bestBETs

An 8-month-old girl has been referred to the emergency department by her general practitioner with a 24-h history of drooling, intermittent screaming and low-grade fever (maximum 38.2°C). She is refusing solids and her fluid intake has decreased. Her parents report that her nappies are drier than normal but her stools are looser. She has had some relief from oral paracetamol syrup. Her parents suspect teething. On examination she is found to be miserable. She is not clinically dehydrated and has a diffusely hyperaemic right cheek. On examination of her mouth you notice a raw area on her upper gums where two teeth are erupting. No other abnormal clinical signs are noted. You agree that the infant may be teething, but wonder if there are any symptoms that would distinguish between teething and an alternative diagnosis.

A 4-year-old girl presents with low-grade pyrexia and dysuria. A urine dipstick test shows positive results for leucocytes and nitrite, suggesting urinary tract infection. On examination, you notice partial adherence of the vulval labia minora. Her mother reports that the girl has intermittently had discomfort in the genital area over the last year. While waiting for the results of the urine microscopy, you remember that one of your colleagues has mentioned treating labial adhesions with oestrogen creams in the past. You wonder whether there is good evidence to support their use in this condition.

A 5-week-old infant is admitted to a high dependency unit with paroxysmal cough associated with dusky episodes. The severity and frequency of cough paroxysm increases and 48 h later pernasal swab confirms the diagnosis of pertusis. You want to treat the infant with erythromycin. However, you have heard that erythromycin can cause hypertrophic pyloric stenosis in young infants. So you decide to find out more before starting the treatment.

"A 35 year old male presents to the physiotherapy department two weeks after an acute episode of low back pain with referred leg pain. You make a clinical diagnosis of acute lumbar disc prolpase. Evidence based national guidelines suggest it is effacious to give advice on back care education & the stay active concept, but you want to add in manual therapy as you feel this will further speed up his improvement.You decide to see if there is any evidence to support this."

A 45 year old man presents to the emergency department with a painful shoulder following a direct fall with hyper extension of the shoulder. After examination and appropriate investigations a tear of the rotator cuff is diagnosed. You wonder whether conservative management is suitable for this patient.

An 80 year-old man is admitted on the medical take with a three day history of melaena. He is on aspirin 75mg following an MI 18 months ago. He is not on a PPI and from his risk factors he does not seem to have any other risk factors for an upper GI bleed? DO you continue the aspirin?

You are dispatched to a house in which a 45yr old man has collapsed. He is in cardiac arrest when you arrive. During the resuscitation process, you and your team wonder if the use of the mechanical autopulse device to provide chest compressions during the resuscitation will result in a better outcome for the patient.

A patient presents to the Emergency Department with acute onset of a left sided hemiplegia. The blood glucose is measured and found to be 12mmol/l. Would using insulin to control the blood glucose closely improve the patients outcome?

A 4 year old child presents to the Emergency Department with a history of fever and symptoms of a viral upper respiratory tract infection. On examination the child is well and apyrexial. However you notice a non-blanching rash over the child's hip. You wonder whether the child will need further investigations or a period of observation to exclude meningococcal disease.

A 56 year old lady has a convulsion whilst waiting in her cubicle in the emergency department. She collapses to the floor and maintains her own airway. You wonder whether an oropharyngeal is better than a nasopharyngeal airway in providing initial airway protection.

A 65 year old man presents to the A&E department with shortness of breath and cough productive of green sputum. There is radiological evidence of pneumonia on chest x-ray and oral amoxicillin is started. You wonder whether adding in a macrolide would benefit the patient.

An elderly lady sustains a displaced Colles fracture that needs manipulating. She is given a Bier's block. Two minutes after the injection of prilocaine, she has an asystolic cardiac arrest. Resuscitation commences following ALS protocols, but after ten minutes, she remains asystolic. Should lipid rescue be used in this situation?

A 40 year old man presents with an acute on chronic exacerbation of lower back pain after lifting. He has no other symptoms. He has suffered minor injuries to his back while playing rugby in his twenties and thirties. He spends most of his working time at a desk. The pain is usually improved with pain relief. He wishes to know if yoga can help to improve the chronic pain.

A 35 year old fit female presents with several years history of lower back ache/pain. She is otherwise well. Her work requires her to be mobile, flexible and strong enough to assist in the movement of heavy objects while also having a minor desk role. She also enjoys an active sporting/social life. She wishes to know if pilates can help her back pain and prevent any further recurrence.

You are a paediatric specialist registrar giving discharge advice to the parents of a 7 year old girl who is recovering from an episode of acute asthma. She has a frequent episodic pattern of asthma and normally receives 100mcg of fluticasone morning and night. Her parents ask you if they should wait to see a doctor before commencing her on prednisolone if she has another 'asthma attack'?

A 63 year old lady presents to the Accident and Emergency department with pain in her right wrist after a fall onto an outstretched hand. She is extremely tender over her distal radius and has poor range of movement. An x-ray of her wrist confirms a diagnosis of Colles fracture. Whilst in the plaster room, the question is raised of which position is best in order to immobilise her wrist in a plaster cast.

A 25 year old woman presents to the emergency department with acute headache. You wonder whether a C Reactive Protein (CRP) measurement will help in excluding the diagnosis of intracranial infection.

You are at a weekly hospital lecture meeting and a guest lecturer has come to discuss the current treatment of pulmonary embolus. The discussion turns to prophylaxis protocols for DVTs in your hospital. It becomes evident that the general physicians, and all non-cardiac surgeons are routinely using low-molecular-weight-heparin for all their patients. The lecturer asks one of your colleagues why you do not use it in cardiac surgery, and he replies that the incidence is very low in cardiac surgery due to the clotting derangements post-operatively and anyway we would give all our patients pericardial effusions if we did. You are not sure that he is correct and therefore resolve to look up the answer.

A 30 year old male presents in surgical outpatient with typical history of chronic anal fissure. Clinical examinations confirms this. You decided to try medical treatment as first line in managing his condition however you wonder whether DTZ (2%) or GTN (0.2%) cream would provide better symptomatic relief and promote healing of anal fissure.

A 45 year old male smoker attends the Emergency department with exacerbation of COPD. Repeated doses of nebulised Salbutamol and Ipratropium Bromide has been administered and Aminophyllin infusion has been commenced. You feel that the patient will require intubation and ventilation. You have got access to Heliox and you feel that it might improve the condition of the patient and might avoid intubation. Is there any evidence to support use of Heliox in such situation?