bestBETs

A thirty year-old lady has fallen onto her outstretched hand and sustained a radial head fracture, which is virtually undisplaced. Knowing that prolonged immobilisation is likely to lead to poor functional outcome, you wonder whether there is any evidence for immediate mobilisation.

A 35 year old man presents to the emergency department with an 18 hour history of a right sided sudden hearing loss. Examination does not reveal a cause. A diagnosis of idiopathic sensorineural deafness is made. Your consultant suggests that a course of prednisolone might be of benefit. You discuss this with the registrar in audiological medicine who does not support this approach. You wonder who is right.

A patient attends the emergency department in status asthmaticus. On examination they have a sinus tachycardia at a rate of 150/min, an oxygen saturation of 92% on high flow oxygen and a pCO2 of 7.0kPa. Despite maximal medical treatment they are becoming exhausted. You decide that the patient needs a rapid sequence intubation and continuous mandatory ventilation. You wonder whether the pretreatment with lignocaine will attenuate the respiratory response (bronchospasm) to airway manipulation.

A 55 year old patient presents to her general practitioner with a 5 day history of lower back pain. Heis previously fit and well, has no neurological symptoms or signs or features to suggest a serious underlying cause. You diagnose a simple low back strain and advise him to take keep mobile, take analgesics as required and expect to improve fairly rapidly. He informs you that his brother in law is a massage therapist and wonders if you think it would help him get better quicker.

A 55 year old woman represents to her general practitioner with back pain of 3 years duration. Previous assessments and investigations have not suggested a serious cause of her back pain but it so severe that she has had to give up work and has become depressed. She attends as she has read on the internet that she can have an epidural to relieve her pain. She asks you if this is true and if so could you refer her for the treatment.

A thirty year old man presents to the emergency department with a spontaneous onset of atraumatic pleuritic chest pain. He is in a low risk group clinically. The medical registrar suggests that the fact that the ECG is normal makes the diagnosis of pulmonary embolus much less likely. You wonder whether his assertion that a normal ECG will help to exclude a pulmonary embolus is safe.

A 35 year-old man presents to the Emergency Department two hours after experiencing an episode of central squeezing chest pain lasting thirty minutes. Initial ECG is normal. You wonder whether serial measurement of CK-MB plus serial electrocardiography will allow you to effectively rule out myocardial infarction (MI), thus avoiding admission for troponin testing at twelve hours.

An 18-month-old boy has been brought into the Emergency Department after having a febrile convulsion. His parents give a history of vomiting and being off his food that day, for approximately the last 12 hours. You wonder how long you should observe him for, or whether you need to admit him.

A 37 year old lady returned from a holiday in Barbados. 3 days later later she presented to the emergency department with a red painful itchy area on her left foot which started on the last day of her holiday. You are not sure whether to prescribe antibiotics.

A 24 year old male presented the emergency department with a painful, red, inflammed area on his arm. He noticed this 4 hours after playing a game of football on the pitch. You wonder whether steroids will reduce his inflammation and symptoms.

A 63 year old lady presents to the Emergency Department with a 3 week history of intermittent dark urine. She says it has become worse over the last 2 days and is now convinced that she is passing blood. You wonder if cytology testing will detect significant underlying pathology or if cystoscopy is necessary as well.

A 70 year old man presents to the Emergency Department with a tummy ache. As part of your examination you dipstick his urine and find that he has microscopic haematuria. At the end of your history, examination and investigation you find that he is constipated. You conclude that the haematuria was an incidental finding. You wonder if further investigation of the haematuria would uncover significant underlying pathology. The man's 20 year old grandson who is accompanying him tells you that after his GP dipsticked his urine and found the same thing as part of a check-up he was referred for further investigation at the hospital.

A 33 year old lady who has had cystitis before presents to the Emergency Department with pain on passing urine. Urine dipstick reveals haematuria. You wonder if it is necessary to send a sample for microscopy or whether you can assume the cause is infective and treat blind with empirical antibiotics.

A 44 year old man presents to the Emergency Department with a week long history of blood in his urine. You wonder if this patient would be more appropriately referred to a nephrologist or a urologist since you are aware that there are many causes of haematuria and that in a younger person a lot of them are not surgically defined urological problems.

A 71 year old lady on warfarin for her atrial fibrillation presents to the Emergency Department with blood in her urine. You know that warfarin increases the chance of bleeding but wonder if urological investigation might reveal a significant pathologic finding.

A 31 year prison warden presented to the emergency department with a human bite wound to his leg after a quarrel with an inmate. There was deep puncture of tissue and a lot of blood. Pain releif and tetanus immunisation was given. After the wound was cleaned you want to know whether surgical debridement reduces the risk of infection.

A 2-year-old boy is brought into the Emergency Department one evening and his parents say he has been feeling hot the last 24 hours, and has a sore throat and is feeling irritable. They have measured his temperature at home using an oral thermometer and it read 39oC. You wonder if the tympanic thermometer in the Emergency Department is a more accurate way of measuring his temperature.

A 2-½ year-old girl has been brought to the Emergency Department with a simple febrile convulsion with unclear focus of infection on examination. She does not appear septic. Her parents say she is potty training and have noticed her urine has smelt strong the past day or two. You test a sample of her urine and diagnose an UTI. You wonder if an UTI is a common cause of febrile convulsions.

A 3-year-old boy has been brought to the Emergency Department after a convulsion at home, which has now resolved. His parents say he has been hot, sleepy and irritable that morning, and has been crying when his bedroom light was turned on. After investigation, meningitis is diagnosed and treated. You wonder how commonly meningitis is a cause of febrile convulsions.

A 2-year-old girl has been brought to the Emergency Department having had her first febrile convulsion, which has now resolved. On examination she has a runny nose and a cough and she has been off her food. You suspect she has a viral URTI. She is her parent's first child and they are very concerned and anxious to know whether she has anything serious and whether this will happen again. You wonder whether you should admit her, or give the parents advice and discharge her.