Archives: BETs

A 44 year old man presents to the emergency department with a four hour history of severe epigastric pain. You consider a diagnosis of pancreatitis and organise a serum amylase to be taken. You wonder if a single normal serum amylase result is sufficiently sensitive to rule out pancreatitis in this patient.

A 14-year-old boy attends your general clinic suffering from weekly headaches for the last 6 months. The description of the headaches are typical for migraine headaches, neurological examination is normal. There is a strong family history of migraines in the mother and a sister. He already has made adjustments to his lifestyle by avoiding trigger foods and a regular sleep pattern with limited improvement. He is reluctant to take regular prophylactic medication but his parents are concerned about the amount of analgesia he takes. As his mother uses sumatriptan with good effect she wants to know if this would be an option for him.

You have seen a toddler in clinic, and as a "by the way" on leaving the mother tells you that the child has a very red bottom and cries on defaecation although she is not constipated. On examination you see the classic signs of perianal dermatitis. You prescribe penicillin, and subsequent culture confirms streptococcal A infection. After clinic the staff grade doctor, who works with you and has expertise in child protection informs you that you should be considering sexual abuse as an issue. You decide to find out if there is an association between perianal dermatitis and child sexual abuse

A 14 year old male is under your care and being treated for diabetic ketoacidosis. Fluid resuscitation occurred and insulin was commenced. However, his blood gases continue to reveal a severe degree of acidaemia (pH<6.9). You wonder whether this patient will benefit from bicarbonate therapy and if there is any evidence to prove its efficacy.

Parents of a 6 year old with cerebral palsy want to know if hyperbaric oxygen will be an effective treatment for their child's gross motor problems

A 20 year old man is brought into the emergency department having been hit by a high-speed vehicle while crossing the road. He has a large haematoma to the head and is confused and combative. Plain radiographs of his cervical spine are normal, as are radiographs of his chest and pelvis. You request a CT brain scan and a CT of his upper cervical spine, as you have heard that plain radiographs can miss injuries in this area. The radiologist does not agree that this is indicated as the plain radiographs of the cervical spine appear normal. You wonder if there is any evidence to support your request.

A 30 year old woman presents to the emergency department with distressing, left sided pleuritic chest pain. She may have had a pulmonary embolism and you request a D-dimer. You know the lab in your hospital utilises the IL D-dimer test and wonder whether a normal result would be sufficiently sensitive to rule out a pulmonary embolus.

A 27 year old woman attends the emergency department with a suspected amitriptyline overdose. She has a Glasgow Coma Score of 7, is trypsilating, and has a broad complex tachycardia and a blood pressure of 70/30. After intubation and ventilation and sodium bicarbonate she remains tachycardic at 130 although her complexes have narrowed somewhat and her BP is still low at 80/40. You have heard that tricyclic overdoses may respond to glucagon and wonder whether there is any evidence for this.

A 70 year old known COPD patient presents to your emergency department with pleuritic chest pain and dyspnoea suggestive of pulmonary embolus. Initial investigations do not exclude pulmonary embolus. As part of your diagnostic strategy, you wonder if V-Q scintigraphy has better diagnostic utility than CT for pulmonary embolus.

A 36 year old man is brought to the emergency department after a road traffic accident. He complains of neck pain. A 'pulled' lateral is taken, but fails to show the C7/T1 junction. You wonder whether a pair of supine oblique views or a swimmers view would be best to visualise this region.

A 21 year old man attends the emergency department complaining of cardiac sounding chest pain. He has no risk factors for ischaemic heart disease but admits to recent cocaine abuse. His ECG reveals appears ischaemic. You wonder if nitrates or benzodiazepines, in combination or alone, compare at resolving chest pain and clinical outcome.

A 25 year old male attends A&E after a fight in which he sustained a laceration to the eyelid. There are no signs of intra-occular injury. You clean and suture the wound and wonder whether you should cover the wound with prophylactic antibiotics as you have recently seen a case of peri-orbital cellulitis associated with an eyelid wound.

A 22 year old insulin dependant diabetic presents to our emergency department with a raised blood sugar and urine dipstick showing +++ of ketones. You suspect diabetic ketoacidosis and would like the know the degree of his acidosis, but the patient refuses arterial blood gas sampling due to a previous bad experience. You wonder whether venous blood would accurately show the degree of his metabolic acidosis.

A 25 year old man who has been involved in an RTA is brought into your department by the paramedics. He has signs of cord transection and is complaining of low back pain. You wonder if a logroll to examine his back is appropriate.

A 42 year old women presents with pain on thumb movements in her dominant hand. On examination, she has tenderness over the radial styloid process and crepitations over the first dorsal compartment of the distal radius. Finkelstein test was positive. You diagnose de Quervain’s tenosynovitis and plan to give her a splint, but wonder if steroid injection is better than splinting for the treatment of de Quervain’s tenosynovitis.

You are called to see a young adult male who is accompanied by two members of Her Majesty's Customs and Excise. They tell you that he is under suspicion of trying to smuggle drugs into the country and that he may have done this by ingesting packets of cocaine. Physical examination is unremarkable, but abdominal radiography does reveal multiple, oval foreign bodies in the bowel. You know that such 'body packers' might well develop intestinal obstruction and/or get potentially fatal cocaine toxicity from leakage of the contents of these packages in their bowels. You wonder whether to simply leave the patient as he is and observe him for signs of obstruction and/or pending cocaine toxicity, intervene conservatively and do the latter as well, or whether to do something more aggressive to remove the packages from the patient's intestines.

A 50 year old man attends the emergency department with a plethoric, swollen left calf. Ultrasound examination reveals a posterior tibial vein thrombosis. You are unsure what the risk of a pulmonary embolus is, or whether he should be anticoagulated.

You are called to see a 60 year old man who has been increasingly breathless for a week. Examination reveals him to be mildly dyspnoeic at rest with a raised JVP and bibasal creps. There is evidence of ischaemia on his ECG. The CXR shows upper lobe diversion and Kerley B lines. You wonder whether buccal suscard would be an appropriate alternative to a GTN infusion.