what we thought was a very light and heart healthy meal, which I thoroughly enjoyed, and then promptly returned. This was not going to be easy.

Monday ("Today," as of original email)

So here we are. Today is finally the first day where I feel almost normal. I still have to tiptoe around my stomach issues, but we've learned that the chemo is basically shredding my stomach lining and generally making lots of things a real chore that weren't before. I still have no idea what's causing my sclera to turn blue, nor why my lipase levels are sky high, nor why my stomach is going haywire-- but the common thread appears to be simply "chemo."
Thank you again to everyone who reached out, who sent us gifts, who kept my wife and me company, who simply reads my updates. It helps me feel not so alone writing these emails, knowing that someone out there is reading my story.
This is only week one. I still got 8 more weeks of this shit. Still, with my support group-- you all-- I know I'll see the other side.
As for final thoughts on the chemo... 0/10, wouldn't recommend.
And there it is. If anyone has more questions, feel free to reach out. I'd be happy to help.

So this is a case not so much about the diagnosis (which is interesting), but the process of getting this patient cared for. For those that want to consider what they would do, I'll break up the post a bit to allow you some space between important decision points.
A little background information about me. I'm a US emergency medicine attending who works in a community/academic setting. This case is at a 14 bed 30,000 annual visit ER in a hospital that is part of a large system of hospitals in the city I live in. We have CT capabilities, an ICU, and most specialties available for consult. I am working an overnight and have 3 nurses and a tech with me.
So its 0450, I am an hour away from ending my uneventful shift when I am told that a 50 something YO gentleman is checking in for generalized weakness and can't pee. They bring him back to a room and I immediately notice that he is LLS (looks like shit) score positive. He is breathing 35x per minute. He is too distressed/tachypneic/weak to talk, so his wife tells me that he has a history of DVTs (on xarelto), peripheral arterial disease, HTN, DMII, and frequent kidney stones and he presented due to feeling poorly and being unable to urinate for the last 2 days, now is too weak to even stand. She states about 5 days ago he urinated out some stones, and 2 days ago he went completely anuric. The wife states that being a stubborn man, she had to beg him to come in this morning.
The rest of his VS are a HR of 81, BP 190/91, temp 37.1 C, O2 96%.
What is the first test you want on this patient? Also, consider what else you are doing and ordering on this patient.
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If you stated an ECG, you are correct.
Now I feel this ECG is fairly obvious, but maybe not so much for medical students, so I'll ask what your interpretation is.
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This ECG demonstrates an irregular, wide complex rhythm with no evidence of sinus activity, with diffuse peaked T-waves consistent with severe hyperkalemia. You will also some right axis deviation, a tall R wave w/ downsloping ST segment in aVR, and a brugada-like pattern in V1 and V2 which is frequently seen in hyperkalemia (along w/ sodium channel blocker toxicity). While peaked t-waves is typically taught to us in med school as what we should look for when concerned for hyperkalemia, isolated peaked t-waves in the setting of hyperkalemia actually does not portend any worse outcome for the patients it is present in. The typical hyperkalemic ECG changes that do portend worse outcomes are absence of p-waves, QRS widening, and bradycardia¹ .
As for the rest of the tests I ordered, VBG (as the patient clearly has severe metabolic acidosis from acute renal failure based on his tachypnea), cbc, cmp, CXR, and added on some blood cultures as a just in case.
His VBG came back with a pH of 7.1, pCO2 of 21, and HCO3 of 6. Unfortunately our blood gas analyzers cannot perform istat electrolytes.
I also performed a POCUS of his bladder (because of course every interesting EM case needs some POCUS) while we were obtaining the ECG, which demonstrated an absence of urine which confirmed what I was suspecting.
So how are you going to treat this?
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You should now be focusing on cardiac membrane stabilization and shifting the patients potassium intracellularly. I think of hyperkalemia treatment in 5 separate treatments. You have your membrane stabilizers (calcium gluconate/chloride), your potassium excreters (lasix, kayexalate, ion-exchange resins), your potassium shifters (albuterol, insulin, bicarb), your diluters (fluids), and dialysis.
