bestBETs

You are about to perform a coronary arterial bypass graft on a 70 year old lady who has left main stem disease and an ejection fraction of 30% on echocardiography. She was an urgent referral from the cardiologists after being admitted 3 weeks ago with unstable angina, but has been stable since admission. You realise that she is a high risk case and you wonder whether preoperatively inserting an intra-aortic ballon pump would be of benefit to her?

You are a registrar performing the sternotomy on a 65 year-old patient who is undergoing an aortic valve replacement, supervised by your consultant. You open the chest and start liberally applying bone wax to the sternal edges. Your Consultant is greatly alarmed and tells you that bone wax is 'poison' and should only be used for friable, bleeding sternums. You heed his advice but wonder what evidence exists for his strongly held views.

A six year old girl comes to your outpatient pediatric clinic with a two-month history of cough and shortness of breath, requiring, nearly three times a week, administration of beta 2 agonists by jet-nebulizer. She has often been noticed to wheeze at school during the gymnastic class and when she's laughing or crying; almost once a week she awakes during the night complaining of cough and respiratory difficulties. Your diagnosis is persistent asthma (1) and after a short course of nebulized salbutamol (albuterol) and oral steroids you decide to start, twice a day, a prophylaxis with inhaled steroids, via a spacer device. As her mother is working outside home till late afternoon, she asks you if a once-daily administration would have the same efficacy.

A 45 year old man presents to A&E with a 2/7 history of painful left elbow. He admits to undertaking a lot of gardening in the previous 3 weeks. Clinical examination reveals tenderness over the lateral humeral epicondyle and pain on resisted extension of the wrist. A clinical diagnosis of lateral epicondylitis is made. The patient is anxious to return to work and has heard that an injection can cure him.

A 23 year old male presents to the emergency department following a fall on the outstretched hand. X-rays reveal a mid clavicular fracture. You know that a figure of eight bandage is of no benefit but are unsure whether a sling or a collar and cuff is best.

A 37 year old female patient attends the emergency department with a 4 hour history of epigastric pain. The patient has been taking NSAIDs for backache for the last few months. On examination they have mild tenderness in the epigastric region but no peritonism. You wonder whether an erect chest Xray is sensitive enough to exclude a perforation of an abdominal viscus in this patient.

A 35-year-old man with a severe head injury is brought to the emergency department. He has fallen from a ladder and is leaking CSF from the left ear suggesting a base of skull fracture. He has a GCS of 3 and dilated pupils. There are no other apparent injuries. You decide to intubate him using an RSI technique. Laryngoscopic view is poor despite the use of a McCoy laryngoscope and cricoid pressure. You eventually intubate using a gum-elastic bougie. Your assistant performing cricoid pressure asks during the procedure if you want a BURP. Other bodily functions come to mind! Later your colleague explains that BURP (backwards, upwards, to the right, with pressure) on the thyroid cartilage improves the view. You wonder if in fact it is any better than simple cricoid.

A 35 year old man returns unplanned to the emergency department. He had been assaulted a week previously and suffered a blow to the head. At the time of initial presentation a skull x-ray did not reveal a fracture and he had been discharged home with head injury instructions. Currently he describes non-specific symptoms of a persistent but not progressive headache. Examination does not reveal any abnormal neurological signs. You wonder about his further management and specifically as to whether he requires a CT scan of his brain.

A 70 year old known COPD patient presents to your emergency department with pleuritic chest pain and dyspnoea suggestive of pulmonary embolus. Initial investigations do not exclude pulmonary embolus. As part of your diagnostic strategy, you wonder if V-Q scintigraphy has better diagnostic utility than CT for pulmonary embolus.

A 44 year old man presents to the emergency department with a four hour history of severe epigastric pain. You consider a diagnosis of pancreatitis and organise a serum amylase to be taken. You wonder if a single normal serum amylase result is sufficiently sensitive to rule out pancreatitis in this patient.

You are evaluating a patient who has just been punched on the jaw. He is having difficulty opening his mouth and talking but you can see no step deformity or loose teeth. You recall that while you were on elective you saw the tongue blade test being used routinely in America to select patients for mandibular imaging. For this test the patient is asked to bite on the tongue blade and if the examiner can break the blade while the patient grips it, the patient does not need a radiograph. You wonder whether this is a sensitive test to use in this patient.

A 73 year old woman presents with a six hour history of a left sided hemiparesis. She has a past history of hypertension. On examination she is GCS 15 with a dense left hemiparesis and her basic observations are stable. You wonder whether the use of supplemental oxygen in the acute stage is needed and will have any effect on long term prognosis.

A 20 year old woman presents to the emergency department with shortness of breath and chest pain. Her D-dimer level is abnormal and you have sent her for a ventilation-perfusion scan. The scan result is reported as "low probability for pulmonary embolic disease, however this does not rule out pulmonary embolism". You have assigned her a low clinical probability of pulmonary embolism score and wonder if this helps interpret the scan.

You are evaluating a 90kg acutely dyspnoeic diabetic woman in the emergency department. She has a history of left ventricular failure and was an inpatient 2 weeks ago with a small myocardial infarction. Her BP is only 90/50 and you feel that she is a high risk patient with poor peripheral venous access who may need high dependency care possibly with inotropes, and you therefore decide that a central line would be of great benefit. Your department has just bought a handheld USS probe and you wonder whether it is worth having a go with this rather than your usual blind landmark technique.

A 38 year old man presents with moderate to severe left sided renal colic. He is known to suffer from renal stones. Examination reveals mild loin tenderness and there is blood in the urine. Oral analgesia seems unlikely to control his pain. You speak to a colleague who suggests that you use buscopan (hyoscine butylbromide) - an antispasmodic. You wonder if there is any evidence that this works.

A 41 week gestation male infant, birth weight 4320g, is born by an emergency caesarean section at a District General Hospital for fetal distress and a poor fetal scalp blood gas. The infant is in poor condition at birth and requires intubation and ventilation. As the Tertiary Neonatal transport fellow you are called to transfer the infant to the Tertiary unit as he is hypoxic despite 100% oxygen and a peak pressure of 32. You calculate his oxygenation index to be 32. Your Consultant talks you through the use of the portable Nitric oxide equipment before you leave. You wonder what the long term neurodevelopment effect of Nitric oxide is in Term babies.

A 65 year old man on aspirin presents to the emergency department having fallen sustaining a minor head injury. You wonder whether he is at higher risk of intracranial bleeding due to aspirin.

You are a Paediatric Registrar on duty. The S.H.O asks you to review a child recently returning from Spain, presenting with acute gastroenteritis. The mother shows you a prescription indicating treatment with a Probiotic preparation started by the doctor abroad and wonders about whether you would continue with the same. The S.H.O also quotes some studies supportive of this intervention. You have some time and go off to search for evidence in this regard.

A patient presents to the Emergency Department with a laceration to the right forearm. The wound will need cleaning and then closing. There appear to be many different cleaning solutions available - you wonder which is best.

A 25 year old woman is brought to the emergency department having taken an overdose of drugs. She will require gastric lavage but you consider that her airway is at risk. You call the duty anaesthetist who examines her and states that she does not need intubation as her gag reflex is present. You wonder whether gag reflex is a good test to predict the need for intubation.