Archives: BETs

A patient over the age of forty five presents to the accident and emergency derpartment with new onset atrial fibrillation. This has been going on for less than 48 hours.

A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5°C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You wonder if rectal thermometry is the most accurate available method for recording the patient’s core body temperature.

A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You wonder if the patient’s serum procalcitonin might be a useful indicator of disease severity.

A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You have heard contradictory evidence as to the most effective cooling modality available and wonder if whole body ice-water immersion might be the best option.

A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You wonder which factors of this patient’s situation in the ED might be prognostically predictive.

On a routine neonatal check on the postnatal ward you come across a neonate whose mother developed chickenpox 3 days before delivery. You are aware that according to UK guidelines a baby should be given prophylactic varicella-zoster immunoglobulin (VZIG) if its mother develops chickenpox during the period that spans 7 days prior to delivery to 7 days after (and that the US Red Book recommends VZIG for neonates born to mothers with onset of chickenpox 5 days prior to delivery to 2 days after). The mother, who is keen for her baby to have this preventive treatment, asks you how likely it is that this measure will prevent the disease. You are unsure and consult the Department of Health (UK) publication Immunisation against Infectious Diseases (the Green Book), which provides limited information on this aspect, citing one reference only. The British National Formulary for Children (2007) offers even fewer details, and refers you to the former publication. Therefore, you wonder what evidence exists for the effectiveness of VZIG in preventing or modifying chickenpox in this setting.

You are the specialist registrar in paediatrics in a district general hospital which provides shared care for paediatric oncology patients. A girl on cyclical maintenance chemotherapy for acute lymphoblastic leukaemia was admitted 10 days ago with neutropenic sepsis. Blood culture from her Hickman line at admission had grown Staphylococcus epidermidis. She was treated according to the sensitivity pattern of the organism. She is now free of signs of systemic infection. However, the most recent blood culture from her Hickman line continues to grow S epidermidis. Concurrent peripheral venous blood cultures are sterile. At this point, you are keen to remove the central line. However, her parents want to avoid line removal as venous access has always been extremely difficult for her. You consult the oncologist at her referral centre, who suggests a trial of antibiotic lock of the Hickman line. The microbiologist at your hospital is not in favour of this approach and wants the colonised line to be removed immediately. You are unsure about the best therapy in this situation. You decide to do a literature search on the benefits and risks of antibiotic line lock technique (ALLT) and critically appraise the evidence.

An 8-week-old baby is admitted with bronchiolitis. His parents mention that he has always cried a lot and that he is having a course of cranio-sacral therapy to try and improve things. You wonder whether there is any evidence for this.

A 9 year old girl attends the Emergency Department following a fall from her horse on her right (dominant)side. Examination and x-rays confirm an isolated, uncomplicated fracture of the clavicle. Overlying skin is not in jeopardy and there is no neurovascular impairment. You wonder whether broad arm sling, adequate analgesia and parental advice sheet would be enough or would the orthopaedic follow up improve the outcome.

A patient presents with a known abdominal aortic aneurysm presents to your hospital with symptoms indicating rupture. The patient is haemodynamically stable enough to have a CT scan, which confirms this diagnosis. The patient is treated by traditional open surgery, though it is noted that the anatomy of the aneurysm is suitable for endovascular repair (EVAR) using a stent graft. Subsequently the case prompts discussion about establishing a service for the treatment of ruptured abdominal aortic aneurysms (rAAA) preferentially by EVAR. You decide to search for the evidence for this in order to investigate whether such a service would be beneficial to patients.

A 25 year old factory worker presents to the ED with a history of painful red right eye following chemical exposure at work , the eye ph was checked with the litmus paper which gave reading of ph 7.8, the eye was irrigated thoroughly then the eye ph checked again - which was 7.2. You want to know accuracy of the litmus paper before discharging the patient

A 6 year-old boy presents to the emergency department with vomiting and diarrhea for 4 days. He is able to hold down liquids but appears dehydrated. After adequate fluid administration orally, the patient appears well enough to be discharged home. Is the BRAT (bananas, rice, applesauce, and toast) diet going to improve the patients overall outcome?

A seventy four year old female presents from a nursing home with altered mental status and recent diagnosis of pneumonia. She is febrile, tachypnoeic, tachycardic, anuric, and has a blood pressure of 72/35. Your attending physician suggests you start her on an infusion of norepinephrine, however epinephrine has more inotropic effect. You wonder what is the best vasopressor for your patient?

An 18 year old female presents to the emergency department with lower abdominal pain, vaginal discharge. She is currently 8 weeks pregnant by dates and ultrasound confirms a viable intrauterine gestation. You wonder if this patient could have pelvic inflammatory disease even though she is pregnant.

56 years old man presented with history of sever back pain which is radiating to the left hip joint and associated with numbness over the left calf . you prescribed oral paracetamol which did not give any relife , so you prescribed diclofenac IM but one of your junior doctors told you that he read article recently in one of the medical journals about the efficacy of rectal diclofenac in the quick relife of the back pain .

A patient attends the Emergency Department after a hyper abduction injury of his thumb. On examination there is laxity of his ulnar collateral ligament (UCL). You wonder whether conservative treatment is adequate or will the patient require surgery. Would ultrasonography be helpful in assessing UCL ruptures which are going to require surgical input?

You are a resident at the Emergency Department of a hospital in the Netherlands, when a 53 year old male presents with acute abdominal pain, diarrhea and a mild fever. He has a history of diverticulitis. After thorough evaluation of your patient, including labs and abdominal CT scan, you want to discharge him with the diagnosis 'acute, uncomplicated diverticulitis, since there was no evidence for an intra-abdominal abcess or bowel perforation. You are about to reassure your patient and give him some supportive therapy, when your supervisor, an Emergency Physician trained in the USA, suggest that you give the man a prescription for oral antibiotics. You wonder if there is any evidence for this treatment...

A 21 year old lady present to your Emergency Department with a laceration of the upper lip after accidentally being hit the by the tennis racket of het co-player. You wonder what kind of sutures provides the best result but nobody in your department really knows for sure, and the plastic surgeon can not be contacted.