bestBETs

A 64 year old lady on long term warfarin for atrial fibrillation attended the A&E department following a fall. She has sustained a frontal head laceration with very brief loss of consciousness. She has a GSC score of 15 with no neurological symptoms. You wonder if patients on warfarin and a minor head injury are at risk of intracranial injury and as a result if they all require admission for neuro-observation

A one year old child is admitted following their first febrile seizure (FS). We wish to prevent recurrences during further febrile episodes. The nursing staff ask you to prescribe an antipyretic. Later you come to advise the parents on methods of preventing further febrile seizures.

A 30 year old man presents to the emergency department with a spontaneous onset of atraumatic pleuritic chest pain. He has no previous medical history and has no shortness of breath or haemodynamic compromise. You wonder whether his clinical features and risk factors can help to safely exclude a pulmonary embolus.

A 38 year old man presents to the emergency department with left posterior pleuritic chest pain. He had a DVT 8 years ago and his D-dimer levels are elevated. He is haemodynamically stable with normal oxygen saturations, ECG and chest Xray. You would like to rule out a pulmonary embolism, but it is 8pm. You wonder whether it would be safe to discharge the patient home overnight before his VQ scan tomorrow.

You are called to see a 60 year old man who has been increasingly breathless for a week. Examination reveals him to be mildly dyspnoeic at rest with a raised JVP and bibasal creps. There is evidence of ischaemia on his ECG. The CXR shows upper lobe diversion and Kerley B lines. You wonder whether buccal suscard would be an appropriate alternative to a GTN infusion.

A 22 year old insulin dependant diabetic presents to our emergency department with a raised blood sugar and urine dipstick showing +++ of ketones. You suspect diabetic ketoacidosis and would like the know the degree of his acidosis, but the patient refuses arterial blood gas sampling due to a previous bad experience. You wonder whether venous blood would accurately show the degree of his metabolic acidosis.

A 34 year old woman presents with a 2 day history of pleuritic chest pain. There are no abnormal physical signs and her only risk factor is that she is taking the oral contraceptive pill long term. You wonder if a combination of clinical examination and the available d-dimer test (SimpliRED) would be suitable to rule out pulmonary embolism.

You are working in an African hospital during the malaria season. A 10 year old boy is admitted in coma with a fever after having had a convulsion at home. A blood slide shows asexual forms of Plasmodium falciparum, his blood sugar has been checked to be normal, and he has been loaded with Intravenous quinine. Antibiotics have been given until meningitis can be excluded by a normal lumber puncture. Local experience suggests intravenous mannitol is of benefit in unconscious patients with cerebral malaria, its use however, is not recommended by the World Health Organisation (1).

A 20 year old student presents to the emergency department with a three day history of urinary frequency, dysuria and lower abdominal pain. Examination is unremarkable and dipstick urinalysis is normal. You wonder whether normal dipstick urinalysis is sufficient to rule out a UTI, or whether antibiotics anyway should be prescribed whatever the result.

A 30 year old woman presents to the emergency department with distressing, left sided pleuritic chest pain. She may have had a pulmonary embolism and you request a D-dimer. You know the lab in your hospital utilises the IL D-dimer test and wonder whether a normal result would be sufficiently sensitive to rule out a pulmonary embolus.

A 19 year old woman is brought to the emergency department 6 hours after paracetamol overdose. She is fully conscious and admits ingestion of 32 tablets of paracetamol. She is complaining of abdominal discomfort but no nausea or vomiting. Her examination is unremarkable. You arranged blood investigations. IV access and n-acetyl cysteine infusion started as per protocol. You wonder whether oral methionine would have been as effective as n-acetyl cysteine in her treatment.

A 40 year old woman presents to the emergency department with pleuritic chest pain. She comments that she has had 'cramp' in her left leg since discharge from the surgical ward, post hysterectomy. Her ventilation-perfusion scan shows a high probability of pulmonary embolism. You have scored her as a high clinical probability of PE and therefore diagnose pulmonary embolic disease. She is comfortable with normal oxygen saturations, and keen to return home to her family. You wonder whether treating her as a outpatient would be an option.

You have reviewed a 48 year old man who presents with isolated pleuritic chest pain on the left side. His fingers are nicotine stained. He tells you he regularly coughs up yellow phlegm in the morning. His PaO2, PaCO2 are normal and D-dimers elevated. You would like to discharge him to the care of his GP if you are able to rule out pulmonary embolus. Would a CT pulmonary angiogram allow you to do this?

You are seeing a 70 year old American man with three discrete 70% stenoses in the mid LAD, mid Circumflex and Proximal RCA. He has grade III angina and apart from Hypertension and a high cholesterol he has no other significant past history. You advise him that his best option is certainly to have Coronary Arterial Bypass grafts in terms of relief of symptoms. However he tells you that he had a friend in the States with the same problems as him who had 3 stents that were impregnated with drugs that will keep his arteries open forever. You wonder whether drug-eluting stents would be just as good for him if he could get them.

A 45 year old woman is admitted to the emergency department with a minor head injury after being involved in a road traffic accident. She had a GCS of 14 in the ambulance and had a witnessed loss of consciousness of around 10 minutes at the scene. However she now has a normal GCS, a mild headache but no other clinical symptoms or signs. All investigations are normal and you are about to send her home. However she is worried about her headache and tells you that she had a friend who was 'never right again' after a head injury 2 years ago. You wonder whether she should be followed up but you don't know which patients are at high risk of long term disabilities such as headache, dizziness, or symptoms classed as post-concussional syndrome.

A young man has been drinking all night with his friends and staggers home. He is found snoring on the pavement and is brought to hospital by ambulance. Clinical examination is unremarkable and there is no evidence of trauma or other injuries. His blood tests are normal. He smells heavily of alcohol and is not fit for discharge. Would IV fluid therapy increase ethanol clearance facilitating his discharge?

A 45 year old man presents having been assaulted the day before. He has no signs of external injury to his chest and is in significant discomfort. He denies shortness of breath, he has a normal respiratory examination and his pulse oximetry registers 99% on air. Does he require a chest radiograph to rule out a traumatic pneumothorax?

A 4 month old infant attends the emergency department in the late morning with bronchiolitis. It is the first episode of wheeze. Clinically, there is moderate indrawing and recession, tachypnoea (RR=50), reasonable air movement on auscultation, and the oxygen saturation is 94% in air. You want to admit the infant, but the mother is breast-feeding and keen to get home by 3pm, when her other children get home from school. You have heard that in North America, nebulised adrenaline has been used in some cases and admission has been avoided.

A 38 year old man presents with moderate to severe non-specific abdominal pain that is colicy in nature. He has no significant past history. Examination reveals mild tenderness but no signs of peritonism. 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 27 year old woman attends the emergency department with a suspected amitriptyline overdose. She has a Glasgow Coma Score of 7, is trypsilating, and has a broad complex tachycardia and a blood pressure of 70/30. After intubation and ventilation and sodium bicarbonate she remains tachycardic at 130 although her complexes have narrowed somewhat and her BP is still low at 80/40. You have heard that tricyclic overdoses may respond to glucagon and wonder whether there is any evidence for this.