Archives: BETs

A 65y/o gentleman presents to the Emergency Department complaining of acute onset of shortness of breath. You suspect on clinical grounds that this may be due to heart failure. His ECG shows sinus rhythm with a rate of 96bpm and no abnormalities that you can detect. You wonder if this suggests that there is another cause for his symptoms.

A 22 year old male presents to you in Accident and Emergency complaining of sudden onset of shortness of breath and right sided pleuritic chest pain. He has clinical signs in keeping with a pneumothorax and is not currently tensioning. You request a plain PA erect chest radiograph which shows a small right tided pneumothorax. After aspirating 200ml of air, you repeat the chest radiograph which shows no improvement in the pneumothorax. Can you rely on the x-ray ?

A 55 year old man, known to have angina, presents to the Emergency Department with new-onset typical ischaemic rest pain that is not relieved by his nitrate spray at home. His ECG shows ST depression in V3-V6. He is haemodynamically stable. You treat him with oxygen, aspirin, nitrates, beta-blockers and heparin, after which he becomes pain free. You also give him clopidogrel 300 mg because you have heard that patients with unstable angina and non ST-elevation MI have a better cardiovascular outcome when treated with a combination of clopidogrel and aspirin versus aspirin alone. You wonder whether there is any evidence to support this.

A 76y old gentleman with a known history of ischaemic heart disease presents with a history of recent onset of severe dyspnoea. On questioning a history is revealed of mild exertional dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea. On arrival in the department the gentleman had been started on high-flow oxygen via a mask with a reservoir. You wonder if there is evidence to support the use of supplemental oxygen in patients with heart failure.

A 2 1/2 year old girl is brought to the Emergency Department in respiratory distress. Her father tells you that he noticed a barking cough throughout the night and that her breathing was becoming noisier. On examination the child is alert and tachypnoeic, has got a tracheal tug and recession, an audible inspiratory and expiratory stridor, SpO2 > 92%, Temp 38.3C. You decide that you are going to treat with Dexamethasone and wonder whether heliox might be effective as a 'bridging therapy' in relieving symptoms and improving croup score.

You have a 4 year old girl with hemihyperplasia limited to the left leg in your clinic come for review. This child was originally referred to your clinic a few weeks back after her mother noticed leg length discrepancy when she bought a new pair of trousers. You notice asymmetry between the two legs, with the left leg larger and longer than the right. An orthopaedic surgeon was consulted, who ruled out a hip problem and suggested the possibility of hemihyperplasia of the left leg. There is an increased risk of cancer, especially of Wilm's tumour in these children, and hence a paediatric surgeon was consulted. Ultrasound scan of abdomen ruled out an intra-abdominal tumour. Her parents were trained to feel their daughter's abdomen weekly. You are unsure about the actual incidence of the risk of tumour (cancer) development and the best scheme for surveillance. Hence you decide to look at the evidence base for these answers so that the family can be counselled appropriately.

A preterm baby on the neonatal intensive care unit develops anaemia of prematurity, requiring a blood transfusion. The parents of the baby are Jehovah's Witnesses and do not believe in blood transfusions. They do agree to allow their baby to have recombinant human erythropoietin (rHuEPO) treatment instead. However, the clinical staff are unsure whether giving coexisting iron supplementation with rHuEPO treatment will further reduce the requirement for transfusion, and if so in what dose and form should the iron supplement be given?

In [the stable adult, blunt abdominal trauma patients] is [ultrasound as sensitive as computed tomography] in [diagnosing intra-abdominal organ injury?]

You are the senior house officer on duty in the emergency department and a 79 year old male is brought in by his son who states that the patient collapsed at home after having sudden onset central abdominal pain radiating through to the back. He is cold and clammy with a pulse rate of 126/ min and his blood pressure reading is 74/46 mm Hg. You commence active resuscitation and the nurse provides you with a blood glucose reading of 1.2 mmol/l. The test was done with a glucometer on a capillary finger prick sample. You commence IV glucose after sending a venous lab sample. The lab result comes back as 23 mmol/l. You dont understand the reason for the difference between the lab result and the glucometer reading. Meanwhile your consultant has also arrived and she says that she has read somewhere in one of the journals that in cases of impaired peripheral perfusion, the glucometer result on a venous sample is more accurate than the capillary sample for assessment of blood glucose. You decide to do a literature search to find the evidence.

