bestBETs

A fifty eight year old man, who is medically well but relatively inactive, presents to the emergency department after feeling a painful snap at the back of his left heel while running for a bus. On examination you note swelling and ecchymosis over the achilles tendon with a tender and palpable gap. He has weakness of plantar flexion and is Thompson's test / Simmonds' test positive. After being informed of the pros and cons of operative and non-operative treatment he opts to be managed non-operatively. You wonder how he can be best managed.

A middle aged man presents with a painful right index finger after stubbing it on a door. He clinically has a classic mallet deformity with swelling and tenderness over the dorsum of the distal interphalangeal joint and loss of active extension. Radiographs confirm there is no fracture. You wonder how this can be best managed non-operatively.

A 3 year old child presents to the emergency department with a twenty four hour history of vomiting, diarrhoea and reduced oral intake. You wonder whether giving oral ondansetron would improve the success of oral rehydration and reduce the requirement for IV rehydration.

A 36-year-old man presents to the emergency department following ingesting one bottle of OTC diphenhydramine. A friend found the patient down with the empty bottle next to him. The patient was last seen in his normal state of health over 24 hours before his discovery. In the ED, the patient is awake, has a GCS of 14, but is extremely agitated. He also exhibits anti-cholinergic signs and symptoms, such as tachycardia to 118, mydriasis, flushing, absence of perspiration, dry mouth, and decreased bowel sounds The patient was given benzodiazepines for his agitation and started on IV normal saline. The patient had a BMP completed, as well as a CKMB. The patient had a Creatinine of 2.6, elevated from previous data from 0.9 and a CKMB of 38,000. During his treatment, his CKMB continued to elevate to 43, 000 and his renal function continued to decline, reaching a Creatinine of 3.1. An EKG showed tachycardia and NSR. You have heard of sodium bicarbonate use and mannitol use in the treatment of rhabdomyolysis, but you wonder if there is any data supporting their use and if they have been found to decrease morbidity, such as acute renal failure.

A 25 years old lady presented to emergency department screaming with pain due to superficial burn and scald to her left hand. She dropped the full kettle of boiling water and in trying to hold it she spilled all the boiling water on her left hand. She was scared to put her hand under running tap water as it was painful but agreed to put her hand in saline in a tub. She had some blisters and was asking for antiseptic dressings on it. You wonder whether simple petroleum gauze impregnated dressing would be better than using antimicrobial or iodine dressing?

Your relative has returned from their general practitioner with a prescription for antibiotics. They ask you if there is anything they could take to prevent diarrhoea following the antibiotics, as, on occasions, it has resulted in them stopping the antibiotics early. You have some recollection regarding the use of probiotics and wonder whether there is evidence to support their use in this manner.

Tom is a 12-year-old boy who presents with a 6-month history of breast enlargement. He is extremely embarrassed about the size of his breasts and avoids sport because he does not want to be seen while getting changed. He wonders if anything can be done to reduce the size of his breasts. Tom has Tanner stage III breast development. He has entered puberty and his height and weight are both on the 99th centile. He has a male karyotype and his hormone levels are all within the normal range. As Tom is so distressed, you decide that something needs to be done. You have heard that anti-oestrogens, such as tamoxifen, and aromatase inhibitors, such as anastrozole, can be used to treat pubertal gynaecomastia. You start Tom on 10 mg of tamoxifen daily, but after 6 months of treatment this has made little difference to the size of his breasts. You wonder whether anastrozole would be a more effective therapy.

A 42 year old woman attends the emergency department after having been stung by a bee on her shoulder. You examine her and find marked local reactions. The woman tells you that she used tweezers to remove the sting. You wonder if the method of removal might have affected the reaction to the bite.

A 6-year-old girl with acute lymphoblastic leukaemia (ALL) presents with another episode of febrile neutropenia with positive blood culture from her Hickman line. On a ward round, her parents suggest that they would like her to have a Portacath device inserted so that she can go swimming and be more comfortable around her friends. However, they are worried that she will be more susceptible to infection as the needle passes through the skin each time the device is accessed and have spoken to a few parents of children who have had to have their ports removed because of infection. They would like to avoid further hospital admissions if possible. They ask whether the Portacath will increase their daughter’s risk of infection during the remainder of her treatment.

An 56 year old female presents to the emergency department with altered level of consciousness. She if found to have a systolic blood pressure of 200/100 and the CT confirms your suspicions of a intracerebral hemorrhage. You wonder how aggressive should I be in lowering her blood pressure acutely.

32 years old chronic alcoholic patient was brought in the Emergency department with symptoms of withdrawal from alcohol, as he did not drank for last few days, in an attempt to stop drinking without taking medical advice. Patient been shivering, sweating, had some epigastric pains, stomach cramps, nausea & sickness. After getting intravenous access, taking routine blood sample and giving him Librium (chlordiazepoxide), he got stabilized; you wonder whether oral thiamine and multivitamin supplements are better compared to intravenous thiamine and multivitamins, in order to avoid development of Wernicke – Korsakoff Syndrome?

a patient presents in A/E with Severe Acute Upper Gastrointestinal bleeding. After conservative management, how urgent should endoscopy be performed? Is there is benefit from very early endoscopy?

A 24 year old healthy man presented to minors department with deformity to his right hand middle finger, as it was hit by cricket ball in the cricket match. Right hand middle finger distal interphalngeal joint was dislocated, confirmed on xrays, reduced successfully using entonox & position confirmed on check xray. When the patient was about to be discharged home, you wonder whether to put neighbour strapping or leave it without neighbour strapping for the patient to mobilise his finger, so to return to his daily life activities straight away.

A 70 year old man on warfarin, presents to Emergency Department , having ischaemic sounding chest pain, i wander if Aspirin, would give the patient more benefit in reducing morbidity and mortality

A 49 y/o women is brought to the emergency department by ambulance. She was having lunch with friends when she suddenly collapsed at the table. On arrival, she is aphasic and has a marked weakness of her right side. Her partner attends and informs you of her medical history which consists of treated hypertension and nil else of note. You arrange for an urgent CT scan and contact the on-call stroke physician. The patient has attended within 1h of onset of symptoms and you wonder if she would be a candidate for thrombolysis. You mention this possibility to the patient's partner and he bombards you with a series of specific and highly appropriate questions regarding the risks and benefits of thrombolysis in patients with stroke. You point out that the diagnosis needs to be confirmed by CT scan before this treatment can even be considered and then cunningly deflect his questions towards the stroke physician who has just arrived in the department. You are aware that thrombolysis for acute ischaemic stroke is considered beneficial for a certain group of patients within strict inclusion and exclusion criteria, but feel that you should know more about the outcomes of a treatment that is usually administered in your department.