bestBETs

A 64 years old woman is suddenly unresponsive and pulseless. A few minutes after prompt cardiopulmonary resuscitation initiation by her husband, the paramedics arrive on site. Defibrillation is performed twice with an external defibrillator. Return of spontaneous circulation is achieved but she stays unconscious. On emergency department arrival, her vital signs are stable and she is normothermic. The electrocardiogram is not showing any ST-elevation. You decide to put this patient on therapeutic hypothermia. You ask yourself if a coronary angiography with or without percutaneous coronary intervention could improve her chances of survival.

A 4-week-old term baby is brought into your DGH ED by his mother. He is crying inconsolably, and examination reveals a swollen and deformed right femur. Xrays confirm a midshaft fracture. You want to alleviate his pain and discuss strong analgesia. The ED nurses tell you that opiates are unsafe in his age group and state that paracetamol is the only option. You wonder about the evidence for this.

A 34 years old man presents to the emergency department at 11:00PM with severe left flank pain and vomiting which began abruptly 4 hours ago. The patient is not known for any health problem nor does he take any medication. He denies fever of chills. You suspect obstructing renal colic. His creatinine level is normal. You administer him NSAIDs and opioid medication, which relieves his pain. You wonder if this patient can safely be discharged at home if your bedside ultrasound is reassuring, with outpatient imaging and follow-up.

Ward 32 is an acute rehabilitation ward. Many patients that come across for further rehabilitation have had hip surgery following a fractured neck of femur. It had been observed that several patients had a leg length discrepancy following their surgery and so an audit on the prevalence of post-surgical leg length discrepancy demonstrated that 50% of patients transferred to ward 32 post hip fracture had a LLD and these patients were routinely referred to orthotics for correction. On discussion with both Podiatrist and Orthotist it was established that common practice would be to correct half the LLD. The physiotherapists delivering rehabilitation on the ward felt that clinically patient’s functional improvements were greater following LLD correction.

A 45 year old female with a diagnosis of Rheumatoid Arthritis (RA) presents to the physiotherapy department requesting the current best physiotherapy treatment and advice for her chronic, multiple joint pains and stiffness.

A 75 years old man presents with acute onset of central abdominal pain. He has never had this pain before. Abdominal examination revealed central abdominal tenderness but no guarding or masses. The general examination was unremarkable. Routine blood tests came back as normal. You request a CT scan of the patient’s abdomen as he continues to be in pain with no obvious pathology but wonder if the CT scan is a sensitive predictor of significant underlying pathology and if it will help you in clinical decision making.

A 65 year old gentleman presents with his wife after collapsing at home. He is FAST positive with a clear onset time of 1 hour. On examination in the emergency department he has a dense right hemiplegia and expressive dysphagia. CT shows no bleed. Stroke thrombolysis is considered however the patient is unable to tell you how much he weights and his wife is unsure. The doctor and nurses looking after him think he is around 70kg. Is this an accurate enough estimation for drug dosing?

A 40- year-old woman presents at the ED with complaint of severe lower back pain of 2 days duration after carrying a heavy load. She is able to ambulate with no sciatica but reports having urinary incontinence. Physical examination is unremarkable with no neurological deficits in limbs and intact perianal sensation with good anal tone. You wonder whether her urinary symptoms are indicative of cauda equina syndrome.

A 78 years old man presents to the Emergency Department with central abdominal and back pain for 2 hours. He is smoker, overweight, hypertensive and is on bisoprolol and amlodepine 5 mg each daily. Clinical examination reveals tenderness and pulsation in the epigastrium and around the umbilicus his pulse is 78 beat per minute and systolic blood pressure is 85mm Hg. You wonder if you can rely on your examination to rule out a leaking AAA.

A 79 years old man presents to the Emergency Department with acute onset of central abdominal pain and one attack of bloody diarrhoea. The pain is severe and not relieved by simple analgesia. Abdominal examination shows central abdominal tenderness but no guarding. On general examination the pulse was 110/minute irregular but other examination was unremarkable, serum amylase was also normal. The patient gave a history of hyperlipaedemia, hypertension, smoking and peripheral vascular disease. You started titrated doses of morphine to relive the pain. You suspect acute mesenteric ischaemia and wonder if any blood test can help in supporting or excluding the diagnosis.

35 year old builder presented to A&E after having bleach spashed into eyes. Does the new solution Diphoterine offer better visual outcome compared to normal saline when used to irrigate acutely contaminated eyes?

A 25 year old female presents to the emergency department after falling from her bicycle on to her left shoulder. After x-ray and physical exam, she is determined to have sustained an uncomplicated anterior shoulder dislocation and undergoes closed reduction. She has no prior history of shoulder dislocation. You wonder how long her shoulder should be immobilized, and whether you should place her shoulder in external or internal rotation.

A 65 year old female presents to the Emergency Department acutely short of breath. You diagnose an acute exacerbation of COPD. You take an arterial blood gas, but wonder whether a venous one would have sufficed.

A non-obese 68-year-old man is brought to the emergency department by his family with a history of progressive dyspnea over the last week; he has both a productive cough and a fever. He’s very confused and non-combative. His initial saturation is 84% with a reservoir oxygen mask; he is tachypneic with a respiratory rate of 35. You decide to intubate this patient and you need to optimize his saturation before induction. One of your colleagues suggests that you should try Continuous Positive Airway Pressure (CPAP) prior to intubating him. You have not yet used this technique in similar situation. You wonder if CPAP should be used as a means of optimizing oxygenation in non-obese patients with hypoxia before intubation.

A 78 years old lady presents to the Emergency Department with right lower quadrant abdominal pain for 2 days. She is known hypertensive and take bisoprolol 5 mg every morning. Clinical examination showed very slight tenderness in the right lower quadrant and suprapubic area, there is no guarding, masses or organomegaly. Urine dip and bowel sounds were normal. General examination is otherwise normal with temp of 37 degree Celsius, pulse of 58 beat per minute. You wonder if you can rely on normal blood tests to be able to exclude appendicitis.