Archives: BETs

A 41 year old female presents to the department hours after a FOOSH. She has pain on the radial side of the wrist and over the ASB. You wonder if she has had a fracture of the scaphoid and want to know the best clinical test to help the diagnosis

A 50 year old woman is referred to physiotherapy with a diagnosis of frozen shoulder. There is a history of minor trauma. The pain is severe, & sleep disturbed. There is marked, global loss of range of movement actively & passively, especially external rotation.Serious pathgology has been excluded.Debate ensues as to the most effective way of improving pain & function in this patient group.

A 28-year-old man is brought to the emergency department by ambulance. He was thrown out from a club following an argument with a bouncer. As he tried to escape from the bouncer he was sprayed in the eyes by another doorman. At the scene the paramedics tell you that the bouncer had a can of CS spray with him that had been confiscated by the police. He has watery and painful eyes with a foreign body sensation. You ask one of the senior nurses to perform an eye washout but she suggests that he would be better off standing in front of a fan and letting the air blow the CS particles off. You wonder how on earth they know this but remember that sister Milly Terry is a weekend warrior with the Territorial Army and that they use CS gas for Chemical, biological, radiological and nuclear (CBRN) training.

A pediatric patient presents to the ED in acute respiratory distress, with increased work of breathing and reduced oxygen saturation. The patient is treated with multiple rounds of nebulized albuterol, ipratropium, oxygen supplementation, and parental steroids, with none to minimal improvement in clinical and objective evidence of respiratory distress. You have heard that ketamine is the anesthesia of choice in pediatric and adult patients with bronchospasm of history of reactive airway disease. However, you wonder if ketamine’s bronchodilatory effects can reduce patient’s airway distress, prior to the need for intubation or admission, when added to standard therapies.

A 67-year-old woman presents to the Emergency Department (ED) with a 3-day history of a dysuria, nausea, vomiting and fever with rigours. She is confused and looks pale. Her respiratory rate is 40/min, heart rate is 120/min, blood pressure is 80/40 mm Hg and temperature is 38.9°C. You diagnose severe sepsis secondary to a urinary tract infection. You wonder whether crystalloids or colloids are best in the initial fluid resuscitation to improve her survival.

A patient with sternal fracture following sterring wheel injury after Road traffic accident was complaining of chest pain . His ECG was within normal limits. I wonder whether he merits admission for 12 hour troponin I and echocardiogram to identify cardiac injuries

A 50 year old male presents with a tender abdomen that is mildly distended and surgical history of an appendectomy.

A 45 year old woman in brought into the emergency department following a house fire, during which she was trapped in a smoke-filled room for a period before being extricated by the fire service. She has no thermal burns and is fully conscious and orientated but is complaining of a headache and dizziness. You are concerned about possible toxicity secondary to carbon monoxide inhalation. The department has invested in a non-invasive fingertip carbon monoxide saturation meter, and you wonder whether this is sufficiently sensitive to rule out significant carbon monoxide toxicity and is sufficiently accurate to guide treatment.

A 14-year-old girl with type 1 diabetes mellitus (DM) attends clinic for her annual review appointment. An albumin creatinine ratio (ACR) on spot urine is 7.3 mg/mmol. Her blood pressure is 125/67 and HbA1c is 9.2%. Subsequently, three consecutive early morning urine samples have ACR of 6.8, 5.7 and 7.3 mg/mmol, respectively, and remain elevated when repeated 3 and 6 months later. You are aware that in adult women with diabetes persistent microalbuminuria (MA) is defined as an ACR greater than 3.5 mg/mmol on two out of three successive occasions, and that in such adults, treatment with angiotensin converting enzyme inhibitors (ACEi) confers renoprotection. You wonder whether your patient should be treated.

A 9-month old infant has been admitted with fever, cough, shortness of breath and poor feeding. He is tachypnoeic with bilateral crackles and occasional rhonchi. Initial management is started with a provisional diagnosis of bronchiolitis. Nasopharyngeal aspirate for respiratory syncytial virus turns out to be negative. Over the next few hours, he is noted to have high grade pyrexia with a gradual clinical deterioration. As the on-call specialist registrar in paediatrics, you are now worried about a possible bacterial aetiology. You decide to commence antibiotics after sending a sample for blood culture. A chest radiograph, full blood count and C-reactive protein level do not help to distinguish between a viral versus bacterial infection. You are aware that in an infant with bacterial pneumonia, the most common causative organism is Streptococcus pneumoniae. A colleague informs you that your hospital laboratory can perform a rapid immunochromatographic urine antigen detection test which is widely used for diagnosing pneumococcal infections in adults. You are not sure about the diagnostic utility of this test in children. You decide to do a literature search and critically appraise the evidence.

A 52 yr old man presents with painful swollen right leg. On examination, he has moderate risk on wells score for DVT. Blood tests show a Raised D-Dimer. You wonder if compression Ultrasound has suffiently accurate in ruling in or ruling out the diagnosis of deep vein thrombosis.

A 35 year old man presents to the emergency department after falling off his bicycle while drunk. He has a large scalp laceration, some blood in his right ear canal and his GCS has dropped from 15 to 13 in the ambulance. He is now combative. His pupils are equal and reactive. Our concern is that his GCS is reducing because of a significant head injury with increasing intracranial pressure (ICP). How can you identify if the low GCS score is due to raised ICP, and initiate emergency treatment before the CT scan confirms the diagnosis.

A 25 year-old man presents with a fever and cough productive of yellowish sputum. You take a history and examine the patient. You wonder whether it is possible to rule in or rule out pneumonia without the need for a chest x-ray, to save time, money and radiation.

A 65-year-old male, with past medical history of pulmonary tuberculosis, attends the Emergency Department with shortness of breath and central chest pain for 7 days. Physical examination reveals raised JVP and chest x-ray shows a globular-shaped heart. You wonder whether pericardial fluid adenosine deaminase level would assist in the diagnosis of tuberculous pericardial effusion.