Archives: BETs

A 5 month old boy attends the emergency department with a history of fever given by his mother. His temperature as taken with a tympanic thermometer is 37.5oC. His mother says he is hot to the touch. He has no focus for his fever on examination. The departmental protocol recommends a full septic screen in this age group if the temperature is above 38oC. You would like to know how accurate temperatures taken by this method are and whether you should check the temperature using another method.

A 50 year old female patient presents to the physiotherapy department for treatment of medial ankle and foot pain that came on insidiously 6 months ago. The clinical diagnosis of Stage 2a posterior tibialis tendon dysfunction (PTTD) has been confirmed with an MRI scan and she has been referred to physiotherapy and podiatry for a trial of conservative management.

A mother brings her two-week-old baby to your clinic. The child has a small umbilical granuloma but is otherwise well. Should you use silver nitrate to cauterize the granuloma?

A girl aged 3 years and 6 months has neurofibromatosis with significant visual impairment and mild to moderate learning difficulties. She has always been difficult to settle to sleep and has frequent nocturnal wakenings. A sleep programme with specific behavioural management techniques has been used as have sedative medications such as Trimeprazine, which caused deterioration in concentration and daytime sleepiness. Should she be tried on Melatonin?

A 30 year old man presents to the emergency department after a road traffic accident. On initial assessment you identify a haemothorax/pneumothorax on the left side of his chest; there are no signs of tension. You elect to place a chest drain and discover that you have a seldinger 'over-the-wire' technique chest drain in front of you. You wonder whether this method of placement is be better than any other at achieving succesful management of the injury without complication.

An eight year old boy is brought to the emergency department by his parents, after tripping and hitting his head on the table edge. He has a 2cm laceration over the occipital region. You examine the wound and wonder whether staples might be an easier alternative to sutures.

An elderly lady is admitted to the emergency department after collapsing in the street. She has a 3cm laceration in the left parietal area. Neurological examination and skull X-ray are normal. You have examined and cleaned the wound, but wonder if staples would be a better option than sutures for wound closure.

A 46 year old man is brought to hospital after a road traffic accident, involving a rear end shunt, to "get checked out". He is fully alert and co-operative. You are aware that many people advise x-rays in all patients to exclude cervical spine injury. You wonder whether it is really necessary.

You are a neonatal junior doctor looking after the special care nursery. You process a capillary blood sample taken on the morning blood round by someone who has now gone home, and find the haematocrit to be high at 69%. You go back to the baby and find the child to be term, of low birthweight, and admitted to the special care nursery because of low Apgars the previous day. He has not been feeding too well, but the neonatal nurses are not otherwise concerned. He is normal on examination, and his venous haematocrit comes back at 68%. Does this baby need a partial plasma exchange transfusion (PPET)?

Mrs A. presents with her 6-week-old baby complaining of his excessive and uncontrollable crying behaviour, particularly in the evening and at night. The child is otherwise healthy, thriving and has a normal weight gain. Following questions regarding the pattern of crying, and associated signs, it is apparent that the child is exhibiting typical colic behaviour. There are clear signs that the continual and excessive crying behaviour is impairing the mother-child relationship, and you consider the child might be at increased risk of harm (or neglect). In discussing the treatment options, Mrs A. tells you that her chiropractor has offered to treat her baby for the excessive crying behaviour. She herself has been treated by this chiropractor in the past for back pain, and it is obvious she has considerable confidence in him. She asks your advice.

A 16-month-old boy with stage IV neuroblastoma and hypoalbuminaemia presented with a left sided haemorrhagic pleural effusion. He subsequently developed generalised oedema. You wonder if there was a role of albumin infusion in correcting hypoalbuminaemia and colloid osmotic pressure (COP), in order to treat the extravasation of fluid into tissue spaces.

An 18-month-old boy with cerebral palsy is brought to your office because of "spitting up" after feeds. It has been a problem for the past several months but is progressively worsening and now occurs after every meal and even at night. He was breast fed for 12 months and has slight developmental delay. Height and head circumference are between 25-50th percentile, but weight is below 5th percentile for age. A barium swallow reveals significant gastro-oesophageal reflux to the pharynx. A gastroscopic examination with biopsy reveals moderate esophagitis without eosinophilia. You wonder if a proton pump inhibitor will be an effective treatment.

A 12 year old boy is admitted to the paediatric intensive care unit after a motor vehicle collision, where he sustained a severe closed head injury. He lost consciousness at the scene and was intubated in the Emergency Department for a Glasgow Coma Score of 8 and no gag reflex. The boy has no history of seizure activity in the past or at the scene. Your local "Traumatic Brain Injury Protocol" recommends that he receive phenytoin for seizure prophylaxis. You have recently cared for a child who nearly died from phenytoin hypersensitivity syndrome and would like to know if there is a good indication for the drug.

A 25 week gestation male infant, birth weight 520g, is transferred ex-utero to your Neonatal Unit for intensive care. On day 19 he remains ventilator dependent and is hypoxic on 60-95% oxygen. The Oxygenation Index (OI: a measure of respiratory failure) is 18. Chest X-ray shows clear lung fields. Echocardiogram by a senior Paediatric Cardiologist shows evidence of pulmonary hypertension. In view of these findings it is felt that a pulmonary vasodilator may help. You discuss entering the INNOVO Trial (a multicentre RCT of addition of inhaled nitric oxide (inNO) to babies with severe respiratory failure) with the parents, who agree and the baby is entered into the control (no addition of inNO) arm. In spite of this, parents ask for "everything" (including inNO) to be tried. Reluctantly you agree and inNO is administered as per the trial protocol (you inform the trial co-ordinators). The baby does not improve, and dies 24 hours later. Was it reasonable to administer inNO to this baby?

A 32 year old man presents to the emergency department with central chest pain suggestive of cardiac ischaemia. He has had pain for 50 minutes after nasal cocaine. He is an occasional cocaine user who has not had chest pain previously. He is previously well. His 12 lead ECG is normal and he is now pain free. You see him in the resuscitation room and prescribe oral aspirin 300mg. He is cardiovascularly stable. You admit him and do a 12 hour troponin T, which is normal. The next day a colleague suggests that there was no need to admit as he was well, had a normal ECG, had few risk factors and that as cocaine causes spasm rather than clots he could have gone home. You wonder whether this is good advice.

A 44 year old man presents to the emergency department with a foreign body sensation in his right eye. Fluorescein examination reveals a piece of grit. After removal there is a small corneal abrasion with no evidence of perforation. The patient has had a primary course of tetanus antitoxin and thinks his last tetanus booster was less than ten years ago but is not sure. You wonder if the patient requires a tetanus booster to reduce any risk from the abrasion.

An asymptomatic conscript walks into the Medical Centre and provides a urine sample for testing for glycosuria as part of a screening procedure for Diabetes Mellitus. How useful is a urine dipstick in screening for the condition.

A 73 year old lady, who is usually fit and well, is brought to the emergency department following a fall. She is complaining of severe pain in her left groin. Examination shows that her left leg is shortened and externally rotated. You make a clinical diagnosis of fractured neck of femur (which is later confirmed radiologically). You wonder whether regional nerve block is better than intravenous analgesia for pain relief.