Archives: BETs

A 12-year-old boy presents to the Emergency Department (ED), with pain and swelling around his left clavicle which occurred during a game of rugby. You explain his clavicle might be broken and an x-ray is required to confirm the diagnosis. His father points out that he has multiple x-rays in the past for other sporting related injuries and asks if the x-rays are necessary? You wonder whether Ultrasound (US) would be an alternative means for diagnosing a fracture of this bone.

A young child attends the emergency department with her concerned parents. She has been complaining of right sided lower abdominal pain for 2 days, with several associated episodes of vomiting. There is no fever, the child looks well and urinalysis is normal. On further questioning, several members of the family have had a recent viral illness. On examination the child has some generalised discomfort around the umbilical and right iliac regions, but no localised peritonism. Observations are within normal limits. After you have finished your examination, the father declares himself to be a barrister with a medicolegal firm. He mentions appendicitis and is very insistent that further tests be done to refute the diagnosis. You have recently read a research article about a new biomarker for acute appendicitis and wonder whether the test would go some way towards reassuring you and/or the family. You resolve to consult the literature.

You receive an emergency call to a 47 year old male with a fractured right ankle from playing football. On arrival you can identify a possible closed fracture of the distal tibia and proximal fibular. Your patient is in a great deal of pain causing him to move his leg and irritate his injuries. On closer inspection you find a strong pedal pulse with good perfusion distal to the injury. There are no other injuries. You turn your attention to pain relief. On taking a history you find your patient has not been SCUBA diving or ever had any pulmonary problems, you patient has also never been exposed to opiate based drugs. You wonder whether you should give Morphine or Entonox? Which one is more effective and safer?

A 27 year old lady presents to A&E with a one week history of worsening whole right upper limb swelling. She admits to lots of heavy lifting days prior to the swelling commencing. No acute injury can be found and she has no previous medical history. You are concerned she may have an UEDVT. Given she has no risk factors, you consider carrying out a d-dimer to exclude the diagnosis.

You have been treating a 30 year old woman in the ED for classic migraine. Her symptoms have improved and she is keen to go home. She was given steroids to reduce recurrence when she last visited the ED with migraine and she asks you if you are going to do the same.

A 42-year-old man presented to the emergency department with unilateral parasternal chest pain of recent onset. Examination revealed reproducible tenderness overlying the 2nd to 4th right sided costochondral junctions. Significant differentials were excluded subsequent to clinical examination and normal investigations, and a diagnosis of costochondritis was made. You prescribe ibuprofen, however he states he is intolerant to all non-steroidal anti-inflammatory drugs and asks whether there are any alternative treatments. Your registrar suggests giving either a local corticosteroid injection or oral soluble format prednisolone. You wonder what evidence exists to support this.

You see a patient following rotator cuff repair. You wonder whether treating them in a gym rehabilitation class would be as efficacious as a course of 1:1 physiotherapy treatment at improving pain, range of movement and function.

There is new emerging technology designed to electrically stimulate key muscles involved in swallowing for treating people with dysphagia. This is more commonly used in the United States but it is now being provided in the UK by independent practitioners. The Royal College of speech and language therapists do not endorse this treatment due to lack of a robust evidence base so we do not know if this type of therapy is effective and for which client group it is most effective for. Patients are beginning to ask therapists about this kind of treatment so a search of the available evidence is useful to inform patients of the most up to date evidence.

A 72 year old man is admitted to the Stroke Unit following collapse and a suspected CVA. He presents with dysarthria and a CT scan confirms an acute stroke. You wonder whether oro-motor exercises will help to improve the intelligibility of his speech.

You are part of a HEMS crew tasked to a 50 year old farmer who has trapped his arm in a machine on his farm. The patient has sustained a traumatic amputation of the right arm at the level of the mid humerus and there is catastrophic blood loss. Bleeding has not been controlled with simple elevation, compression or a combat application tourniquet (C-A-T). You wounder which of the available haemostatic agents will best control this man's life threatening haemorrhage.

A 36 year old female patient is admitted to the ICU following a significant burn injury, with more than 50% of the body surface area involved, sustained in gas exploding accident. She is being managed in accordance with Burn injury guidelines but in addition, since she had an high risk factor for stress-related UGI bleeding, she was prescribed Esomeprazole 40 mg i.v od, for stress-related upper gastrointestinal bleeding prophylaxis. However, this was changed to Ranitidine 50 mg i.v tid, two days later on the advice of the Gastroenterologist. Is there is any difference in benefit between the two drugs for the prevention of stress-related upper gastrointestinal bleeding?

A 25 year old male attends the emergency department after he slipped on some ice and onto his outstretched right hand. He has attended complaining of tenderness in his wrist and a lack of function. There is also marked swelling around his right wrist.