Thursday, September 18, 2014

Imagine if the wards were really like the boards

1. You have a new patient with a drug you've never heard of before. Your next step is to:

  1. Look it up on your phone.
  2. Ask a colleague what the drug is.
  3. Take a careful look at the patients medical history and try to figure out the purpose of the drug from the context. Hopefully it won't be relevant to the question you are asked.

2. The patient develops an infection and ID suggests adding clarithromycin. The patient is on a number of cardiac drugs and you are worried about QT prolongation. You should:

  1. Look up the possible interactions on your phone.
  2. Depend on your memory of potential drug-drug interactions. Because, though you hate to brag, you did pretty good in medical school and have a keen mind.
  3. Give the clarithromycin, but also order telemetry for the patient, because you are a careful doctor.

3. A patient presents for confusion and is found to have hyponatremia. She has the following labs:

  • Urine Na 80
  • Urine K 40
  • Serum Na 105
  • Urine output 600 mL over the last 18 hours
Calculate the electrolyte free water clearance.
  1. Don't worry that you are bad at math, this is probably SIADH so just prescribe tolvaptan.
  2. I can't remember the equation, but this just smells like an experimental question. I'm sure I can take care of the patient without this calculation. Let's look at the possible choices and I'll take a logical guess.
  3. Fire up MedCalc, put in the values. Out comes the answer.

4. The biopsy comes back for a patient with proteinruia. The Pathologist calls it dense deposit disease. You have never seen a patient with this before but you did do presentation on MPGN type two 11 years ago in fellowship.

  1. Perfect, you've got this. This is nephrology, there's no way the standard of care has changed in the last decade.
  2. Hit the computer and look it up on UpToDate and do a quick lit search focusing on the top nephrology journals. Consider eculizumab.
  3. Review KDIGO GN clinical practice guidelines. Scream out loud when you find that it is not covered. Fall back on answer 2.
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