bestBETs

A 35 year old man presents to the emergency department with acute back pain sustained whilst lifting a heavy box. He complains of low lumbar spine pain. There are no neurological symptoms or signs and no "red flags" to indicate a potentially serious cause of his back pain. You diagnose a simple acute low back strain and advise analgesia and mobilisation. He tells you that he knows a local acupuncturist who could see him for acupuncture but wonders if it is worth spending the money. He asks if you are aware of any evidence for it's effectiveness.

A 24 year old man presents to the emergency department with severe lower back pain. He developed back pain after twisting awkwardly whilst lifting a box. There are no neurological signs on examination and he has no "red flag" signs or symptoms. You make a diagnosis of low risk musculoskeletal back pain, reassure him and prescribe analgesia. He was brought to the emergency department by ambulance and initially treated with NSAIDS, paracetmol and Codeine. You review him later and he tells you that the pain killers were worthless and that the last time this happened his GP gave him a presciprition of oramorph. He asks that you do the same.

A 42 year old woman presents to the emergency department with gradually progressive worsening of headache over 48hours refractory to analgesics.She is known to suffer from migraines and says that she has had increasing frequency of episodes recently and her pain is similar to her migrainous episodes.She has had CT scans lately which haven't shown any abnormality.You diagnose her to be suffering from severe migraine and treat her with parenteral Imigran (sumatriptan) and metocloparamide which makes her pain better.You have heard somewhere that using dexamethasone reduces the frequency of migraine episodes.You wish to know the evidence for it.

A 52 yr old known epileptic is brought in fitting for short time period to the Emergency Department (ED). She has received an appropriate dose of PR Diazepam pre-hospital and the seizure continues despite further IV lorazepam. You wonder whether there is any evidence to suggest a benefit of IV Fosphenytoin over IV Phenytoin as second line treatment of status epilepticus.

A 35 year old man presents with a dislocated shoulder. You are about to undertake the reduction under sedation in the emergency department and wonder whether the use of a propofol infusion rather than boluses of midazolam would give effective sedation with shorter recovery time without compromising safety.

A 14-year-old boy attends your general clinic suffering from weekly headaches for the last 6 months. The description of the headaches are typical for migraine headaches, neurological examination is normal. There is a strong family history of migraines in the mother and a sister. He already has made adjustments to his lifestyle by avoiding trigger foods and a regular sleep pattern with limited improvement. He is reluctant to take regular prophylactic medication but his parents are concerned about the amount of analgesia he takes. As his mother uses sumatriptan with good effect she wants to know if this would be an option for him.

A 32 year old female is receiving physiotherapy 2 weeks after her grade 2 ankle sprain. She asks if she still has to wear the Tubigrip™ bandage she was supplied with as she still has swelling but has heard from her sister that her ankle will be weaker as a result of wearing it long term. You wonder if there are any adverse long term effects of wearing Tubigrip™.

A patient attends the emergency department with pain in keeping with a fractured scaphoid. The standard scaphoid views failed to identify a fracture. Should magnetic resonance imaging be conducted or is it too expensive.

A 52 year old man presents to the primary care emergency centre with a 5 month history of back pain. He is dissatisfied with the care given by his usual GP. His GP has performed an X-ray which "Just showed a bit of wear and tear" and he has blood tests (FBC, UE, LFT, ESR, CRP) which have all been normal. He has no neurological signs or "red flag" type symptoms. A diagnosis of musculoskeletal back pain is confirmed. The patient is keen to try one of "those electrical thingies" as his daughter had one during labour and she said it marvellous. You wonder if there is any evidence to support the use of TENS in patients like this.

A 30 year old male presents to the Emergency Department with multiple stab wounds to soft tissues of chest/ abdomen and limbs. You wonder whether cleaning and allowing to heal by secondary intention is better than wound closure to prevent wound infection.

An otherwise well 3 week old infant born at 28 weeks gestation has a haemoglobin level of 68 g/l and is prescribed a blood transfusion. The departmental protocol states feeds should be withheld during the transfusion to decrease the risk of development of necrotising enterocolitis (NEC). What is the evidence that blood transfusion increases the risk of NEC?

You are a senior house officer in a paediatric assessment unit and commonly see children with acute otitis media who are febrile but otherwise well. You are not sure about the role of antibiotics in this condition and note that various existing guidelines have different recommendations about use of antibiotics. You wonder if measurement of C-reactive protein can be used as a screening test to differentiate between viral and bacterial otitis media and to decide which group of children require antibiotic therapy. You decide to find out more.

A 70-year-old male is admitted to the intensive care unit with a severe biliary sepsis. He is develops multi-organ failure, is placed on a ventilator and receives inotropic and vasopressor support. He becomes anuric over the next two days, despite adequate fluid resuscitation. He is commenced on renal replacement therapy when he develops fluid overload. You wonder if you could have preserved his renal function and reduced his chances of requiring renal replacement therapy by the use of a loop diuretic.

You are assessing a toddler who has presented with paroxysmal cough with a whoop and post tussive vomiting. A clinical diagnosis of 'whooping cough' is made and this is duly confirmed on pernasal swab cultures that reveal the growth of Bordetella pertussis (B. pertussis). From history, you note that he is allergic to Penicillin and has been given Erythromycin for a previous episode of tonsillo– pharyngitis. His mother recalls that he suffered severe abdominal pain when taking it and did not complete the course. You wonder whether newer macrolides such as Azithromycin or Clarithromycin could be effective alternatives to Erythromycin for the treatment of Pertussis in this setting.

A 2-week-old infant, born at 36 weeks gestation was admitted to the paediatric ward in November with a 24h history of runny nose, cough and episodes of shallow breathing and apnoeas. This was thought to be due to bronchiolitis, and the consultant paediatrician suggested starting the baby on caffeine (theophylline derivative with less side effects). As the resident middle grade doctor, I knew that caffeine has been used widely in neonatal units for apnoea of prematurity, but I wondered if there was any evidence for its use in this clinical situation.

A 46 year old man is brought to hospital after a road traffic accident, involving a rear end shunt, to "get checked out". He is fully alert and co-operative. You are aware that many people advise x-rays in all patients to exclude cervical spine injury. You wonder whether it is really necessary.

You were called to see a 56 year old woman who was admitted to a medical ward two days before with a right basal pneumonia. She was in respiratory failure, hypotensive and oliguric. After intubation, ventilation, resuscitation with fluids she remains hypotensive and a vasopressor has been started. You wonder whether she would benefit from low-dose steroids?

A 76 year old patient attends the Emergency Department following a fall in the street. She has a wound over her left lower leg that can be treated with steristrips. You enquire about her tetanus immunisation state and discover that she has had a full course of ATT and two booster doses. The last was 15 to 20 years ago. You are sure you have read somewhere that not only should this provide lifelong immunity but also that booster doses may cause severe local side effects in such individuals. You wonder whether this is correct.

A 2 year old child is brought into the emergency department with a general malaise and irritability for the last 24 hours. Examination of the right ear reveals a diffusely red bulging ear drum. A diagnosis of acute otitis media is made. You wonder whether there is any evidence that oral antibiotics would decrease the time to recovery and prevent secondary complications.

A patient/relative/member of staff has a mobile phone switched on in the Emergency Department. Is there any evidence to suggest that it may affect the Departments Medical Monitoring Equipment.