bestBETs

A pregnant woman presents to the ED with symptoms describing a PE. A D-Dimer test you order is unequivocal so you wish to order further investigations. At that time helical CT and V/Q scanning are available, you wonder how reliable they are in pregnancy.

A 98 year old woman is brought to the Emergency Department on an unseasonally chilly summer's morning. The paramedics had picked her up from home in a peri-arrest state with a respiratory rate of 3, bradycardic, hypotensive, hypoglycaemic and hypothermic. Despite some degree of ridicule from Sister, you decide to resuscitate her. Her initial lactate, on an arterial blood gas, is 12. 4 hours later, she is sat up chatting with a lactate of 6. You wonder whether her rapid rate of lactate clearance, rather than the initial absolute level, is a predictor of survival.

You see an 8 year old girl who developed a widespread rash which appears to be target lesions after a viral URTI. You make a diagnosis of erythema multiforme. You wonder whether steroids may be of some benefit, but your consultant questions whether there is any evidence.

A 6 month old baby is admitted to hospital with a 4 day history of coryzal symptoms, increasing cough, wheeze and decreased feeding. Respiratory syncytial virus was detected in nasopharyngeal secretions. She is needing oxygen and is on nasogastric feed. You wonder whether starting physiotherapy will improve her clinical condition.

A patient with sternal fracture following sterring wheel injury after Road traffic accident was complaining of chest pain . His ECG was within normal limits. I wonder whether he merits admission for 12 hour troponin I and echocardiogram to identify cardiac injuries

A 50 year old male presents with a tender abdomen that is mildly distended and surgical history of an appendectomy.

A 2 1/2 year old girl is brought to the Emergency Department in respiratory distress. Her father tells you that he noticed a barking cough throughout the night and that her breathing was becoming noisier. On examination the child is alert and tachypnoeic, has got a tracheal tug and recession, an audible inspiratory and expiratory stridor, SpO2 > 92%, Temp 38.3C. You decide that you are going to treat with Dexamethasone and wonder whether heliox might be effective as a 'bridging therapy' in relieving symptoms and improving croup score.

A 14-year-old girl with type 1 diabetes mellitus (DM) attends clinic for her annual review appointment. An albumin creatinine ratio (ACR) on spot urine is 7.3 mg/mmol. Her blood pressure is 125/67 and HbA1c is 9.2%. Subsequently, three consecutive early morning urine samples have ACR of 6.8, 5.7 and 7.3 mg/mmol, respectively, and remain elevated when repeated 3 and 6 months later. You are aware that in adult women with diabetes persistent microalbuminuria (MA) is defined as an ACR greater than 3.5 mg/mmol on two out of three successive occasions, and that in such adults, treatment with angiotensin converting enzyme inhibitors (ACEi) confers renoprotection. You wonder whether your patient should be treated.

A 5 year old boy was admitted to a rural New Zealand hospital with 10 day history of abdominal pain. The pain was localised to the RIF with guarding and examination revealed a palpable mass in the RIF. He had previously presented with a 1 day history of severe abdominal pain and fever and had been discharged the following day with a diagnosis of gastroenteritis. He was transferred to the tertiary hospital and a diagnosis was made on ultrasound scan of appendiceal mass with abscess. His condition was stable. He was commenced on conservative management and supportive care with intravenous (iv) antibiotics followed by a 2 week course of oral antibiotics. He responded well to conservative management and was scheduled for appendectomy after an interval of 6-8 weeks. You wonder whether it is necessary, now he is well, for him to have an appendectomy.

A 9-month old infant has been admitted with fever, cough, shortness of breath and poor feeding. He is tachypnoeic with bilateral crackles and occasional rhonchi. Initial management is started with a provisional diagnosis of bronchiolitis. Nasopharyngeal aspirate for respiratory syncytial virus turns out to be negative. Over the next few hours, he is noted to have high grade pyrexia with a gradual clinical deterioration. As the on-call specialist registrar in paediatrics, you are now worried about a possible bacterial aetiology. You decide to commence antibiotics after sending a sample for blood culture. A chest radiograph, full blood count and C-reactive protein level do not help to distinguish between a viral versus bacterial infection. You are aware that in an infant with bacterial pneumonia, the most common causative organism is Streptococcus pneumoniae. A colleague informs you that your hospital laboratory can perform a rapid immunochromatographic urine antigen detection test which is widely used for diagnosing pneumococcal infections in adults. You are not sure about the diagnostic utility of this test in children. You decide to do a literature search and critically appraise the evidence.

A 53 year old male is brought in by ambulance from a nearby building site after a collapse, on an uncharacteristically hot day. In the resuscitation room he has a GCS of 3. He is found to be warm and dry and to have a temperature of 42.3°C. You diagnose heat stroke and wonder if Dantrolene would be useful in this scenario.