I avoided lasix because the patient is anuric and avoided kayexalate and ion-exchange resins because they limited utility in the acute setting. I also avoided fluids given the patient was anuric.
If we were to give a hyperkalemic patient fluids, I think there is an interesting conversation to have. Classic teaching would suggest avoiding balanced solutions like lactated ringers due to the presence of potassium in them; however, there is some literature to suggest LR has improved potassium levels compared to NS, at least in renal transplant patients in the OR ^2,3,4 . This is likely due to the miniscule amount of potassium in LR (4 mEq) along with with LR's pH (6.5) being closer to physiologic compared to NS (5.5), given that we know acidosis leads to potassium shifting extracellularly.
The first med I gave was 3gm of calcium gluconate (the equivalent of 1gm calcium chloride), then 10u insulin along with an amp of D50, then two amps of bicarb, then a 15mg albuterol neb was started. There has been some discussion in EM circles about reducing insulin dosage to 5u to decrease the incidence of hypoglycemia with similar efficacy in potassium lowering, however, the literature seems to be mixed on this from my own reading^5,6 .
The QRS narrowed following calcium administration. While meds were being administered, I made a call to nephrology and our intensivist. The nephrologist stated he would prepare to set up dialysis while myself and the intensivist worked on placing a quinton catheter (I love my consultants, they didn't even bat an eye when I explained that we had no lab values back yet). We then took him quickly to CT to confirm my suspicion that the patient had bilateral ureteral stones with one side having a proximal 1.5cm stone and the other side having a mid ureteral 8mm stone.
I then gave a call to the patient's urologist and we agreed that the more pressing issue was starting dialysis and he could work on placing bilateral percutaneous nephrostomy tubes vs bilateral ureteral stents in a day or two once the patient was off his anticoagulation.
Finally, about an hour and a half after presentation, I got a call from lab stating that the patients creatinine was 20 and his potassium was 8.9.
Of course as I was about to leave my shift about an hour after it ended, and two hours after the patient had arrived. I heard a code blue call in the ICU in the room we transferred him to. So I ran over there. Luckily I did, as when I arrived the patient was in stable-ish V-tach vs a sinusoidal rhythm on the monitor (appeared to be more consistent w/ V-tach), and the intensivist was ready to push amiodarone before I stopped him explaining that giving a medication with sodium channel blocking properties to a severely hyperkalemic patient could potentially kill them. We instead opted for an additional dose of calcium, which did not work, so made the sphincter tightening decision to perform an electrical cardioversion (sphincter tightening because cardioverting a hyperkalemic patient can potentially put the patient into v-fib). Luckily he converted back to his junctional rhythm following cardioversion and was started on dialysis.
The patient was discharged from the hospital 7 days later after bilateral ureteral stents were placed. I went and visited him the last day of his admission and seemed to be doing great, and was thankful that his dialysis line was finally removed.
I think some important conclusions you should have from this case is not to wait for potassium levels before starting therapy on a hyperkalemic patient which highlights the importance of recognizing evidence of hyperkalemia on ECG. Also probably important not to wait 2 days to go to the hospital after becoming anuric.

1. Durfey, N., Lehnhof, B., Bergeson, A., Durfey, S., Leytin, V., McAteer, K., Schwam, E., & Valiquet, J. (2017). Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. The western journal of emergency medicine, 18(5), 963–971. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576635/
   
2. O'Malley CM, Frumento RJ, Hardy MA, Benvenisty AI, Brentjens TE, Mercer JS, Bennett-Guerrero E. A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation. Anesth Analg. 2005 May;100(5):1518-24, table of contents. doi: 10.1213/01.ANE.0000150939.28904.81. PMID: 15845718. https://pubmed.ncbi.nlm.nih.gov/15845718/
   
3. Khajavi MR, Etezadi F, Moharari RS, Imani F, Meysamie AP, Khashayar P, Najafi A. Effects of normal saline vs. lactated ringer's during renal transplantation. Ren Fail. 2008;30(5):535-9. doi: 10.1080/08860220802064770. PMID: 18569935. https://pubmed.ncbi.nlm.nih.gov/18569935/
   