A young adult who is keen on sport asks you about a suitable stretching routine for the lower limb in order to prevent injury. You are unsure which, if any, is effective and seek out the evidence.

Hannah is a 7 year old girl with Henoch-Schonlein purpura (HSP). She has a lot of abdominal pain which is not settling with simple analgesia. An ultrasound scan reveals that she does not have an intussusception. The SHO on-call tells you that her handbook of paediatrics says that such pain can be treated with steroids, but is there really any evidence to support this?

You are a paediatric registrar on the children's intensive care unit. You are about to intubate a 2 year old child with severe meningococcal septicaemia. Your recent experience in ventilating children with this condition is that they often develop acute respiratory distress syndrome, and require high pressures to maintain adequate oxygenation and ventilation. At these high pressures significant leaks occur around the endotracheal tube, impairing effective ventilation, and on occasion it is necessary to change to an endotracheal tube of greater diameter. Re-intubation under such circumstances carries a greater risk of hypoxia because of the inevitable loss of positive airway pressure during the procedure. You think it would be wise to insert a cuffed endotracheal tube, in which the cuff could be inflated if leak becomes a problem. It has been traditionally taught that only uncuffed endotracheal tubes should be used for intubation in children under the age of 8 years to decrease the risk of airway mucosal injury and post-extubation stridor. You wonder if there is any evidence to the above statement.

A 3 year old boy is admitted to a paediatric intensive care unit with a history of fever, non-blanching petechial rash, decreased conscious level, and grunting; capillary refill is poor. After screening for sepsis, antibiotics are started. He is intubated, receives fluid resuscitation (total of 100 ml/kg), and a central catheter is placed, showing a central venous pressure of 12 mm Hg. Despite dopamine infusion the attending physician is unable to stabilise his blood pressure, and he requires noradrenaline infusion to achieve and maintain his haemodynamic state.

A 3-year-old previously well boy presents with a fever of 38.6°C and several ulcers and erosions extending from his lips, along the tongue and cheek, to the back of the throat. The lesions have all appeared within the last 2 days. He has been crying inconsolably over the past 24 h and is refusing food and drink. Considering the current evidence we question whether the use of oral aciclovir is indicated for primary herpes gingivostomatitis in children.

A 4-year-old boy with steroid-dependent minimal change disease has symptoms of a viral upper respiratory tract infection (URTI). Will changing from alternate daily to daily steroids reduce the risk that this infection will provoke a relapse?

A 2 day old baby born at 28 weeks gestation is currently on ventilator. He is doing well on minimal respiratory support and you decide to extubate him. You decide to start caffeine prior to extubation.

A 38 year old man presents to the emergency dept with moderate to severe abdomen pain. He requires intravenous morphine for pain and is complaining of feeling nauseous so you decide to give him an intravenous anti-emetic. However, you are concerned that intravenous metoclopramide can increase gastric emptying and contra- indication in intestinal obstruction. You wonder whether there is any evidence to support the fact that metoclopramide is detrimental to patients with moderate to severe abdomen pain.

A 60 year-old lady presents to the emergency department complaining of a 3 day history of a sudden onset single floater in her left eye with no history of flashing lights or other visual problems. Her visual acuity is 6/6 aided in each eye. Dilated fundal examination of her retina with a direct ophthalmoscope is unable to exclude peripheral retinal pathology. You wonder whether she needs specialist dilated fundal examination by an ophthalmologist to exclude a retinal tear or detachment?

An asymptomatic 25 year old female requesting for a screening gonorrhea and chlamydia test at a primary care clinic. The patient is actively menstruating and a speculum exam cannot be performed at the time of evaluation.