bestBETs

A previously well 40 year old female is admitted with fever, headache, neck stiffness & photophobia. No neurological deficit is found on examination, you wonder whether LP can be safely performed without the need for a CT scan?

A 5 year old child comes into the Emergency Department with abdominal pain. On 'auto-pilot' you order a plain abdominal film. You wonder - will this actually help me make a diagnosis?

You are examining a 4 year old child with abdominal pain - with appendicitis at the top of your differential diagnosis. If the child is tender at McBurney's point is that enough to confirm your suspicion of appendicitis and prompt surgical referral?

A 40 year old female presented with inferior heel pain after jogging. She is otherwise fit and well, and a keen jogger. A similar episode had occured to her few weeks prior to this presentation and it resolved by rest and NSAIDs. A diagnosis of Plantar Fasciitis was established. Which treatment modality is best for this condition in an Accident & Emergency setting:a conservative approach (rest/physiotherapy) with NSAIDs or the use of Ultrasound Shockwave Therapy?

A 4 year old boy comes to the Emergency Department complaining that his tummy hurts. He tells you it's really painful. You wonder, does this child's severity of pain mean he is more likely to have more serious underlying pathology?

A 38 year old female presents with a 4 month history of plantar fasciitis. You wonder whether ultrasound will be beneficial in the treatment of plantar fasciitis, but before deciding on treatment you check the evidence first.

A child presents to the ED with ulcers in their mouth causing significant pain and difficulties with eating and drinking. You wonder if they may have Herpes gingivostomatitis and whether antiviral therapy may speed their recovery.

42 year old lady presented with acute onset of migraine headache in the ED similar to her previous episodes but unresponsive to her usual triptan and amitryptiline medications; you have tried NSAIDs and metoclopramide after ruling out other etiology (like SAH) but hasn't made a lot of difference; your colleague mentions opioids but you are not very keen as you think it doesn't help much but you want to consider Haloperidol because you have read somewhere about its anti-migraine and anti-emesis effects; you look up the evidence

A gentleman attends the emergency department with a typically urticarial allergic reaction, which is not compromising either his airway, breathing, or circulation. You prescribe an H1 antihistamine and observe for resolution. At 2 hours he is no better. You wonder if you could have improved his chances of rapid relief with the use of an H2 antihistamine?

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 attending the thoracic multidisciplinary meeting. The case of a 44-year-old man with localised, resectable oesophageal carcinoma is discussed. One of the oncologists suggests neoadjuvant chemotherapy for this patient, however, the thoracic surgeon disagrees with his suggestion claiming that there is no benefit of this strategy and it would make surgery more difficult. You resolve to investigate this further.

A 5 year old girl presents to your ED complaining of a 2 day history of painful lesions in her mouth, fever and difficulty in eating. You diagnose primary herpetic stomatitis and wonder if aciclovir will reduce the duration of her symptoms.

While on duty in the emergency department a 35 year old known idiopathic epileptic is brought in in status epilepticus. After 2 benzodiazepine doses and intravenous phenytoin the seizure activity continues. You wonder if intravenous magnesium may be helpful in terminating the siezure.

A 2 year old boy attends the Emergency Department after pulling a pot of tea over himself. Using the hand method (child's palm including fingers equals 1%) you estimate he has a 12% burn. Using a Lund-Browder chart results in estimation of a 9% burn. You wonder how accurate the hand method is.

A 25 year old man is brought into the emergency department after being hit by a car. He has a closed midshaft femur fracture with no neurovascular compromise and no other injuries. The orthopaedic registrar asks you to put him in a thomas splint. You are unsure how to apply the splint and wonder if an above knee back slab would be reasonable since he is likely to be operated on tomorrow.

An eight year old boy present to the Emergency Department with acute abdominal pain. His parent tells you that the boy hasn't passed any stools for a few days. You wonder whether an abdominal x-ray would be useful in diagnosing constipation.

An eight year old child presents to the A and E department complaining of abdominal pains and not having passed a stools for two weeks. You wonder whether the use of an osmotic laxative would have a lower risk of recurrence of constipation and if it would mean fewer side effects for the child over the course of the treatment.

An Emergency Department Registrar presented a paper at our journal club showing the efficaciousness and cost effectiveness of home treatment with unfractionated heparin (UFH) in comparison to low-molecular-weight heparin (LMWH). We decided to look at the possibility of altering our outpatient treatment guidelines for DVT and low risk PE as a way of lowering the cost of treatment. As part of the process this BET was produced.

You are about to operate on a 32 year old i.v. drug abuser who has been under the care of your cardiologists for 8 weeks with Tricuspid valve endocarditis. She has successfully undergone 6 weeks of antibiotic therapy and 3 blood cultures off antibiotics have all been negative. However she has severe tricuspid regurgitation with hepatic congestion and peripheral oedema and requires tricuspid replacement. You wonder whether to use a biological or mechanical valve.

You have performed a coronary artery bypass graft on a 72 year recent ex-smoker with triple vessel disease and hypercholestrolaemia, who has done very well post-operatively. You usually prescribe dispersible aspirin on discharge, but this gentleman has taken enteric-coated aspirin for 3 years and he tells you that he got terrible indigestion with dispersible aspirin but that the enteric-coated aspirin tablets were no problem at all. You wonder if you should prescribe enteric-coated aspirin to all your patients if it is so 'good to your stomach' instead of your usual dispersible aspirin.