Archives: BETs

A 2-year-old girl has been brought to the Emergency Department having had her first febrile convulsion, which has now resolved. On examination she has a runny nose and a cough and she has been off her food. You suspect she has a viral URTI. She is her parent's first child and they are very concerned and anxious to know whether she has anything serious and whether this will happen again. You wonder whether you should admit her, or give the parents advice and discharge her.

A 48 year old female with a known history of recurrent paroxysmal supraventricular tachycardia arrives in A & E complaining of dizziness and palpitations. An ECG reveals a 160 bpm regular rhythm with visible p waves distorting the start of the QRS complex. Physical manoeuvres are attempted unsucessfully and an adenosine bolus is given. The tachycardia appears to be refractory to treatment and the lady goes into shock. A decision to electrically cardiovert is made. The physician on-call wonders which waveform would be more efficient at restoring sinus rhythm.

A 55 year old women presents to A & E with palpitations and shortness of breath. The physician on-call performs an ECG revealing a regular rhythm, with a p-wave distorting the start of the QRS complexes. The patient is diagnosed with atriventricular nodal re-entry tachycardia. Induction of AV block is attempted using both the carotid sinus massage and the valsava manoeuvre unsucessfully. The clinical team considers using either verapamil or adenosine as the next step in the managing this patient's arrhythmia.

An 18-month-old boy has been brought into the Emergency Department after having a febrile convulsion. His parents give a history of vomiting and being off his food that day, for approximately the last 12 hours. You wonder how long you should observe him for, or whether you need to admit him.

An eight year-old girl was seen in an epilepsy clinic with a diagnosis of left cerebral hemi-atrophy with right hemiparesis and complex partial seizures. Eight months previously, she was on 800mg sodium valproate and 12.5mg lamotrigine and still having 18 seizures a week. She then spent seven weeks as an inpatient under specialist observation. A ketogenic diet was recommended and commenced five months ago. Since then she has less seizures, but has a major episode requiring midazolam every two weeks. Her seizures now involve intermittent paraesthesia on the left side. Her medication has been decreased to 400mg sodium valproate and 5mg lamotrigine. The patient is struggling with the diet (particularly the Liquigen medium chain triglyceride) and urinary ketones have been ranging from trace to high. The current plan is to continue with the diet, increase the valproate to 500mg and gradually take her off the lamotrigine.

A 55 year old woman represents to her general practitioner with back pain of 3 years duration. Previous assessments and investigations have not suggested a serious cause of her back pain but it so severe that she has had to give up work and has become depressed. She attends as she has read on the internet that she can have an epidural to relieve her pain. She asks you if this is true and if so could you refer her for the treatment.

A 68yr old man, on warfarin for a mechanical aortic valve replacement, is brought into A&E after a minor head injury. He has a haematoma over the occipital region, however has no symptoms relating to his head injury. On examination, his GCS is 15/15 and there is no focal neurological deficit. You wonder if a CT scan of the head is indicated in this situation to safely rule out any significant intracranial injury.

A 24 year old woman presents to accident and emergency with vaginal bleeding. She tells you she did a home pregnancy test and it was positive. You want to assess her clinical risk of having an ectopic pregnancy.

A 27 year old women presents to the A&E department with vaginal bleeding. She has a positive pregnancy test, and you wonder what is the best imaging modality to rule out an ectopic pregnancy?

A 24 yr old, otherwise fit and health student presents to the ED with pleruritic chest pain and shortness of breath. On examination he has absent breath sounds in the upper zone on the right side of his chest and his chest X ray confirms your clinical suspicion of a spontaneous pneumothorax. You decide to aspirate the pneumothorax. You have heard that this procedure may cause a vasovagal sycope and wonder whether this may be prevented by a injection of atropine prior to the procedure.

A 45 year old man is seen with a 4 year history of severe low back pain. He has undergone well conducted periods of rehabilitation under the care of chiropracters and physiotherapists with no success. Diagnostic imaging has revealed no isolated lesion as a cause of his back pain. He is depressed with his degree of disability and you are concerned for his mental and physical health. He was managing with NSAIDs, paracetamol and codeine but has recently had a severe GI bleed as a result of the NSAIDs and is very reluctant to take them again. You have read about long term epdural infusions of opitates and wonder if they might help your patient.

