bestBETs

A 35 year old man presents to the emergency department with acute lower back pain. He has a normal neurological examination and no symptoms to suggest a serious cause. You discharge him from the emergency department with some NSAIDs and advice to stay active. He returns to the department 5 days later still complaining of ongoing back pain. You ask one of your emergency department physios to have a look and he offers to take him on for out-patient physio and Laser therapy. You wonder if there is any evidence to support the use of Laser in back pain patients.

A 55 year old woman presents to her GP with lower back pain radiating to her right buttock. The pain has been present for 4 months and you have seen her on many occasions with persistance of symptoms. She has been investigated with an MR scan which revealed no specific pathology except moderate OA changes. Neurological examination is normal and there are no "red flag" symptoms or signs to suggest that this is anything other than simple low back pain. You have treated her with oral paracetamol and NSAIDs but she now requests that you supply some muscle relaxants as her friends have told her that it is probably spasm causing her pain. You wonder if this is a good idea.

A 55 yr old man comes to A&E with persistant lower back pain. He has been suffering from back pain for the last 5 yrs for which he takes NSAIDS and goes for regular physiotherapy. His pain doesn seem to be getting better. On examination he has paraspinal muscle tenderness and no neurological deficit. Apart from offering him different oral analgesia and advising him to continue his physiotherapy, there is little else you can offer him. You have heard that accupunture offers some benefit in such cases and wonder what the evidence is to support this?

You are scheduled to perform corrective surgery on a 3-year-old boy with a diagnosis of secundum atrial septal defect (ASD). The child presented with progressive cyanosis of one year's duration accompanied by easy fatigability on exercise. There were no indications of hepatic disease. On physical examination, clubbing was noted. Oxygen saturation was 74% in room air, and hemoglobin was 21 g/dl. Echocardiography demonstrated an interrupted inferior vena cava with azygos continuation to a right superior vena cava and a small secundum ASD. Heart catheterization was performed revealing anomalous drainage of all hepatic veins into the left atrium and a small secundum ASD with no measurable cross shunting. Contrast echocardiography confirmed the presence of a pulmonary arteriovenous malformation. You explain to the boy's father that during surgery you will be diverting the hepatic flow and coronary sinus from the left to the right atrium using an autologous pericardial patch. The father asks if this procedure will improve his child's oxygen saturation and if the child will regain a normal level of activity. You are unable to answer him to your satisfaction and therefore you resolve to check the literature for evidence of regression of intrapulmonary shunts after surgical correction of anomalous hepatic venous drainage.

A 56 year old woman arrives at A & E complaining of palpitations and lightheadedness. An ECG is performed and she is diagnosed with paroxysmal supraventricular tachycardia. She is haemodinamically stable but distressed with the palpitations. The physician attending this lady wonders which vagal manoeuvre to use before giving any drug intravenously.

A 48 year old female with a known history of recurrent paroxysmal supraventricular tachycardia arrives in A & E complaining of dizziness and palpitations. An ECG reveals a 160 bpm regular rhythm with visible p waves distorting the start of the QRS complex. Physical manoeuvres are attempted unsucessfully and an adenosine bolus is given. The tachycardia appears to be refractory to treatment and the lady goes into shock. A decision to electrically cardiovert is made. The physician on-call wonders which waveform would be more efficient at restoring sinus rhythm.

a 54 year old lady with a history of palpitations is refered to A & E by her GP, complaining of palpitations and lightheadedness. The attending registrar performs a 12 lead ECG revealing revealing a regular rhythm, an absent P wave and a narrow complex QRS with a ventricular response of >150 beats/min on the bedside monitor strip on leads II and V5. She is diagnosed with atriventricular nodal reentrant tachycardia and the valsava manoeuvre is attempted unsuccessfully. IV Adenosine is given which restores sinus rhythm but fails to maintain it as the lady relapses into the arrhthmia. A beta-blocker is then considered and the attending clinician debates which beta-blocker is more efficient at restoring and maintaining sinus rhythm.

a 54 year old lady with a history of palpitations is refered to A & E by her GP, complaining of palpitations and lightheadedness. The attending registrar performs a 12 lead ECG revealing revealing a regular rhythm, an absent P wave and a narrow complex QRS with a ventricular response of >150 beats/min on the bedside monitor strip on leads II and V5. She is diagnosed with atriventricular nodal reentrant tachycardia and the valsava manoeuvre is attempted unsuccessfully. IV Adenosine is given which restores sinus rhythm but fails to maintain it as the lady relapses into the arrhthmia. A beta-blocker is then considered and the attending clinician debates which beta-blocker is more efficient at restoring and maintaining sinus rhythm.

