Archives: BETs

Mrs. S, a 72-year-old female retired piano teacher presented to the AECC clinic with a 30-year history of upper cervical stiffness. She has had a history of corticosteroid use and had early menopause. Mrs. S has also not had any HRT. Cervical series of x-rays were taken, which showed generalised osteopaenia throughout the cervical spine. Mrs. S was referred for a DXA bone scan, which revealed a bone density of 2.2SD (standard deviation) below normal. Mrs. S is being treated with general mobilisation and myofascial therapy of the cervical spine. She asks your advice on whether supplements could be beneficial.

A 2-week-old infant, born at 36 weeks gestation was admitted to the paediatric ward in November with a 24h history of runny nose, cough and episodes of shallow breathing and apnoeas. This was thought to be due to bronchiolitis, and the consultant paediatrician suggested starting the baby on caffeine (theophylline derivative with less side effects). As the resident middle grade doctor, I knew that caffeine has been used widely in neonatal units for apnoea of prematurity, but I wondered if there was any evidence for its use in this clinical situation.

You are assessing a toddler who has presented with paroxysmal cough with a whoop and post tussive vomiting. A clinical diagnosis of 'whooping cough' is made and this is duly confirmed on pernasal swab cultures that reveal the growth of Bordetella pertussis (B. pertussis). From history, you note that he is allergic to Penicillin and has been given Erythromycin for a previous episode of tonsillo– pharyngitis. His mother recalls that he suffered severe abdominal pain when taking it and did not complete the course. You wonder whether newer macrolides such as Azithromycin or Clarithromycin could be effective alternatives to Erythromycin for the treatment of Pertussis in this setting.

A 15-year-old boy is admitted with sudden onset chest pain and breathlessness. Chest x-ray shows a small pneumothorax. He has no background health problems. He is treated conservatively with high-flow oxygen, as the registrar has been taught this can improve the resolution rate of pneumothoraces. The consultant questions the biological plausibility of this treatment.

A 4 year old boy is brought to the emergency department having fallen over at home. He has sustained a 3 cm deep laceration to the forehead. He was never unconcious and you have no concerns of an underlying brain injury. The wound clearly needs closure and cleaning but he is upset and would not be able to cooperate without sedation. You suggest this but his mother states that he ate 3 hours ago. You phone the anaesthetist on call who tells you that you should wait a further 3 hours to ensure that he is fasted. You wonder if this is really necessary.

A 41 year old man comes to the emergency department complaining of sudden onset of excruciating headache with photophobia and episodes of vomiting.He is afebrile and has a blood pressure of 180/110mmHg. You are worried he may have a subarachnoid haemorrhage and arrange an urgent CT scan.The radiologist kindly agrees to it and reports no haemorrhage seen on a non-contrast CT head scan. He is still symptomatic and gets admitted for a lumber puncture. You have heard about Computed Tomographic Angiography (CTA) as a primary diagnostic study for SAHs and wonder if this should have been the first step and if he should still go onto have a CTA instead of an LP?

An 8 year old child has a 5cm laceration that requires closure with sutures. You wonder if TAC or LAT would be more effective in reducing the pain of suturing.

A 72-year-old woman with a past history of untreated hypertension presents with palpitations, shortness of breath and ankle swelling for the past 72 h. Examination shows that she has atrial fibrillation with a ventricular rate of 162 bpm, a blood pressure of 146/78 mm Hg and signs of mild left ventricular failure (LVF), both clinically and on the chest x ray. ECG shows atrial fibrillation with a ventricular rate of 160 bpm and voltage criteria for left ventricular hypertrophy. You decide that ventricular rate control is the most appropriate therapy for her. You have been told recently that the chronotropic effects of digoxin are of slow onset and amiodarone runs the risk of cardioversion. You wonder therefore whether diltiazem, a calcium antagonist, may be of use.

A 62 year old, has been admitted to the intensive care unit following an emergency Hartmann’s procedure for a perforated diverticulum. He is clearly septic, with persistent pyrexia, hypotension, tachycardia and is being ventilated. He has been started on the sepsis bundle, including noradrenaline to maintain a decent MAP. He has a past medical history of treated hypertension, hypercholesterolaemia, and diverticullar disease. It is clear that low dose dopamine has no renal protective effects but, you discuss the use of dopexamine on the ward round as an alternative. No one clear about the evidence for and against so you investigate.

A 55 yr old man comes to A&E with persistant lower back pain. He has been suffering from back pain for the last 5 yrs for which he takes NSAIDS and goes for regular physiotherapy. His pain doesn seem to be getting better. On examination he has paraspinal muscle tenderness and no neurological deficit. Apart from offering him different oral analgesia and advising him to continue his physiotherapy, there is little else you can offer him. You have heard that accupunture offers some benefit in such cases and wonder what the evidence is to support this?

A patient attends the emergency department (ED) with atraumatic pleuritic chest pain. She is 12 weeks pregnant with no other medical history. A junior doctor has dutifully followed the ED guideline, noted that the patient is at ‘low clinical risk’ of pulmonary embolism (PE) and requested a D-dimer level, which has returned within normal limits. The junior doctor is now keen to discharge the patient, who has remained well in the ED, but wants to ‘run it by you’ first. You are surprised by the normal D-dimer level in pregnancy but wonder whether the sensitivity and negative predictive values are as high in pregnant patients as they are in low risk non-pregnant patients.

A 47-year-old female presents to the emergency department with fever, shortness of breath, tachycardia and tachypnea. Her O2 saturation is 90% with an Fi02 of 50% and her blood pressure is 75/35 mmHg. Her x-ray reveals a large consolidation compatible with the diagnosis of community-acquired pneumonia. After adequate fluid resuscitation and early antibiotics, she remains hypotensive and poorly perfused. You have dopamine and norepinephrine at hand for vasopressor support, and you wonder which one is the best in septic shock.

A 3 year old child attends the Accident and Emergency Department with a 2 day history of vomiting and diarrhoea. You wish to estimate the child's hydration status to determine whether rehydration therapy is needed but wonder how reliable is the clinical sign of skin turgor.

A 75-year-old man presents to the emergency department at 06:00 hours sweaty, acutely short of breath and coughing pink frothy sputum. You diagnose acute left ventricular failure/acute pulmonary oedema. You know intravenous nitrates are part of first line therapy but wonder whether a high dose will provide increased benefit.

65 yrs old gentleman comes with SOB for last 12 hrs, has got previous history of COPD and IHD, would Ultrasound be helpful to differentiate between Pulmonary edema and COPD?

You were called to see a 56 year old woman who was admitted to a medical ward two days before with a right basal pneumonia. She was in respiratory failure, hypotensive and oliguric. After intubation, ventilation, resuscitation with fluids she remains hypotensive and a vasopressor has been started. You wonder whether she would benefit from low-dose steroids?

You are about to perform a rapid sequence intubation on a 26 year old man with a severe head injury. You have been told that the gentleman has consumed a significant amount of alcohol in the last 3 hours. The nurse asks you whether the application of Cricoid pressure will stop him aspirating.

A 6-year-old child presents to the ED with a painful wrist following a fall. His x ray shows a buckle fracture of the distal radius. You apply a removable brace as you have recently read a 2008 BestBET that suggests that it will support healing as much as a full cast. Your next question is whether he really needs fracture clinic follow-up with repeat x ray(s) or whether this type of fracture will always heal with no risk of loss of position or residual functional deficit.