4. Modi MP, Vora KS, Parikh GP, Shah VR. A comparative study of impact of infusion of Ringer's Lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation. Saudi J Kidney Dis Transpl. 2012 Jan;23(1):135-7. PMID: 22237237. https://pubmed.ncbi.nlm.nih.gov/22237237/
   
5. LaRue HA, Peksa GD, Shah SC. A Comparison of Insulin Doses for the Treatment of Hyperkalemia in Patients with Renal Insufficiency. Pharmacotherapy. 2017 Dec;37(12):1516-1522. doi: 10.1002/phar.2038. Epub 2017 Nov 27. https://pubmed.ncbi.nlm.nih.gov/28976587/
   
6. Moussavi, K., Nguyen, L. T., Hua, H., & Fitter, S. (2020). Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Critical care explorations, 2(4), e0092. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188424/
   

TLDR: 50 year old anuric, ECG demonstrates severe hyperkalemic changes. Meds given to treat while placing dialysis line. CT obtained demonstrating bilateral ureteral stones. Pt goes into v-tach and is almost given amiodarone. Electrically cardioverted. Started on dialysis. Discharged 7 days later in good health.

Thought it might be cool to share some stuff we've all learned recently! I'm an IM PGY-1 btw. Below are some random points I've written down starting chronologically since June. I didn't include everything because it's already long enough already, but maybe we can share some learning points together and next time we get pimped we will know the answers :)

