bestBETs

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 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.

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.

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.

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 45 year old man returns to the UK after spending 3 months working in Kenya. He complains of headache, myalgia and nausea. He is not vomiting, his observations are stable and his temperature remains below 38 degrees Celsius. Blood film confirms the presence of Plasmodium falciparum malaria parasites.

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 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?

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.

You see a 6 year old boy in clinic with nephrotic syndrome who is on low dose alternate day prednisolone. He has coryzal symptoms but is otherwise well, with 1+ proteinuria and no oedema. You know that he has previously relapsed following a viral infection and you wonder what you can do to prevent a further relapse. You ask the consultant who suggests increasing his prednisolone dose to daily and you wonder what the evidence is for that.

A 61 year old female with MS is about to start a programme of rehab. She has pain in her right hip, stiffness throughout her right lower limb. She finds it difficult to mobilise independently and to climb stairs. Should the rehab programme be land based in rehab gym or a course of hydrotherapy?