A 42 year old female patient presents with moderate to severe right upper quadrant colicky pain radiating to the back with one episode of vomiting. She is apyrexial and examination reveals mild right subcostal tenderness with no guarding. You diagnose biliary colic and wonder is buscopan is effective in relieving pain.

A 27 year old man comes into the emergency department with a suspected opiate overdose. He exibits marked miosis and depressed mental status and had needle track marks on his arms. His mother, on questioning, shows you an empty temazepam bottle she found in his pocket. You wonder if he has had a polydrug overdose and if this will result in a poorer outcome.

A 28 year old diabetic attends having been found unrusable by friends. Initial examination shows her to be GCS 5/15 with a BM measurement of high. Blood gases show her to have a pH of 7.02 and a blood sugar comes back at 41mmol/l and her urine shows three plus ketones. You begin treatment with insulin and IV fluids and contact ITU for an opinion on airway management and ventilation. The ITU registrar asks you to start a bicarbonate infusion while he is on the way down. You are unsure if this is beneficial and decide to find evidence on who is right.

A fifty year-old man with no previous medical history presents to the Emergency Department with two hours of vague dull central chest pain. Initial ECG is normal. You arrange admission for troponin T testing at 12 hours but can't help thinking that there must be a better and quicker way to exclude acute coronary syndromes. A colleague tells you that myeloperoxidase (MPO) is set to make world headlines as a new definitive early cardiac marker.

A known asthmatic adult patient is brought into the emergency department with signs consistent with acute asthma. Little improvement is noted with nebulised beta agonist therapy. You wonder if adjunctive nebulised furosemide would provide any benefit.

A 21 year old male presents to the emergency department with sudden onset of left lumbar pain radiating to the groin. A clinical diagnosis of renal colic is made. You wonder whether rectal NSAID's would be more effective than IV or IM NSAIDs?

A healthy 25-year-old man involved in an altercation with another man sustains a bite wound on the arm and presents to the Accident and Emergency Department. The wound is thoroughly cleaned and no signs of infection are present. You wonder whether prophylactic antibiotics are indicated to reduce the risk of wound infection in this patient.

A 21 year old man attends the emergency department having sustained an undisplaced, closed fracture of his distal radius. You wonder whether giving the patient a course of NSAIDs will delay fracture healing.

A 68yr old man, on warfarin for a mechanical aortic valve replacement, is brought into A&E after a minor head injury. He has a haematoma over the occipital region, however has no symptoms relating to his head injury. On examination, his GCS is 15/15 and there is no focal neurological deficit. You wonder if a CT scan of the head is indicated in this situation to safely rule out any significant intracranial injury.

A 45 year old man is seen with a 4 year history of severe low back pain. He has undergone well conducted periods of rehabilitation under the care of chiropracters and physiotherapists with no success. Diagnostic imaging has revealed no isolated lesion as a cause of his back pain. He is depressed with his degree of disability and you are concerned for his mental and physical health. He was managing with NSAIDs, paracetamol and codeine but has recently had a severe GI bleed as a result of the NSAIDs and is very reluctant to take them again. You have read about long term epdural infusions of opitates and wonder if they might help your patient.

A 56 year old lady present in Emergency Department with a history of severe pain in his right shoulder following a busy day working in his garden. She had pain on resisted abduction and tenderness over supraspinatus tendon.

A 42 year man presents with a history of chronic back pain that has not resolved with good primary care management and active rehabilitation. MR and CT of the lumbar spine reveals a significant internal discdisruption at the L4/5 disc.You discuss surgical options of fusion but the evidence is not in favour. Reluctantly you suggest that conservative management is his best option. He returns 2 weeks later with information from the Internet on intradiscal electrothermal annuloplasty. The technique involves coiling a wire within the disc and then heating it to high temperature to seal any annular disruption. You wonder if this is another fad treatment or whether there is some evidence to support it's use.