Archives: BETs

A patient presents with a good clinical history and examination of ureteric colic. To provide good symptomatic relief and also treatment, is the use of nifedipine indicated?

A 12 year old boy is brought in unconscious following an attempted hanging. CT of his brain and cervical spine are normal. There is no clinical evidence of a spinal cord injury. You wonder if giving steroids will improve his neurological outcome

26 year old male presented to the Emergency department with a two days history of paraphimosis. Rather than using granulated sugar the local practice is to make the patient soak his in a paper cup containing 50 ml of 50% dextrose water for approximately 20 minutes. This appeared to be easy and straightforward with a successful outcome. You wonder therefore whether there is any evidence showing concentrated sugar solution being better than granulated sugar in reducing a paraphimosis.

A fine Irish male professional rugby union player is spear tackled by 2 nasty New Zealand players and sustains a totally undeserved dislocated shoulder. He undergoes operation to reduce the dislocation and repair the associated detached glenoid labrum. The surgeon wants to play safe in the post-operative phase whilst the physios are keen to get him back to playing as soon as possible but are worried about re-dislocation rate and permanent loss of function. Debate ensues about whether an accelerated rehabilitation programme or a more conservative approach should be adopted for him.

A 60 year old man with known COPD presents to the emergency admissions unit with a history of breathlessness, worsening cough with expectoration. He is hypoxic, blood gases show ph 7.36, PaCO2 6.7, PaO2 7.0 on 24% oxygen. You start him on regular salbutamol and ipratropium nebulisers, steroids and antibiotics. He appears still breathless after 2 hrs with respiratory rate of 36/ min. You wonder whether addition of intravenous aminophylline would hasten his recovery and discharge.

A 19 year olld presents to the ED with redness tracking up the left arm. A diagnosis of cellulitis is made. However, he is going on holiday in 3 days time and is keen not to miss the trip. The patient attends the ED regularly for the administration of iv antibiotics, over 3 days and is then discharged with a 5 day course of oral antibiotics.

You are called to see a middle aged man with an acute onset of severe, colicky, left-sided loin pain. Clinical examination rules out peritonitis while urinalysis reveals '+ + +' microscopic haematuria. You strongly suspect a diagnosis of ureteric stone disease. In such circumstances, impacted renal calculi trigger the production of prostaglandins which subsequently stimulate pain. While opiates can offer pain relief by subduing patients' awareness of these stimuli, NSAID's can actually treat the pathophysiological mechanisms that cause them in the first place. You wonder whether they would be more effective at providing analgesia?

The patient is a 39 yo Afr-Am G3P0Ab2 with IUP at about 22 weeks with hyperemesis gravidarium and clinical Grave's disease. At 20 weeks, blood tests show that her serum TSH is suppressed at 0.02 mIU/ml (0.4-3.5), free T4 is 3.0 ng/dL (0.8-1.8) and free T3 is 2.6 ng/dL (0.2-0.6), her pulse is about 120. Ultrasound shows borderline normal fetal growth with a fetal heart rate of 170 (120-160). She is currently being treated with PTU (propylthiouracil) 200 mg TID. At about 22 weeks, targeted ultrasound reveals low normal fetal weight, a fetal anterior neck mass consistent with fetal goiter, normal amniotic fluid volume, and fetal heart rate of 150. How should the mother be treated?

A 40 year old man presents to the emergency department 30 minutes after drinking 500ml fenthion. He has a Glasgow Coma Scale score of 13/15, and has pinpoint pupils and excessive sweat. A rapid sequence induction and intubation is done. Given the recent onset and the undefinite efficacy of activated charcoal in organophosphate you wonder whether he is a candidate for gastric lavage.

A 35 year old accountant with recurrent shoulder dislocation presented to Emergency department with yet another episode of dislocation that happened this time while lifting a heavy load in his garage. The department is busy and he is in severe pain and considering his history you would like to reduce the shoulder without taking a pre-reduction shoulder X-ray but you are obliged by departmental policy to do the x-ray. You wonder if the pre reduction x-ray in this case would change your management.

