Archives: BETs

A 17 y/o patient who is otherwise fit and well attends for removal of their tonsils. The patient has no contraindications to steroid use and you wonder whether giving steroids postoperatively will improve their pain control.

You are the registrar on duty in the Children’s Emergency Department. A registered children’s nurse asks you about an 18-month-old child who came in with his parents. He has been vomiting for the last 24 hours and has today developed loose watery diarrhoea. His mother is concerned that his oral intake is poor and his nappies are not as wet as normal. The GP prescribed some Oral Rehydration Solution (ORS) yesterday but the child is refusing to drink it. A neighbour told the mother that allowing the child to drink “flat” cola was a good way to prevent him from getting dehydrated. The nurse asks you if this is a safe and acceptable treatment to recommend for children. You have heard it mentioned by parents of children with gastroenteritis before but feel unsure whether any evidence supports it.

A young adult with kidney stones amenable to extracorporeal shock wave lithotripsy (ESWL) attends for their first session of treatment and you wonder whether such patients should routinely be given opioid analgesia.

A 25 year old man presents to the emergency department after inversion injury to his ankle. He has sustained an unstable closed ankle fracture, which requires open reduction and internal fixation. An orthopaedic consultant has told you previously that the patient should have a pneumatic foot pump incorporated into the cast, as this will speed the patient''s time to surgery by facilitating the resolution of traumatic oedema. You wonder what the evidence there is to support this.

A 15 year old boy with type 1 DM is admittd to the ED unwell, with a BM of 29. O/E he is pale, sweaty and lethargic with a BP of 90/40 and pulse 120. Otherwise exam is unremarkable. You site an iv cannula and take a VBG which shows pH 7.1 and HCO3- 10. You give a 900ml 0.9% NaCl fluid bolus (20ml/kg) and are about to start a sliding scale when the paediatric SpR tells you that local policy is to hold off insulin for the first 2-3 hours as it may increase the risk of development of cerebral oedema. You wonder what the evidence shows.

A 67 year-old man with a history of angina presents with a sudden onset of left sided weakness in the early evening. You know that the patient will not receive a CT scan until the following day and that if he is having a cerebral infarction he may receive some benefit from administration of aspirin. You wonder if the potential benefit out-weighs a possible increase in the risk of worsening any intracranial haemorrhage.

A 12 year old boy with Osgood-Schlatter's disease presents to the ED with knee pain unresponsive to regular paracetamol and ibuprofen. You wonder if immobilising his leg would improve his pain, and if so, the best method for this.

A 50 year old female patient presents to the physiotherapy department for assessment of medial ankle and foot pain that came on insidiously 6 months ago. She has been diagnosed with posterior tibialis tendon dysfunction (PTTD) by an orthopaedic consultant, but the patient would like to know what the accuracy/validity of the clinical diagnosis is without also having an MRI scan.

An unwell infant presents with high intermittent fever and irritability. She has had no previous illnesses. A urine sample showed >100 white blood cells and >100,000 E.coli/ml, confirming a diagnosis of urinary tract infection (UTI). The mother asks whether she could be treated with just one dose of antibiotic as she herself was treated this way for a recent urinary tract infection, instead of the standard 5-7 days of antibiotics currently recommended.

You just finish a busy call night and want to go home to get some sleep, you run into your colleage who is just returned from having a few beers at the bar. He challenges you that he could perform better in his intoxicated state, that you, in your sleep deprived state.

A 5 year old girl presents to the Emergency Department with a one week history of polydipsia, polyphagia, polyuria, and nocturia. She has also had one day of non-localized abdominal pain and low grade fever (T 99ºF). Labs at the urgent care center one day prior show a non-fasting blood glucose of 284; labs at the PCP's office the day of the ED visit include a non-fasting CBG of 190 and HbA1c of 7.3. You wonder if the elevated glycosylated hemoglobin is acceptable for diagnosing diabetes or if she needs further testing with an oral glucose load.

A 29-year-old white woman with no background history of cardio-pulmonary or rheumatic disease was admitted with rather abrupt onset of exert ional dyspnoea, dry cough and recurrent syncopal episodes in absence of chest pain or haemoptysis. Clinical examination revealed evidence of right heart failure. There was no clinical or echcardiographic evidence of valvular heart disease, cardiac constriction or restriction. A subsequent V-Q scan was reported to be low probability for pulmonary thrombo-embolism. Cardiac catheterization showed elevated pulmonary arterial pressure (measured 113/57 mm Hg) and normal pulmonary arterial wedge pressure (excluding left sided heart disease). Apparently the patient was commenced on oral contraceptive pills five years prior to the admission. One wonders if the sudden onset of primary pulmonary hypertension without any overt pulmonary thromboembolism, in a previously healthy woman with no positive family history could be associated with oral contraceptive pills.

A 5 year old boy presents to the Emergency Department with a 2 day history of limp and right hip pain he is afebrile. Is an ultrasound of the hip better at diagnosing septic arthritis than blood investigations (WBC, ESR, CRP)?

A 72-year-old woman presents to the emergency department with severe back pain after a mechanical fall. Plain radiographs of her thoracic spine show osteopenic vertebrae with a wedge compression fracture of the body of T8. Her pain is controlled acutely with paracetamol, ibuprofen and oral morphine sulphate. She is mobilised and arrangements are made for her to have physiotherapy in the community. You are keen to discharge this patient but want to maintain pain control and, given the potential side effects, would prefer to avoid opiates and non-steroidals. You have heard that some bisphosphonates relieve the pain of pathological fractures and wonder whether they do so in vertebral compression fractures.

You are with a 72-year-old patient who is 15 h post emergency Type A dissection repair and CABGx1. It was a difficult operation with a long bypass time. Post-operatively he has been bleeding profusely. He has been reopened but no bleeding points have been found, and he has returned to the CICU packed and with the chest open. He has received 12 units of fresh frozen plasma and 2 pools of platelets and cryoprecipitate, but has still bled 400 ml per hour for the last 3 h. You discuss the patient with the haematologist and he tells you that they now have recombinant activated Factor VII available for use, and asks whether you would like to use it. He has no experience with this post-cardiac surgery and neither have you and you are a little anxious about the patency of the graft that you had to place, but you elect to give it and then search for reports of its use.

A neonate born at 26 weeks and weighing 930 g underwent laparotomy on day 21 of life for perforation secondary to necrotising enterocolitis (NEC). He required fluid resuscitation during the procedure and Gelofusine was given rather than normal saline or blood products. We reviewed the evidence for the use of Gelofusine for volume replacement in neonates.

A middle age male presents to emergency department with sudden onset of painful, swollen, red and tender joint at the base of big toe. Blood test showed normal serum uric acid level. There is no previous history of gout. The patient asks if he suffers from gout. Does normal serum uric acid level rules out gout?

A 6 year old child arrives in the emergency department with a temperature of 39°c in order to reduce the child's fever and distress you would like to prescribe an antipyretic

A 27 year old male presents to the emergency department with a severe headache. A subarchnoid haemorrhage is suspected, the diagnosis is confirmed by CT. His GCS on admission is 8, you wonder if this will have any implication on his overall outcome.

A 20 year old gentleman presents to the Emergency department with a one hour history of an acute onset of severe testicular pain. On examintion the left testicle was found to be rather swollen and tender.