bestBETs

You are seeing a 65 year old patient who has been referred for aortic valve replacement due to aortic stenosis. He has no symptoms of angina but smoked for 25 years, finally quitting 10 years ago. His father also died of a heart attack when he was 60 years old. You tell him that you would like to get an angiogram to check his coronary arteries. He is not that keen on the idea and asks if there are any other scans that could do the same thing without the risks of angiography. You wonder whether a CT angiogram would be as sensitive a test for this patient

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?"

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

A 27 year old woman attends the emergency department with a two day history of headache with mild neck stiffness. She appears otherwise well. Her CT scan is normal and you feel that if a lumbar puncture is normal she can be discharged. The duty physician advises you that the patient will require four hours bed rest after the lumbar puncture. The duty anaesthetist overhears and says that the patient will be able to go home immediately. You wonder if either of them is right.

You are performing urgent CABG surgery on a 56-year-old lady. She becomes profoundly hypotensive, unresponsive to traditional vasoconstrictors and catecholamines during cardiopulmonary bypass. One of your colleagues tells you that he has used methylene blue as a vasoconstrictor in such vasoplegic patients. You wonder if there is any evidence to support this observation.

A 28 year old female accountant is brouught in the the Emergency department. She has a glasgow coma scale of 8/15, her BP is 80/50 and her ECG shows signs of QRS prolongation. You wonder whether sodium bicarbonate will improve her condition

A 33 year old woman arrives to the emeregency department with suspected tricyclic antidepressant overdose. Blood samples and an ECG are taken. You wonder whether the ECG or the serum drug level is better at prediciting arryhthmias and seizures.

You are called to the emergency department following the arrival of a 23 year old male electrician who is suspected of ingesting 25 imipramine tablets. You are shown an ECG that was taken shortly after his arrival. You wonder which ECG abnormalities are predictive of complications.

A 13 year old girl attends outpatients with frequent migraines. She has tried pizotifen and propranolol for migraine prophylaxis but was unable to tolerate the side effects. You have heard about topirmate for this indication and wonder whether it may help.

A 45 year-old man presents to the Emergency Department with a 48-hour history of palpitations, postural light-headedness and exertional dyspnoea. ECG demonstrates atrial fibrillation (AF) at a rate of 130 beats/minute. There are no apparent reversible causes following history, examination, chest radiography, urinalysis and haematological and biochemical screening. You feel that pharmacologic or electrical cardioversion to sinus rhythm rather than rate control would be most beneficial to the patient, but as you are aware of the possibility of atrial thrombus and systemic embolism you opt for rate control and refer for anticoagulation. You wonder if measuring D-dimer, a product of clot breakdown, would have allowed accurate exclusion of atrial thrombus, thus enabling the safe acute administration of flecainide.

A 28year old female presents with a 4 month history of 'tennis elbow' (lateral epicondylitis). She receives physiotherapy in the form of manual and electrotherapy and you wonder if there is any benefit from additional use of an epicondyle clasp.

A 4-month-old boy presents with a fever of 38.9°C and no focus on clinical examination. He does not appear septic and clean catch urine is normal. There are no respiratory symptoms and no clinical signs of meningitis. You think he has a low risk of a serious bacterial illness. You wonder if procalcitonin can help you exclude serious bacterial illness that may need antibiotics?

A 46 year old female presents to the emergency department. Subarchnoid haemorrhage is confirmed by CT. Upon examination there are signs that she has raised intracranial pressure and her clinical condition is deteriorating. You ask one of your colleagues if you should administer mannitol. Neither of you are sure what to do as you have both heard that it is important to maintain cerebral blood pressure fairly high to prevent rebleeding. However, you wonder if the administration of mannitol would help this patient.

A 50 year-old lady presents with a fever and cough. Physical examination of her chest reveals crackles in the left base. You wonder whether this means that you can be confident of a diagnosis of pneumonia before the results of further investigations are obtained.

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 40 year old male presents to the emergency department with a 4 day history of cellulitis of the lower extremity, fever and chills. How useful is an initial serum lactate concentration drawn in the ED as a predictor of mortality?

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.

You are the neonatal registrar reviewing a newborn infant whose mother is infected with HCV (but not infected with human immunodeficiency virus (HIV)). She wishes to breast feed but is concerned about whether this would affect the risk of her infant acquiring HCV infection. You would like your decision to be based on sound evidence.

A 78-year old male presents to the Emergency Department in a coma two days after a minor head injury. You note he is taking clopidogrel for treatment of his ischaemic heart disease. CT scan shows a large sub-dural haematoma. You wonder whether the clopidogrel has contributed to the development of this haematoma?

An obese forty year old woman is brought in to the resuscitation room following a closed head injury, Her GCS is 6/15 and you need to urgently secure a definitive airway. The anaesthetist is busy so you have to proceed with the RSI alone and while drawing up the drugs the Nurse asks you what dose of Suxamethonium you would like. Her husband says she weighs 140kg. You wonder how best to calculate the dose of Suxamethonium to give optimal intubation conditions with shortest time to return of breathing should a failed intubation and ventilation scenario develop.