Archives: BETs

A 34 years old man presents to the emergency department at 11:00PM with severe left flank pain and vomiting which began abruptly 4 hours ago. The patient is not known for any health problem nor does he take any medication. He denies fever of chills. You suspect obstructing renal colic. His creatinine level is normal. You administer him NSAIDs and opioid medication, which relieves his pain. You wonder if this patient can safely be discharged at home if your bedside ultrasound is reassuring, with outpatient imaging and follow-up.

Ward 32 is an acute rehabilitation ward. Many patients that come across for further rehabilitation have had hip surgery following a fractured neck of femur. It had been observed that several patients had a leg length discrepancy following their surgery and so an audit on the prevalence of post-surgical leg length discrepancy demonstrated that 50% of patients transferred to ward 32 post hip fracture had a LLD and these patients were routinely referred to orthotics for correction. On discussion with both Podiatrist and Orthotist it was established that common practice would be to correct half the LLD. The physiotherapists delivering rehabilitation on the ward felt that clinically patient’s functional improvements were greater following LLD correction.

A 13-year-old boy presents with an 8 month history of abdominal pain, diarrhoea and some weight loss. Investigations confirm Crohn’s disease (CD) of moderate severity. To induce remission you consider either a 6-12 week course of corticosteroids or exclusive enteral nutrition with a polymeric formula for 6 weeks. You plan to reserve the thiopurines (azathioprine [AZA] or 6-mercaptopurine [6-MP]) for second-line therapy. After an internet search, the parents are aware that relapse occurs frequently after initial treatment and that the disease often progresses. They are keen for their son to start a thiopurine straight away.

A 75 years old man presents with acute onset of central abdominal pain. He has never had this pain before. Abdominal examination revealed central abdominal tenderness but no guarding or masses. The general examination was unremarkable. Routine blood tests came back as normal. You request a CT scan of the patient’s abdomen as he continues to be in pain with no obvious pathology but wonder if the CT scan is a sensitive predictor of significant underlying pathology and if it will help you in clinical decision making.

A 55 year old man presents to the emergency department with spontaneous epistaxis. He is haemodynamically stable. Simple first aid measures including pinching the soft portion of the nose were ineffective at arresting the bleeding. The patient is previously well with no comorbidities. You are aware that tranexamic acid is effective as an antifibrinolytic in various bleeding conditions and anticipate it may be useful topically at stopping bleeding in epistaxis.

A 40- year-old woman presents at the ED with complaint of severe lower back pain of 2 days duration after carrying a heavy load. She is able to ambulate with no sciatica but reports having urinary incontinence. Physical examination is unremarkable with no neurological deficits in limbs and intact perianal sensation with good anal tone. You wonder whether her urinary symptoms are indicative of cauda equina syndrome.

A 61 year old female with MS is about to start a programme of rehab. She has pain in her right hip, stiffness throughout her right lower limb. She finds it difficult to mobilise independently and to climb stairs. Should the rehab programme be land based in rehab gym or a course of hydrotherapy?

A female patient aged 30 has recently returned to running after a 5 year break. She has developed pain on the lateral aspect of her knee whilst she is running, and she has been diagnosed with iliotibal band syndrome (ITBS). You wonder, given the limited treatment time available, which conservative technique to use in order to get the best results.

A 78 years old man presents to the Emergency Department with central abdominal and back pain for 2 hours. He is smoker, overweight, hypertensive and is on bisoprolol and amlodepine 5 mg each daily. Clinical examination reveals tenderness and pulsation in the epigastrium and around the umbilicus his pulse is 78 beat per minute and systolic blood pressure is 85mm Hg. You wonder if you can rely on your examination to rule out a leaking AAA.

39 year old male presents to the medical facility at an international air show having spent the day on grass and concrete watching the air show. Clinically he presents with significant confusion, disorientation, tachycardia, tachypnoea, and absence of sweating. On initial assessment he is found to have a rectal temperature of 41.2 degrees and HR of 118. Following rapid assessment he is taken to the decontamination shelter where he is taken through the tent which is spraying cool water - he is passed along the tent twice and following this his rectal temperature is 39.3 degrees. He returns to the P1 (resuscitation) area and cooling and treatment continues with fine mist water spraying (plant sprayers), blow by air and IV fluids. After 1 hour of treatment his core body temperature has returned to normal and he is alert and orientated.

A 45 year old female with a diagnosis of Rheumatoid Arthritis (RA) presents to the physiotherapy department requesting the current best physiotherapy treatment and advice for her chronic, multiple joint pains and stiffness.

A 25 year old female presents to the emergency department after falling from her bicycle on to her left shoulder. After x-ray and physical exam, she is determined to have sustained an uncomplicated anterior shoulder dislocation and undergoes closed reduction. She has no prior history of shoulder dislocation. You wonder how long her shoulder should be immobilized, and whether you should place her shoulder in external or internal rotation.

A 55-year-old man with a history of prior abdominal surgery presents to the emergency department with nausea, abdominal distension and absence of bowel movements for 2 days. He is not vomiting. An abdominal X-ray shows signs of small bowel obstruction. You know that there are considerable safety issues in passing and confirming the correct placement of nasogastric tubes (NGT). You wonder if there is any literature supporting these of NGT in such cases, or whether the risks outweigh the benefits.

An adult, over 18 years of age, has a dislocated shoulder and you have been asked to manipulate the joint. It is a primary dislocation with no nerve damage or other associated trauma. While assessing the patient and considering the options for relocation you recall a recent discussion from an ultrasound course regarding the use of interscalene blocks to assist the procedure. You consider the question of "is an interscalene block better at reducing pain and facilitating joint reduction than procedural sedation" considering the time required to recover the patient from intravenous conscious sedation.

A 37 year old male presents with an anterior shoulder dislocation following a rugby match. He states he has not ingested solids for 6 hours or fluids for 2 hours. As you are consenting him for procedural sedation you notice he is chewing gum. Should this patient be regarded as fasted or should an alternate method of facilitating reduction be used due to an increased risk of aspiration?

A 55 years old man brought by ambulance for lost of consciousness without witness. Discover by his wife 5 minutes later, he woke up but still have confusion 20 minutes later in your emergency room. He is not known for any disease and doesn’t take any pill. You wonder if he had a seizure and you heard about a prolactin test that could help you with your diagnosis.

A non-obese 68-year-old man is brought to the emergency department by his family with a history of progressive dyspnea over the last week; he has both a productive cough and a fever. He’s very confused and non-combative. His initial saturation is 84% with a reservoir oxygen mask; he is tachypneic with a respiratory rate of 35. You decide to intubate this patient and you need to optimize his saturation before induction. One of your colleagues suggests that you should try Continuous Positive Airway Pressure (CPAP) prior to intubating him. You have not yet used this technique in similar situation. You wonder if CPAP should be used as a means of optimizing oxygenation in non-obese patients with hypoxia before intubation.