• Where should you draw blood cultures in a patient with central lines? 1 from the central line and 1 from peripheral IV. Time to positivity can help you determine if the line is infected
• Are patients with IBD hypercoagulable? Yes, even though you worry about GI bleeds they have a general inflammatory state which results in hypercoaguable state especially during a flare
• Should cirrhotic patients get DVT prophylaxis even if their INR is elevated? Yes, INR is not reflective of their bleeding/clotting risk as they lack both procoagulant and anticoagulant factors
• Something you should consider before starting DVT prophylaxis in a patient with metastatic cancer? Intracranial tumor - risk of brain bleeding
• Is cooling the patient after achieving ROSC useful? Yes - targeted temperature management goal 32-36 celsius for 24 hours
• Normal (negative) ACTH stimulation test when testing for adrenal insufficiency = cortisol >18
• Positive ACTH stimulation test + high baseline ACTH = primary AI
• Positive ACTH stimulation test + low baseline ACTH = secondary AI
• What's a good time to use captopril = inpatient, it has short-half life and TID dosing so you can titrate/adjust quickly
• Why is atenolol bad nowadays and pts should be switched off if possible = increased risk of diabetes and stroke
• What can hydralazine do to heart rate = tachycardia
• Use hydralazine for HTN + bradycardia, and labetalol for HTN + tachycardia!
• Trial which showed ACEI, CCBs, and thiazides are equivalent for treating HTN = ALLHAT
• What's a reason to be more cautious prescribing a thiazide in a patient with poor follow-up = electrolyte abnormalities, especially hyponatremia and hypokalemia
• Trial which showed combination of ACE/CCB is better than ACE/thiazide for HTN = ACCOMPLISH
• Definition of treatment-resistant HTN = BP not at goal with 3 anti-hypertensive meds (with at least 1 being a diuretic)
• First line agent to try for resistant HTN = aldosterone antagonist
• 4 key components of sepsis treatment = antibiotics, fluids, vasopressors, source control
• What kind of albumin should be given to patient undergoing large volume paracentesis = 25% albumin
• What's a way you can fluid challenge a patient to see if their BP will improve, without actually giving fluids = leg raise
• Wtf is a cuff leak = test to check if there is airway edema prior to attempting extubation
• Narrow pulse pressure is more indicative of cardiogenic shock
• Wide pulse pressure is more indicative of distributive shock
• What's a diuretic you can use in a patient with high bicarb = acetazolamide (diamox)
• Wtf is ECOG score = score to see how functional a person is before getting chemo
• Why do cardiologists like apixaban more than rivaroxaban sometimes = bid dosing, so less peak/trough and less bleeding risk
• Is a normal PTH in the setting of hypercalcemia normal = NO. PTH should be low if you're hypercalcemic so normal PTH is abnormally normal!
• Why can't calcitonin be used long term for hypercalcemia = tachyphylaxis
• Treatment for hypercalcemia which works by being an agonist for calcium-sensing receptor = cinacalcet
• Test to get in a patient who is hypercalcemic and this problem runs in the family = 24 hour urine calcium to check for familial hypocalciuric hypercalcemia
• Sarcoidosis causes hypercalcemia due to increase in what kind of vitamin D = 1,25-hydroxy vitamin D
• Test you should get in patient with hyperparathyroidism to check for one of its main complications = DEXA scan
• #1 cause of antibiotic failure in adequately covered patient (in terms of dosage and sensitivities) = abscess
• Blood clots in what location of lower extremity generally don't require anticoagulation = below the knee
• Should you continue beta blockers in patient having acute heart failure exacerbation = yes, (but no if they aren't already taking beta blocker)
• Lactic acidosis not associated with tissue hypoxia or hypoperfusion = type B lactic acidosis
• What is a cause of a U wave besides hypokalemia = bradycardia
• What antibiotic should you add in a patient >50 years old with suspected meningitis = ampicillin - to cover listeria
• How can you explain a patient with heart failure having an elevated bilirubin/LFTs = congestive hepatopathy
• Why is a GI bleeding patient having diarrhea = blood is a laxative
• Bacteriuria is defined by how many colony forming units in a urine culture = >100,000
• Parkinson's disease but with poor response to levodopa = Parkinson's plus syndrome. Can also see vertical ophthalmoplegia, MRI with hummingbird sign of midbrain atrophy
• Why should you be hesitant to place a PICC in patient with CKD = may stricture and reduce future access sites if they need dialysis
• Why don't you give neulasta/neupogen during chemotherapy = stimulates your normal stem cells to divide, theoretically increasing risk that they will be killed since chemo affects rapidly dividng cells
• Three metastatic cancers that can be treated with curative intent = testicular, thyroid, low-grade colon cancer
• Alternative to zofran which comes in patch form = granisetron (lower association with QTc prolongation too)
• Main side effect of prochlorperazine and metoclopramide = dystonia (dopamine antagonjists)
• Are benzos useful for treating nausea = no, lots of places might put lorazepam but it's not really that good
• What's a useful antipsychotic for treating nausea = olanzapine (zyprexa)
• What daily dose of prednisone would pose a high risk of adrenal insufficiency in a patient about to get surgery = >20 mg/day for >3 weeks. Will need stress-dose steroids
• Test which can assess diaphragmatic strength = negative inspiratory force
• Treatment for ifosfamide chemo neurotoxicity = methylene blue. Remember to give mesna to prevent hemorrhagic cystitis
• Why should you get an echo before doxorubicin chemo = establish baseline EF due to risk of dilated cardiomyopathy. Can reverse with dexrazoxane. Can you tell I'm on heme onc right now?
• Do steroids mainly affect basal insulin or mealtime insulin = mealtime insulin; will need to adjust dose to avoid hyperglycemia
• Why is lasix less effective in patients with low albumin = lasix is highly albumin bound, so less is delivered to kidney in patients with low albumin. Adding albumin doesn't help though
• Can giving beta agonists in patients with asthma cause lactic acidosis = yes; patients will need a thorough assessment for evidence of true tissue hypoperfusion vs type B lactic acidosis

