bestBETs

A 51 year old female patient attends the emergency department with a history of ally trapped her right index finger in a door and developed subungual haemotoma. X-ray was done showed no bony injury. The skin and nail bed margin were intact. You wonder is it safe to simple trephining drainage this subungal haematoma to reduce the pain severity

A 38 year old man presents to the emergency dept with moderate to severe abdomen pain. He requires intravenous morphine for pain and is complaining of feeling nauseous so you decide to give him an intravenous anti-emetic. However, you are concerned that intravenous metoclopramide can increase gastric emptying and contra- indication in intestinal obstruction. You wonder whether there is any evidence to support the fact that metoclopramide is detrimental to patients with moderate to severe abdomen pain.

A 30 year old man is brought into A&E following a bicycle accident. He is complaining of agonizing pain in his Right thigh. On examination his thigh is very swollen and any attempt to move it is extremely painful. You suspect a femoral shaft fracture and want to administer some strong analgesia and a splint and send him for x-ray. The orthopaedic registrar complains that a femoral block could potentially mask the symptoms of a compartment syndrome. You are wondering if there is any evidence to support this.

A 12-month-old boy with acute diarrhea is brought to the emergency department by his parents. He tolerates oral rehydration solution well but his parents still worry very much about his frequent loose stools. You wonder if the use of smectite would provide any additional benefit.

Mrs. S, a 72-year-old female retired piano teacher presented to the AECC clinic with a 30-year history of upper cervical stiffness. She has had a history of corticosteroid use and had early menopause. Mrs. S has also not had any HRT. Cervical series of x-rays were taken, which showed generalised osteopaenia throughout the cervical spine. Mrs. S was referred for a DXA bone scan, which revealed a bone density of 2.2SD (standard deviation) below normal. Mrs. S is being treated with general mobilisation and myofascial therapy of the cervical spine. She asks your advice on whether supplements could be beneficial.

A thirty-five year-old man has presented with 12 hours of chest pain. ECG shows widespread T wave inversion and troponin T is 1.0. In view of his ongoing chest pain and young age the cardiologists decide to perform immediate angioplasty. You have given aspirin, oxygen, nitrates and morphine. As he is about to go for angioplasty, you wonder if a loading dose of clopidogrel will still confer any added benefit.

A 24 yr old, otherwise fit and health student presents to the ED with pleruritic chest pain and shortness of breath. On examination he has absent breath sounds in the upper zone on the right side of his chest and his chest X ray confirms your clinical suspicion of a spontaneous pneumothorax. You decide to aspirate the pneumothorax. You have heard that this procedure may cause a vasovagal sycope and wonder whether this may be prevented by a injection of atropine prior to the procedure.

A 53years old man is referred to physiotherapy with a painful, intact Baker's cyst. His knee is painful and swollen posteriorly, though not warm to the touch and has limited RoM of flexion and extension. In the absence of any firm treatment guidelines, you wonder if there is any additional benefit from using ICE and cryotherapy to reduce the popliteal swelling.

A 28 years old man is referred to physiotherapy with a clinical and radiographic diagnosis of myositis ossificans 3 months after direct trauma to his right quadriceps muscle. He only has about 450 of right knee flexion and severe pain in the right thigh. You wonder whether an aggressive knee mobilisation regime rather than a more conservative approach might be beneficial to improve function quicker.

A 50 years old lady is 3 months post surgery to the wrist for Carpal Tunnel Syndrome. Although her previous symptoms related to CTS have resolved and her wound is well healed, her recovery has been hindered by a hypersensitive surgical scar. Consequently, she is referred to physiotherapy to help resolve these symptoms where there are mixed views about whether electrotherapy or a more manual form of therapy is the best technique for desensitising the scar.

An 18month old girl presents to A&E with coryzal symptoms and wheeze. You wonder whether the addition of oral steroids (prednisolone) would lead to a faster resolution of her symptoms than bronchodilators alone.

A 62 year old man with a longstanding history of peripheral vascular disease and atrial fibrillation presents to the emergency department with a 2 hour history of severe pain in the left forefoot. Examination reveals a cool, pale, pulseless left foot. You wonder whether low molecular weight or unfractionated heparin is better in this patient.

A fifty year-old man presents with tight central chest pain for thirty minutes. There are no abnormalities on physical examination and his initial ECG is normal. He asks, "Is it my heart, doctor?". You explain that you cannot be certain but will do a blood test to make sure he hasn't had a heart attack in twelve hours time. He looks confused. You wonder why the triage of cardiac chest pain is still so difficult in the 21st century. Surely there is a better way of excluding acute coronary syndromes. Having heard about placental growth factor as a promising cardiac biomarker, you wonder if there is any evidence that it would be useful in this situation.

A 27 year old female presents to A&E, she is drowsy and complains of feeling thirsty and having diffuse abdominal pain. She is a known diabetic and has been vomiting for 2 days. She is tachycardic, clinically dehydrated and is breathing very deeply. Initial investigations confirm the presence of diabetic ketoacidosis. You start IV rehydration and an insulin infusion at 6 units per hour. A senior nurse states that another doctor usually gives a bolus of insulin prior to commencing the infusion. You wonder if this is necessary.

You start work in a new unit which routinely uses thromboelastography to manage coagulopathy and guide treatment with blood component therapy following surgery. As you have no experience of the technique you decide to review the literature to identify whether the technique is actually beneficial in decreasing exposure to allogeneic blood and blood component therapy.

You are about to perform four coronary arterial bypass grafts on a 78-year-old ex steel worker. He has a 60 pack per year history of smoking and his lung function tests are significantly abnormal with an FEV1 only 40% of his predicted values. His coronary arterial targets are small and you feel that an on-pump technique is the only option. You discuss the case with the anaesthetist and he asks whether he could keep ventilating while the patient is on bypass in order to improve his post-operative lung function. You have significant concerns that this may make the case even more difficult but rather than refusing this request you resolve to search the literature for evidence that this will improve post-operative lung function as your anaesthetist suggests.

You recently admitted an 82-year-old arteriopath who has had an 8-month history of critical leg ischaemia and who has debilitating pain at rest. Lower limb arteriogram confirms three-vessel disease not amenable to revascularisation. A below knee amputation was discussed with the patient. The patient asks you if anything could be done rather than an amputation. You have heard of sympathectomy, but wanted to confirm from the literature that this may be a viable option.

You are in the resuscitation room and are faced with a combative head injury requiring a CT scan. He needs to be intubated via a rapid sequence induction and you wonder whether you should do this, as you have previous anaeasthetic training or call the anaesthetists down to do it for you.

A 50 year old man attends the emergency department with a plethoric, swollen left calf. Ultrasound examination reveals a posterior tibial vein thrombosis. You are unsure what the risk of a pulmonary embolus is, or whether he should be anticoagulated.

A sixty year-old lady presents to the Emergency Department with a thirty minute history of intermittent resting central chest pain that seems likely to be ischaemic. Examination, baseline obserations and ECG are normal. You follow your department's rapid rule-out protocol, with serial CK-MBmass estimations and continuous ST segment monitoring for 6 hours. The lady completes the protocol and tests negative. You feel rather uneasy about sending her home. As CK-MBmass is a marker of myocardial necrosis, you realise that you have excluded infarction but not necessarily unstable angina. You wonder if there are any novel markers that would help to identify the vulnerable patient, who is at high risk for adverse cardiac events in the near future. Hearing that VCAM-1 has such potential, you wonder if the evidence suggests that it is suitable for clinical implementation.