A 24 year old male presented the emergency department with a painful, red, inflammed area on his arm. He noticed this 4 hours after playing a game of football on the pitch. You wonder whether steroids will reduce his inflammation and symptoms.

A 65 year old man arrives at the Emergency Department with a history of crushing chest pain and shortness of breath. His EKG demonstrates ST elevations the inferior leads, his JVP is elevated and you hear inspiratory rales on lung exam. You have read about the benefits of beta-blockers in the acute phase of MI, but are concerned about the risk of cardiogenic shock in this patient with signs of congestive heart failure.

A 42 year man presents with a history of chronic back pain that has not resolved with good primary care management and active rehabilitation. MR and CT of the lumbar spine reveals a significant internal discdisruption at the L4/5 disc.You discuss surgical options of fusion but the evidence is not in favour. Reluctantly you suggest that conservative management is his best option. He returns 2 weeks later with information from the Internet on intradiscal electrothermal annuloplasty. The technique involves coiling a wire within the disc and then heating it to high temperature to seal any annular disruption. You wonder if this is another fad treatment or whether there is some evidence to support it's use.

A 35 year old man presents to his general practitioner department with a history of long term back pain. he is normally fit and well, but developed lower back pain 3 months previously following a skiing holiday. There are no red flag symptoms and he has a normal neurological examination. You advise that he tries to mobilise as best he can and give advice on lifting. You offer analgesics but he appears to be concerned that you suggest that he takes paracetamol AND ibuprofen. He asks how much additional benefit is he likely to get from the Ibuprofen as he is not keen on taking tablets.

You are performing urgent CABG surgery on a 56-year-old lady. She becomes profoundly hypotensive, unresponsive to traditional vasoconstrictors and catecholamines during cardiopulmonary bypass. One of your colleagues tells you that he has used methylene blue as a vasoconstrictor in such vasoplegic patients. You wonder if there is any evidence to support this observation.

There are a number of patients with poor left ventricular function being referred to the cardiac surgeon with angina who have had previous multiple revascularisation procedures and are on maximal medical therapy. They are clearly unsuitable for further surgical revascularisation either due to diffuse coronary artery disease with poor targets or have no useable conduits. Although some of these patients may be eligible for orthotopic heart transplantation, current waiting times for donor hearts and limitations in organ availability render this option unlikely to occur before the patient has become severely ill and reached status I priority level. Gene based modalities for ischaemic myocardium may eventually constitute a therapeutic option for these patients. You wish to find out what current evidence exists in this area of research.

A 45 year old patient presents with a 2 year history of low back pain. He has had to give up his job as a sign painter as a result of his problem which has resulted in siginificant financial problems for him and his family. He describes no red flag symptoms and has no specific neurological signs. He has been previously investigated with plain X-rays and MR scan which have revealed degenerative disease of the lumbar spine. He wants to know if surgery is an option for the relief of his pain.

A short, obese female with pneumonia enters the emergency department. She is tachypnoeic, febrile, and labouring intensely to breath. She has an oxygen saturation of 76% on room air and becomes decreasingly responsive in front of you. You believe her declining respiratory condition merits intubation. You anticipate a difficult intubation and wonder if any simple manoeuvres might be of some help. You have heard that elevating the head and flexing the neck (sniffing the air position) gives you a better view of the vocal cords.

A 35 year old woman presents to the emergency department with a 5 month history of lumbar back pain. The pain developed after a holiday skiing, but there was no specific injury and there is nothing in the history or examination to suggest a serious underlying cause. There are no red flag symptoms or signs. She has been on light duties at work for the last 3 months and is coming under pressure from her employer and family to get back to normal as soon as possible. She asks if there are any exercises she can do to help and you remember a physiotherapist telling you about an exercise program that can be used by back pain patients. You wonder if it is worth referring her for more advice and information.