RESULTS: NYQUIST!!!!! You are looking at the new Kentucky Derby Favorite. 4 - 3 - 2 - 9
tl;dr 4/9 Ex box
We're running out prep races! Just a few more weeks before the Kentucky Derby and this graded stakes race features 2 fan favorites. Match-ups with undefeated heavyweights are usually reserved for the derby but not this year! Nyquist and Mohaymen. East vs West. blah blah blah....
Alright, look. This could be short and sweet. Just bet Nyquist and Mohaymen in an exacta box. Call it a day. But whats the fun in that! If the top 2 favorites always won, we wouldn't be here. Besides, I like to bet to make money, otherwise, what's the point!
Let's see what Brisnet has to say about Gulfstream: http://www.brisnet.com/cgi-bin/editorial/article.cgi?id=331 Favorite win 35% Favorite ITM 69% Avg. Winning Odds: 5.99-1 9% win wire to wire 1 1/16 - Rail & Inside posts are best.
Hot trainers: Jorge Navarro Peter Walder
Alright, here's the field...
1) Sawyers Mickey - 280k purchase from the OBS sales. Peter Walder trains and he's having a decent meet. Scott Spieth is a good jockey but the horse is 7 starts - 0 wins. Other than some decent workouts, we know what he's up against. The only redeeming factor is that Peter Walder is training since his last start. When a 280k purchase hasn't won yet.... You have to hope he's a late bloomer.
2) Fellowship - 3rd to Mohaymen in his last two races. For all intents and purposes, this may be the trifecta. Its expected he'll run strong down the stretch. Don't think he has it in the tank to catch Mohaymen. All he has to do is run his race see what happens with the extra 1/16 in this race.
3) Majesto - 300K purchase. Broke maiden at GP last out @ 1 1/16 in 1:44 flat. Castellano rides. I tell you, Majesto makes me wonder and I don't think Fellowship has a lock on third IF Majesto repeats his performance. But Majesto will have to improve on his 97 speed rating to do it. Majesto also ran 3rd in a 1 1/8 race at GP in 1:51. He could hit the board... But to go from a 60K maiden to a Gr 1 win? No.. Although, a couple other horses in this race did win a Gr2 after their maiden.... hmmmmmm.... He did finish 3rd to Destin in his maiden at Belmont. A good ride and he could in the top 4
4) Nyquist - 6 for 6. 3 - G1 / 2 - G2. 2 @ 1 1/16... The only reason I doubt his ability to win is that he's shipping in without any workouts (that I know of), no races on the track, and hasn't raced in 47 days. The 4 month layoff didn't prevent him from winning his last race. He's won at Santa Anita, Del Mar and Keenland. Does he win? Does it matter? He should be in the KD anyway. He has the speed to get in front and set a torid pace. I don't think Mohaymen will let him get away with it though.
5) Copingaway - The PP says "may improve returning to dirt". Ummm may improve if sitting on a carousel? The only way this horse is hitting the board, is if the board lands on him. But this is horseracing. I guess anything can happen.
6) Chovanes - 4 starts - 1 win and that was his last start. Had to drop into a maiden claiming race to get the win. Jorge Navaro is the trainer... but I don't see this horse having anything in the tank to get him to the finish. If the horse needs the lead to win, he won't get that here.
7) Takeittotheedge - 1 race. 1 win. 7f. 1:23.2. Wins by 7. Could he step it up into the big leagues? Like Cupid? Danzing Candy? Does he get his start here the way Nyquist and Mohaymen got theirs? It's asking for ALOT. But... Maybe?
8) Fashionable Freddy - Finished 4th behind Isofass in 75kOC. That 1 1/18 contest was run n 1:49.3. Won by Battery. Ran 1 1/16 in an adjusted 1:46. He'll be 10 lengths behind the winner. There's 4 better horses between him and the finish line.
9) Mohaymen - Sets the pace and wins or comes off the pace and wins. 4 consecutive G2 wins. Did I says wins? He wins. Won at GP at 1 1/8 in 1:50.3 in the Remsen @ Aqueduct. Won next 2 @ GP (1 1/16) in 1:42.x... No one else in the field has run those speeds. The only question will be if someone else in the race can beat the 1:50 mark. Maybe Nyquist? Maybe Fellowship? Maybe Takeittotheedge?
