bestBETs

A 7 year-old boy presents to the emergency department with acute onset abdominal pain. His symptoms are not entirely classical for acute appendicitis but you are concerned this could be the start of its presentation and refer him to your surgical colleagues. The surgical registrar on call asks you to arrange an abdominal ultrasound for him which is carried out whilst he is waiting for a hospital bed. Unfortunately the report is returned as “unable to visualise the appendix”. The surgical team say they will adopt a “wait and watch” approach but his parents are unhappy with this as their son is in pain and ask you if there are any other investigations that can be performed. You are reluctant to request an abdominal CT due to radiation exposure and wonder if there is any evidence for the use of MR scanning in diagnosing appendicitis in children as you have seen it used to diagnose appendicitis in pregnant women.

A 58 year old woman with a history of DVT attends A&E with pleuritic chest pain. She is haemodynamically stable with normal saturations, ECG and chest x-ray. D-dimer is positive. You would like to rule out a pulmonary embolism. You wonder whether it would be safe to discharge the patient home overnight before the CTPA, which is booked for tomorrow morning.

A 42-year-old man is brought to the ED with a single stab wound to the left lateral aspect of his chest and a systolic blood pressure of 85 mmHg. He is alert, well perfused and anxious but talking to you. Appropriate management is underway to stabilise his condition; should this include early restrictive intravenous fluid resuscitation prior to definitive surgical intervention?

39 year old male presents to the medical facility at an international air show having spent the day on grass and concrete watching the air show. Clinically he presents with significant confusion, disorientation, tachycardia, tachypnoea, and absence of sweating. On initial assessment he is found to have a rectal temperature of 41.2 degrees and HR of 118. Following rapid assessment he is taken to the decontamination shelter where he is taken through the tent which is spraying cool water - he is passed along the tent twice and following this his rectal temperature is 39.3 degrees. He returns to the P1 (resuscitation) area and cooling and treatment continues with fine mist water spraying (plant sprayers), blow by air and IV fluids. After 1 hour of treatment his core body temperature has returned to normal and he is alert and orientated.

A 29 year old male postman is referred from the acute knee clinic to physiotherapy 4 weeks following a clinically diagnosed ACL rupture. He feels his knee is regularly giving way and asks whether rehabilitation will ease and prevent his recurrent instability.

A 36 year-old gentleman presented with pleuritic chest pain to the emergency department of St Vincent’s Hospital, Melbourne. He was low-risk for pulmonary embolism with a modified Well’s score of 0 but had a raised d-dimer of 0.7 mcg/ml. A CT pulmonary artery scan (CTPA) was performed, showing a subsegmental pulmonary embolus . He was subsequently admitted to hospital for anticoagulation and investigation of underlying risk factors. The prospect of systemic anticoagulation for three months was unappealing for him. He was otherwise clinically well and was a young person with an active lifestyle. This raised the question of whether the use of oral anticoagulation was justified in this gentleman, or whether the potential harm would outweigh the benefits.

A fifty-six year old woman presents at your Emergency clinic with a twenty-four hour history of sudden onset of left sided sensorineural hearing loss. She has no associated co-morbidities. Following a normal examination, a diagnosis of idiopathic sudden sensorineural hearing loss (ISSNHL) is made. You think that she would benefit from a course of steroids as first line therapy but are unsure of the best method of delivery. You discuss the options with your colleagues, one advises oral steroids whilst the other advocates the use of intratympanic delivery. You wonder what would be the best course of action.

A 72-year-old woman presents with a minor head injury (MHI). Her INR was 2, and she has no amnesia or loss of consciousness, therefore not strictly fulfilling the National Institute for Health and Care Excellence (NICE) criteria for a scan. The radiologist on call does not want to scan the patient unless her INR had been >2.5, and so the request is denied. You wonder why the radiologist had chosen an INR of 2.5 and want to find out more about relevance of the INR in the WHI patient, and specifically to question the reassurance that a therapeutic or even subtherapeutic INR could bring for the otherwise asymptomatic MHI.

A 60-year-old female attends the emergency department complaining of floaters and visual loss affecting her right eye. You are concerned that she may have suffered a retinal detachment but are unable clinically to gain a clear view of the fundus. You wonder if ocular ultrasound would be helpful in diagnosing retinal detachment.

A female patient aged 30 has recently returned to running after a 5 year break. She has developed pain on the lateral aspect of her knee whilst she is running, and she has been diagnosed with iliotibal band syndrome (ITBS). You wonder, given the limited treatment time available, which conservative technique to use in order to get the best results.

A 37 year old male presents with an anterior shoulder dislocation following a rugby match. He states he has not ingested solids for 6 hours or fluids for 2 hours. As you are consenting him for procedural sedation you notice he is chewing gum. Should this patient be regarded as fasted or should an alternate method of facilitating reduction be used due to an increased risk of aspiration?

A 55 years old man brought by ambulance for lost of consciousness without witness. Discover by his wife 5 minutes later, he woke up but still have confusion 20 minutes later in your emergency room. He is not known for any disease and doesn’t take any pill. You wonder if he had a seizure and you heard about a prolactin test that could help you with your diagnosis.

An elderly woman attends your emergency department (ED) following a mechanical fall. She takes warfarin for atrial fibrillation and has a small occipital haematoma. Her Glasgow Coma Score (GCS) is 15; she has no amnesia and a normal neurological examination but did briefly lose consciousness. The International Normalised Ratio (INR) comes back within the therapeutic range at 2.9 and a CT scan is requested according to the National Institute of Health and Care Excellence (NICE) guidelines. The scan is reported as normal, and her social circumstances are adequate in that she lives with her husband who can keep an eye on her. You wonder, though, whether it is safe to discharge her or if there is a possibility of delayed intracranial haemorrhage (DICH) due to her coagulopathy, and therefore she should be admitted for a period of neurological observation so that it can be identified and acted upon at the earliest opportunity.

A 55 year old man presents to the emergency department with spontaneous epistaxis. He is haemodynamically stable. Simple first aid measures including pinching the soft portion of the nose were ineffective at arresting the bleeding. The patient is previously well with no comorbidities. You are aware that tranexamic acid is effective as an antifibrinolytic in various bleeding conditions and anticipate it may be useful topically at stopping bleeding in epistaxis.

36 years old patient was transferred to emergency department following a severe blunt trauma in a road traffic accident. When deciding about initial diagnostic investigation, you wonder which one is associated with better survival: whole-body CT or conventional diagnostics.