bestBETs

24 year old gravida 1, para 0 female at 7 weeks gestation presents to the emergency department with a one day history of vaginal spotting, suprapubic abdominal cramping and nausea. You perform a digital exam and wonder if a speculum exam is really necessary.

A 24 year old male pateint presents to the emergency department after a high speed motor vehicle accident. Patient was intubated in the field has a GCS of 7T, multiple lacerations and obvious deformity of his RLE. While ordering diagnostic xrays, you wonder about the radiation exposure to the patient.

A 23 year old man presents to the Emergency Department with abdominal pain that started 2 days ago and yesterday became more intense and moved to the right lower quadrant. He has decreased appetite, two episodes of emesis today, and low-grade fever.

An 18 month old child presents to the Emergency Departmentwith diarrhoea following what sounds like an acute episode of gastroenteritis. She is not significantly dehydrated and can tolerate fluids orally. Mum is concerned as the child has an increasingly sore nappy area and because "things just go straight through her". You have heard that live yogourt and probiotics can be helpful and recommend this to the mother. When you mention this to your junior colleagues later they look at you sadly and shake their heads. Self-doubt sets in and you decide to look for the evidence to show them who knows best

A 77 year old diabetic male attends the emergency department with sudden onset "tearing" interscapular pain and a widened medistinum on CXR. You suspect aortic dissection and request a contrast enhanced CT Angiogram. The radiologist reluctantly agrees, but notes his diabetic history and metformin use as high risk factors for contrast induced nephropathy (CIN). You have no available U&E results, but previous values record an eGFR of 45ml/min. A cardiology colleague mentions off hand that N-acetylcysteine is used regularly to prevent CIN post elective angiography in patients with renal impairment. You wonder whether there is any evidence for its use immediately pre contrast in the acute setting.

A patient presents to the Emergency Department with a 6 mm calculi in the left distal ureter. You wonder if the use of tamsulosin would improve the chances of spontaneous stone passage.

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 25 year old chap with a history of spontaneous pneumothorax presents to the ED with a further large pneumothorax. Unfortunately, attempted aspiration fails due to a permanent leak, and he requires an intercostal drain. He has had a chest drain inserted in the past and admits that it was very painful whilst the drain was in situ. You wonder whether administration of local anaesthetic down the tube would provide good analgesia, and decrease the need for oral/iv meds.

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 6-year-old girl presents to the emergency department with complaints of a painful foot, and the history of having stepped on an unknown foreign body. You wonder whether an x-ray or ultrasound would be better at detecting this.

A 3yr old boy is brought to the Emergency Department suffering with diarrhoea and vomiting. You estimate him to be suffering from moderate (5-10%) dehydration, and feels he needs rehydrating. Aware that he does not want to take oral fluids, and is likely to vomit these back anyway, you wonder whether naso-gastric rehydration would be a satisfactory alternative.

A 47-year-old woman presents to the emergency department with left calf pain which came on suddenly, making walking difficult. Typical DVT risk factors are present and the examination is consistent with this. Being proficient with the portable ultrasound unit you decide to perform a "rule-in" compression test of the vasculature in the left leg. However, a colleague challenges this decision, questioning whether the test itself could cause an embolus when compressing the thrombus. You therefore wonder if there is any evidence for this adverse effect, in which case you would prefer to start anticoagulation without this information and defend your diagnosis on clinical grounds.

You are referred a fit 66-year old man with a 2cm lesion in the periphery of his right lower lobe on CT scanning. Bronchoscopy was normal, and a CT guided biopsy has confirmed non-small cell lung cancer. His lung function is satisfactory for lobectomy. You have just been on a Video-assisted Thoracoscopic (VATs) Lobectomy course and he seems an ideal candidate for this procedure. The patient seems quite keen but then asks you if it cures his cancer just as effectively as the usual way. You reassure him, but resolve to check this in the literature.

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.

You are looking after a 55-year old man with mitral regurgitation who underwent a mitral valve repair with a quadrangular P2 resection and an annuloplasty ring. He is in sinus rhythm and well. You had talked to him about warfarin in the context of a mitral replacement in case you couldn't repair the valve. However he is now keen to eliminate any additional risk of stroke as his mother had a severe stroke 5 years ago. He says that he would like to take warfarin if there was any additional chance of preventing a stroke. You decide to review the literature to answer his question.

A 25 year old man with his second spontaneous right-sided pneumothorax has undergone VATS bullectomy and talc pleurodesis this morning. Patient controlled analgesia (PCA) was set up at completion of surgery and oral paracetamol prescribed. You are asked to see him on the ward later that evening because he is in a lot of pain, and his morphine PCA is making him feel very sick. You think the pain is likely to be muscular and aggravated by his chest drain, and you think he would benefit from a NSAID such as diclofenac, but the thoracic surgical nurse looking after him is unhappy to give it. She was told that it may reduce the chances of a successful pleurodesis.

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.