10) Isofass - 3rd in the OC75k last out. 1 1/8 in (adjusted) 1:50.3. Without a big improvement, he'll fade at the end.
Alright, it's easy to see that this comes down to Mohaymen and Nyquist. Last year, Materiality and Upstart, finished 12 lengths ahead of the pack. In 2013, it was Orb and Itsmylucky day finishing 5 clear of the pack with a 30-1 and 103-1 in 4th. Pretty much the only reason the super paid so much... that and the 2nd favorite finished out of the money.
So here's how the race goes... Nyquist in the lead, Mohaymen sitting off the pace. Freddie may also go for the lead with Takeittotheedge and Chovanes. Thing is, Freddie, Chovanes & Edge have only won when they have wired the field. The top 2 set the early pace and pull away from everyone coming down the stretch. It's easy to see Fellowship trailing behind with Majesto and Takeittotheedge nearby. Barring a meltdown by Mohaymen, Nyquist will have to run a huge race to upset Mohaymen. 9/4/2/3,7,8 or 4,9/4,9/2,3,7
That prediction out of the way.... Let's see it from a $$$ standpoint.
Disclaimer: I'm a cheap better :)
Nyquist barrels down the stretch or keeps the lead and passes Mohaymen at the wire.... Big deal. They're the favorites and wouldn't be surprised to see them both go off at even money. What will the exacta pay?... What if Nyquist doesn't fire.... We've seen this happen with a bunch of our favorites over the past several weeks. The exacta's will pay well even with Mohaymen at 1-1 if Nyquist finishes 3rd or worse. Mohaymen could have a bad day. But we're banking on the horses running their standard race. The biggest unknown in Takeitottheedge or Majesto. Could either of those step in front of Fellowship for 3rd or maybe bump one of the favorites for 2nd? Doesn't seem likely, but the trifecta or super could pay well with the longest of long shots in 3rd & 4th.
Edit:
Let's make an assumption that Nyquist & Mohaymen finish 1-2. I think the generally accepted theory is they'll finish 1/2 or 2/1.... Generally speaking, the rest of the field is racing in a G2 or lower race for 3rd. What does the rest of the field do? The rest of the class falls on Fellowship... But he hasn't won recently (Won @ GP 1 1/16 in Oct), and although he beats the rest of the field, he's still 3rd. Let's consider Ny & Mo as 1 horse (cause we (I) expect them to be neck and neck down the wire), who else in the field has run well enough, at GP, that could beat Fellowship?
Majesto - won @ 1 1/16 last out in 1:44 flat... add 6 seconds and 1 1/8 is 1:50... His previous 1 1/8 was 1:51. Still, the 1 1/16 is a little slower than Fellowships's time in the same distance (adjusted 1:43.x). A little traffic can make all the difference.
Isofass - came in 3rd @ 1 1/8 in an adjusted 1:50.3... So he's still a little behind Fellowship too. I hear he'll be on first time lasix. Maybe that'll be the boost he need to shave another second off his time. But he ran off the pace and didn't fade too much at the end. The last 1/16 will tell the story.
Takeittotheedge - only won at 7f. He's the big unknown. Can he run a solid race? A 3rd place finish here would be the equivalent of him winning a G3/G2 race. Awesome Banner was fast at 7f but it didn't translate into a longer distance.
Fashionable Freddy - Adjusted 1:50.5 for 1 1/8. As you can see, these 4 horses may be tightly bunched at the end. The nod still goes to Fellowship.
Fellowship - 1 1/16 adjusted times- 1:43 & 1:43.2? Add 6 sec. for the extra 1 /16.... 1:49ish....
Again... a simple, logical bet is 4,9/4,9/2/3,10
Cheap tri for Nyquist fans: 4/9/2 Cheap tri for Mohaymen fans: 9/2,4/2,4
If Nyquist burns out in the Florida sun: 9/2/3,10 If Mohaymen stops for donuts on his way to the track: 4/2/3,10/8 If Ny & Mo re-enact brokeback mountain: 7/2/3,10/8 Because this would pay ridiculously crazy: 5,1,6 tri box
I'm done... see you at the betting window :)