A 74y/o lady with a significant medical history of ischaemic heart disease and COPD presents to the Emergency Deparment with acute shortness of breath. You are unsure whether this represents an episode of acute heart failure or an exacerbation of her COPD. You request an urgent CXR in the hope that it makes the diagnosis clearer so that you are able to confidently prescribe the appropriate treatment.

A 65 year old man suffered a witnessed out-of-hospital cardiac arrest. He received 20 minutes of basic and advances cardiac life support measures in the field. On arrival in the emergency department, the rhythm showed persistent ventricular fibrillation and he continued to be pulseless. You decide to continue another cycle of defibrillation and think of anti-arrhythmic drugs apart from correctable causes.You know that amiodarone is helpful. Your colleague mentions the use of magnesium as per ALS guidelines. Is Magnesium really helpful in return to spontaneous circulation in refractory ventricular tachyarrhythmias?

A 24 year old healthy man presented to minors department with deformity to his right hand middle finger, as it was hit by cricket ball in the cricket match. Right hand middle finger distal interphalngeal joint was dislocated, confirmed on xrays, reduced successfully using entonox & position confirmed on check xray. When the patient was about to be discharged home, you wonder whether to put neighbour strapping or leave it without neighbour strapping for the patient to mobilise his finger, so to return to his daily life activities straight away.

You are performing coronary artery bypass grafting on a 49-year-old diabetic with triple vessel disease and normal left ventricular function. He is overweight with a body mass index of 35. You would like to give him the best possible long-term results without causing increase in morbidity. Your colleague suggests the use of bilateral skeletonised internal mammary artery, thus giving long term results due to use of internal mammary artery. You decide to use a skeletonised LIMA and two vein grafts in this high-risk case but resolve to look up the evidence after the case.

One of your patients with borderline pulmonary function is still intubated following CABG 5 days ago. He is haemodynamically stable but his arterial blood gas shows that he is unlikely to be successfully extubated. The ITU staff ask you to site a tracheostomy surgically at the end of your list. In previous units your intensivists routinely inserted them percutaneously. The ITU staff are reluctant for a percutaneous procedure following problems with bleeding earlier that year. As you are unsure of the current evidence on which method is safer you decide to review the literature before returning to the ICU.

A 4 year-old is brought into the Emergency Department after a fall from a slide in a playground. The clinical diagnosis of a left mid-shaft femoral fracture is confirmed by X-ray. Having become familiar with regional anaesthesia techniques during a recent placement it is decided to carry out a femoral nerve block prior to placing the child’s leg in a Thomas’ splint. Can the departmental ultrasound machine be of assistance when compared to the anatomical or nerve stimulator techniques?

You performed a right lower lobectomy on a 67-year-old gentleman who had a 4-cm squamous cell carcinoma of the right lower lobe. He is a life long smoker and his tumour was staged as T2 N0 pre-operatively. You are now due to see him in your clinic but you discover that the histologist found a tumour involving the bronchial resection margin. You wonder whether to offer this patient completion pneumonectomy or whether to send him to an oncologist for post-operative radiotherapy and spare him this additional operation. Thus, you resolve to search the literature before seeing him that afternoon.

A 25 year old man with sickle cell disease presents with a two day history of pain in his arms and legs. His pain is consistent with his usual painful crisis symptoms. He is afebrile, has normal vital signs, and has no acute findings on physical exam. You promptly treat his pain. You order haematologic tests in these situations as a matter of routine. You wonder if the results of his complete blood count or reticulocyte count will alter your management.

A 35-year-old female with sickle cell disease presents with pain in her arms and legs for twenty-four hours. Her pain is consistent with her usual pain crisis symptoms. She is afebrile, has normal vital signs, and no acute findings on physical exam. You promptly treat her pain. You wonder if a chest radiograph or urinalysis will detect an occult bacterial infection that may have precipitated the crisis.