Archives: BETs

You have a patient with known acute renal colic, confirmed by imaging. You have not yet placed an IV and the patient would prefer to try oral pain medications. Although the teaching has always been to give patients with acute renal colic large volumes of IV fluids, you wonder if there is any evidence to support this practice.

A patient presents to the emergency department with fever, headache, and neck stiffness. You feel a lumbar puncture is a neccessary part of the patients work up; can bedside ultrasonography assist in specimen collection?

A 26 year old male presents to the ED with an acute onset severe unilateral frontal headache and photophobia, similar to previous attacks of migraine but unresponsive to paracetamol, ibuprofen and codeine. You have heard anecdotally that aspirin is effective for migraine and decide to consult the available evidence.

A 65-year-old woman presents to the emergency department with signs and symptoms of SBO. She had previously had an abdominal hysterectomy. Plain abdominal radiograph (AXR) is non-specific. You wonder whether abdominal CT would be useful in the management of a patient with presumptive SBO.

In certain neonatal units there is the practice of supplementing vitamin E in therapeutic doses in order to prevent anaemia of prematurity.

A 3 year old boy is admitted to your general paediatric ward with clinical features consistent with a diagnosis of Kawasaki disease. His parents agree for him to receive the current standard primary therapy of intravenous immunoglobulin (IVIG) and high dose aspirin. Given that the key pathological finding of Kawasaki disease is a vasculitis, you wonder whether treatment with steroids in addition to the IVIG can improve outcome, in particular reduce his risk of developing coronary artery aneurysms?

A 75 year old female, who is on multiple medications including a daily aspirin, presents to the emergency department for nosebleed that began 2 hours ago. Initial non-invasive treatments to stop the bleeding have been unsuccessful. After placing a nasal tampon you intend to start a five day course of prophylactic antibiotics. The patient complains, "is this medication really necessary?"

A 7 year old boy presents to the emergency department after swallowing two of his mother's 75mg tablets of amitriptyline. This seems to be a genuine mistake, he is asymptomatic, and there are no concerns about his home situation. Can you send him home with reassurance or does he require further assessment?

You are performing an esophagectomy for a cT2N0M0 adenocarcinoma of the gastro esophageal junction. You have just mobilised the stomach and your surgical assistant asks whether you plan to perform to a pyloroplasty as he has heard it is associated with improved early post-operative recovery. You do not routinely do this but decide to check the literature after the operation.

You are referred a diabetic 78 yr old gentleman with left main stem disease and triple vessel disease. He has severe varicose veins in both his legs, but he has a large first diagonal artery and you would like to place 4 grafts. You would like to use the left internal mammary artery, and both radial arteries and you wonder whether you could also use a cephalic vein from his arm. You resolve to check the patency of these veins in the literature prior to proceeding.

A 22 year old woman attends the accident and emergency department immediately following a deliberate injestion of 8 ibuprofen tablets. You have no reason to doubt her story of impulsive overdose taken with suicidal intent. You wonder whether her management should include 4 hour paracetamol levels.

You have just seen a patient in clinic who had his saphenous vein harvest incision closed using staples 6 weeks ago. You see that there are two series of staple marks either side of the incision which looks ugly to you. You mention it to the surgeon who performed the harvest and he states that actually the incidence of infection is much lower with staples compared to sutures as you can take single ones out in local areas, and they hold better also. You resolved to look up the evidence to back up these comments.

A 17 year old female has had her elbow reconstructed after a compound, comminuted fracture resulting from an RTA. Although the anatomical reconstruction is excellent, she is left with severe restriction of her elbow RoM. Although you are keen to improve her RoM and function, colleagues are cautioning against vigorous physiotherapy as they fear the patient may develop heterotopic ossification. You wonder if there is any real evidence for these fears.

A 9 year old boy presents with severe right iliac fossa pain. You contact the surgical team who are currently in theatre and will not be able to attend for at least twenty minutes. You wonder if administering morphine to the boy will hinder or delay diagnosis.

A 24 year old woman presents to the ED with left sided renal colic. She is not septic and following initial fluid and analgesic administration, an unenhanced CT demonstrates the presence of a 4 mm calculus adjacent to the left vesico-ureteric junction. There is only mild hydronephrosis and by the time the patient returns from X-ray, her symptoms are under control. Before you discharge her with oral analgesics and fluid advice, you ring Urology to arrange an outpatient's appointment. To your surprise, the Urologist on-call asks you to prescribe Tamsulosin, a drug normally used by elderly men in benign prostatic hyperplasia, to your young, female patient with a urinary calculus. You wonder whether there is any evidence behind this?

A 12-year-old girl with rheumatoid factor negative polyarticular juvenile idiopathic arthritis (JIA) attends an outpatient appointment with her mother. Her disease has been controlled by subcutaneous methotrexate, but over the past month, she has stopped taking medication because of adverse effects—in particular, nausea and vomiting after administration of methotrexate injection. On examination, she is found to have a flare of her disease with 10 swollen inflamed joints and early morning stiffness for 2 h/day. You apply for funding for anti-tumour necrosis factor (TNF) treatment and, in the meantime, plan to treat her disease flare with a course of prednisolone. On discussion during the consultation, her mother tells you that she has had a letter from the general practitioner asking her child to attend for a flu vaccination and asks your advice.

An 18 month old child presents to the A&E department with a temperature of 39 degrees celsius. The child's temperature falls to 37.2 degrees celsius following paracetamol. The child has an inflammed pharynx on examination, and when a history is taken, the child's mother reports that the child has experienced rigors in the last 24 hours. There has been no foreign travel. The mother asks if the rigor makes bacterial infection more likely?

A 57y/o man presents with a sudden onset, severe occipital headache. He has never had a headache this severe and has vomited several times. Neurological examination is normal. You request a CT scan of the patients brain but wonder if the acute onset of the headache is a sensitive predictor of significant underlying pathology.

A 19 year hair dresser arrives to emergency department after colouring her own hair with a new type of dye. She has severe allergic reaction with urticaria and facial edema. You remember Britney and suggest to her that shaving all her hair may stop her progressing to further reaction. You wonder whether this will really work for her.

A 23 year American holiday maker arrives to emergency department after having Indian curry with nuts. He has severe allergic reaction and breathing difficulty. He has no cardiac conditions. You are about to give intravenous adrenaline, and your colleague arrives and tells you 'it's too risky', just give it intramuscular. You wonder whether there is any evidence.