bestBETs

A 70-year-old man encountered several episodes of hypotension when standing after bending over to tie his shoes. Last time, he lost consciousness transiently. He asks you for an easy way to prevent passing out, as he lives alone. You once heard about the effect of leg crossing and you wonder if leg crossing actually prevents syncope caused by orthostatic hypotension.

You review a 67 year old female and diagnose Community Acquired Pneumonia (CAP). A junior colleague had requested NT-proBNP levels as part of the work up, and the value was elevated at 1500pg/ml. The patient has no evidence of heart failure. Based on your previous reading of BNP, you wonder whether this may have prognostic significance.

A 35 year old builder presents to the emergency department having dropped a paving slab on his toes. He has swollen painful great toe on the right foot. An x-ray shows he has sustained a closed fracture of the distal phalanx of the great toe. No other injuries have been sustained.

A 10-year-old girl presents to the emergency department (ED) with pain in her right lower quadrant. She states that the pain started 2 days ago when it was diffuse across her lower abdomen. She has had a decreased appetite but no nausea or vomiting. On examination, her abdomen is soft, non-distended, with no guarding and no rebound tenderness. Rovsing\'s sign is negative, but she has positive obturator and psoas signs. Murphy\'s sign is negative. Bowel sounds are heard throughout her abdomen. She is afebrile and her basic laboratory tests show a leucocytosis of 11 000 white blood cells/µl with a left shift. You wonder how likely it is that this patient has appendicitis and how best to manage this individual. You wonder if the Alvarado scoring system used for this purpose in adults is supported by evidence in paediatrics.

A 47-year-old man attends the emergency department with a 12-h history of palpitations and slight chest tightness. On examination he is found to be in atrial fibrillation with fast ventricular response. He is haemodynamically stable. You decide to cardiovert the patient as he is symptomatic. After successful cardioversion he is feeling well and remains stable. His cardiac markers and electrolytes are also normal. You wonder whether he can go home immediately or if he needs to stay in hospital for a further period of observation.

A 3-year-old boy comes in with intermittent bouts of severe abdominal pain. You are thinking of intussusception as the most likely diagnosis. It is night time and in your institution, the access to a formal ultrasound is limited at this time of day. You have heard of case reports of intussusception diagnosed by emergency physicians using bedside ultrasound. You wonder if there is any good evidence at diagnosing intussusceptions with this modality and you decide to search the available literature.

A 12-year-old girl requires a lumbar puncture (LP) for possible meningitis/encephalitis. She has a postdural puncture headache (PDPH). While discussing her treatment options with the anaesthetic team they ask why a cutting point needle was used. You wonder if there is any evidence to back up their claim that cutting needles are associated with a higher incidence of post-puncture headache.

A 45 year old man presents with acute renal colic, with no signs of infection or renal failure. You consider discharging the patient with analgesia and an out-patient urology appointment but remain concerned about the safety of this approach.

A 48yr old male attends your ED with a sensation of foreign body in his hypopharynx after eating lamb curry. You feel he warrants naso-endoscopy and refer him to ENT. You are asked to order a lateral soft tissue neck x-ray by your ENT colleagues. You wonder if this will alter his management.

A 3 month old term male infant of Somali background presented with a history of recurrent left axillary abscess, 1.5 cm in diameter, following BCG vaccination at birth. Swelling of the left axillae was noted at age 1 month along with keloid scarring of the injection site and this was diagnosed as BCG lymphadenitis at 2 months of age, supported by ultrasound scanning. The patient remained afebrile and otherwise fit and well, and there was no family history of Tuberculosis (TB) infection or recent travel and both parents had received the BCG immunisation. At 3 months of age the patient was admitted via the emergency department due to worsening of symptoms; this resulted in incision and drainage of the abscess alongside a short course of oral Co-Amoxiclav. Histopathology showed acid fast bacilli, though swab cultures were negative on Ziehl Nielson staining. A fortnight later the patient re-presented with increased exudate and erythema of the surgical site, alongside presumed viral gastroenteritis. He received a further short course of intravenous Co-Amoxiclav and was discharged with advice on conservative management.

A 34 years old man presents to your emergency department with a dislocated shoulder. You want to use procedural sedation for the reduction of his shoulder. You have used ketamine successfully for sedation in children before and you wonder if it would be as effective as propofol in an adult population requiring procedural sedation.

You’ve just seen a 6yr old little girl with a gaping laceration to the palmar aspect of her index finger. You feel it requires sutures but are unsure if LAT gel is safe to use in digits.

A 30 year old man presents having been involved in a front end collision while driving a car at 40mph. He is found to have sternal tenderness and an x-ray reveals a fracture. There are no other significant injuries.