bestBETs

You are a member of a multi disciplinary team (MDT) working on an adult in-patient neurological rehabilitation unit. A patient is admitted with a neurological condition for a period of rehabilitation. The MDT wants to set goals to direct the patient’s intervention. You want to use an outcome measure that will reflect change in functional ability and/or quality of life.

A 42 year old women presents with pain on thumb movements in her dominant hand. On examination, she has tenderness over the radial styloid process and crepitations over the first dorsal compartment of the distal radius. Finkelstein test was positive. You diagnose de Quervain’s tenosynovitis and plan to give her a splint, but wonder if steroid injection is better than splinting for the treatment of de Quervain’s tenosynovitis.

A 55 year old female patient presents to with a 7 week history of a gradual onset of pain and a range of movement limited in a capsular pattern confirming adhesive capsulitis. Her pain is limiting your treatment options to restore movement. You are unsure if a course of acupuncture or a corticosteroid injection may help to decrease her pain and assist with restoring her range of movement. You wonder if there is any evidence to help you choose.

Mr. Roberts is a 70 year old male that presents to the ED from a nursing home after feeling short of breath and unwell. A note from the nursing home states that Mr. Roberts has been quite fatigued and abnormal with his interactions with the nursing staff. Lab investigations reveals a urinary tract infection and CXR reveals a possible pneumonia. Talking to Mr. Roberts, he is unable to answer basic orientation related questions and appears quite withdrawn. There is no history of Dementia on his medical record, however you suspect a possible cognitive impairment. You wonder which clinical screening tool would be most sensitive, accurate and convenient to use on Mr. Roberts before attending to the many other patients in the waiting room.

A 40-year-old woman with known paroxysmal supraventricular tachycardia (PSVT) presents to the emergency department with an acute episode of palpitations, dizziness and chest tightness of sudden onset. She is found to have a further episode of supraventricular tachycardia on ECG and her systolic blood pressure is 55 mm Hg. Previous episodes have been terminated by DC cardioversion and you are aware of the algorithm recommending such treatment in the 2011 ALS course manual. However, the text also states that it is reasonable to give Adenosine to patients with regular narrow-complex tachyarrhythmias where there are adverse features while preparations are being made for synchronised cardioversion. You wonder whether it is really effective and safe to give adenosine first to unstable patients and whether this is so for children also.

A 14 year old restrained male was involved in a MVA. He has a fractured forearm but no other significant injuries. He is currently alert and oriented times three and does not complain of abdominal pain. Is physical exam combined with laboratory studies sufficient to exclude any significant intraabdominal injury (IAI) in this child?

A 58-year-old man comes to the emergency department complaining of upper abdominal pain, nausea and vomiting during the past 8 h. He has a history of alcohol excess. He is sweaty and pale. His blood pressure is 85/45 mm Hg and blood sugar 250 mg/dl. The upper quadrants of the abdomen are very painful to the touch. Abdominal ultrasound and blood tests analysis confirms a heterogenous pancreas with raised serum amylase, lipase, lactate dehydrogenase and transaminases. His white blood count is 22 000/mm3. The patient is admitted with the diagnosis of severe acute pancreatitis and a nasogastric tube is placed in passive drainage. On admission to high dependency you suggest feeding via the enteral route, but the local protocol suggests total parenteral nutrition (TPN). You wonder whether TPN, with its known associated complications is really needed in this case.

You are about to perform a rapid sequence intubation on a 26 year old man. You’ve heard rocuronium may provide similar intubating conditions to succinylcholine with fewer side effects, and wonder which should be your muscle relaxant of choice.

A 72 year old man is admitted to the Stroke Unit following collapse and a suspected CVA. He presents with dysarthria and a CT scan confirms an acute stroke. You wonder whether oro-motor exercises will help to improve the intelligibility of his speech.

A 62-year-old man comes in with a new vesicular rash on his abdomen that has been present for 24 h. He complains of intense pain and tenderness in the same area as the rash. You diagnose herpes zoster. You start an antiviral medication right away, but you wonder what medication you could use to try to alleviate the patient's pain and reduce the incidence of post-herpetic neuralgia. You have seen your colleagues use pregabalin for that purpose, but wonder if there is good evidence to support this practice.

A 9-year-old boy presents to the Emergency Department (ED) following a motor vehicle collision. He was a restrained rear seated passenger involved in a head on crash at approximately 45 mph. His physical examination is unremarkable, except for the presence of bruising on the lower abdomen in the distribution of his lap belt, consistent with a ‘seat belt sign,’ (SBS). The boy otherwise looks well. You wonder whether there is evidence to help you decide to discharge the patient, pursue additional imaging, or admit the child for observation/further intervention.

A 35 year old man has a dislocated shoulder that will need to be reduced. He will require sedation and will be monitored with standard monitoring (ECG, BP, SpO2). You wonder if addition of capnography would be beneficial for the patient?