bestBETs

You are the specialty emergency trainee doctor working in the emergency department. The next patient is a 42 years old female who is referred by her General practitioner with confirmed diagnosis of Carpal tunnel syndrome since last six months, for symptom management especially pain. She complained of pain, tingling and numbness in the left hand which gets worse at night. She mentioned about disturbed sleep due to aggravating symptoms. She was concerned because she was unable to return to work and look after her family. There was no significant past medical history. On examination there was sensory impairment in the first three digits, Phalen sign was positive. You discussed with the orthopedic Specialty registrar on call who requested to discharge the patient on oral analgesia and refer to the orthopaedic outpatient clinic for further evaluation for surgical intervention. You wonder whether non surgical intervention is better than surgical.

A 22 year old student is sent from the Walk-In Centre because she has complained of pleuritic chest pain. In the referral letter the GP asks you to rule out a Pulmonary Embolism. She is low risk, has no abnormal chest signs and has a normal chest X ray. To your great surprise her d-dimer is reported as >10,000. She has a V/Q scan which is reported as low probability for a PE. You wonder whether her raised d-dimer could be caused by menstruation?

A 34 year old man has been fishing on a Sunday afternoon at his local pond. He has lost his footing and fallen in. A passing dog walker has seen him struggle and managed to pull him out, unconscious. He is resuscitated at the scene. He is brought to the Emergency Department still coughing up brown water, but not obeying commands. One of your colleagues, nearing retirement age, suggests a barbiturate-induced coma.

You are taking some time after your CT3 year to learn some extra skills that would be useful to your job as an EM consultant. One of the jobs you felt would be useful is palliative care. Intuitively, you feel that uncontrolled pain is an emergency we often see and personally you feel there is much for you to learn in the appropriate management and subsequent referral pathway of palliative care patients. You feel pain management is one of our biggest roles, in common with end of life care specialists. You have no evidence base to show to others how Emergency medicine doctors feel about their knowledge in palliative care and if an Educational intervention would lead to increased knowledge of and confidence in this area and hence a better patient experience.

A 65 years old male, with known liver cirrhosis, portal hypertension and oesophageal varices, present with hematochizia at your emergency department. Given the probability of a upper gastro-intestinal bleeding in this patient, you want to perform a diagnostic aspiration with a nasogastric tube, but wonder if the risk of triggering a variceal bleeding with the tube because of mechanic trauma really exist or if it is only a myth.

You are the medical officer intern on-call for paediatrics in a small district general hospital in rural Kenya. You are called to see a young girl with meningitis who is actively convulsing. Her blood sugar is normal. She has already had one dose of IV diazepam 5 minutes ago. The nursing staff ask about giving her a second dose dose as per the Kenyan paediatric protocol book, but you are worried about the risk of hypoventilation in a hospital without high dependency or intensive care facilities. What do you do?

A previously healthy 8-year-old boy, with a three-day history of flu-like symptoms presents to your emergency department. He was admitted with dehydration and hypothermia in the context of persistent vomiting. The following day he developed heart failure secondary to viral myocarditis.

A 43 years old man presents to the emergency department with a moderate cellulitis with lymphangitis of the forearm following a trivial skin trauma in the previous days. The patient is not known for any health problem nor does he have any risk factor for CA-MRSA. You wonder if daily intravenous cefazolin following oral probenecid is as effective as two or three times a day intravenous cefazolin treatment.

A 42-year-old previously healthy woman presented to the emergency department with chest pain and was found to have an ST elevation myocardial infarction. Cardiac catheterization revealed a dissection in her left anterior descending artery. You wonder what is the prevalence of spontaneous coronary artery dissection (SCAD) in patients with acute coronary syndromes.

20 year old student radiographer is brought to emergency department by ambulance after being involved in a RTC a few hours earlier. It’s a busy Friday afternoon and she’s been sat in waiting room. You call her through to be seen and you notice she obviously has difficulty walking; her concerned looking mother helps her in to a nearby wheelchair and brings her through. She is complaining of lumbar back pain. On examination you are concerned by your neurological findings in her lower limbs: clonus, 4/5 power throughout and some subtle paraesthesia. You explain you would initially like to perform an x-ray and that she may require a CT. She asks her mum to go and get her a drink of water and quietly reveals to you she’s 8 weeks pregnant. You think that MRI is likely to be safer but are not sure if there any significant risks?

A 20 year old patient presents to the ED with low mood and suicidal ideation. The patient has been assessed and is for admission by the psychiatric team once medically cleared. You wonder whether the use of mandatory screening studies in the ED actually affects morbidity and mortality in such patients.

“He needs stitches? Will they dissolve? We're going to Disneyland tomorrow!” asks the anxious mother of a 3-year old who presents to your ED with a 2cm vertical forehead laceration. You ask yourself if you can use absorbable instead of non-absorbable sutures for closure for the same results.

A 62 year old male emergency department patient presents with an acute pulmonary embolism. Patient is tachycardic and requiring supplemental oxygen. You debate over where to place the patient (ICU, progressive, general floor). You consider whether elevated plasma lactate (greater than or equal to 2 mmol/L) might be a good prognostic indicator of death or clinical deterioration.

A four year old girl is brought to the Paediatric Emergency Department by her family with her second episode of spontaneous epistaxis in a month. The bleeding resolves within 30 minutes and she is otherwise fit and well. Her parents are requesting blood tests to look for an underlying cause but you are uncertain as to whether this is justified.

A 35 year old female known to suffer with severe depression and suicidal tendencies goes missing from her home address. Search teams are deployed and following a 3 day search the missing person is found alive but very cold and in a remote area of woodland inaccessible to other emergency services. Further medical support is requested to aid with rewarming the MISPER (missing person) and evacuate her to hospital.