bestBETs

A 56 year old female presents to the emergency department after waking up with left sided weakness. She was normal when she woke up to use the bathroom in the middle of the night 4 hours ago. You wonder if she could benefit from air transport (about 30 minutes) to a stroke center which uses the Penumbra System for mechanical clot extraction.

You have just reviewed an 87 year old lady who has presented to the emergency department with a minor laceration after striking her head on a shelf at home. She lives independently in the community, and thinks she may have tripped on a loose carpet. You note that she appears to be quite frail and you wonder if there is an appropriate tool to use, to assess her risk of falling before her discharge.

A 42-year-old man presents to the emergency department following an injury to his right index finger. Whilst at work approximately 2 hours ago, he sustained a significant crush injury to his right index finger. Examination reveals a swollen, bruised and erythematous distal phalanx with a deep laceration proximal to the nail fold. Radiographs confirm the diagnosis of an open fracture of the distal phalanx. You wonder whether prescribing a course of oral antibiotics, in addition to thorough wound toilet, will reduce the likelihood of infection developing.

A septic hypotensive patient required an arterial line for early goal directed therapy but bilateral radial pulses were weak and multiple attempts were unsuccessful. A radial artery catheter was eventually secured under ultrasound guidance.

A twenty year old male dials 999 for an ambulance complaining of acute onset shortness of breath and severe chest pain. The plain is pleuritic in nature, being worse on inspiration and limiting his ability to take a deep breath. His pain score is seven out of ten. He has no past medical history, but smokes ten cigarettes per day. On examination, his observations are normal, including an oxygen saturation of 97%. He has slightly decreased chest expansion on the left. There are no signs of mediastinal shift. There is hyper-resonance to percussion along the left chest. Breath sounds are decreased on the left with decreased air entry. The paramedic makes a provisional diagnosis of primary spontaneous pneumothorax and wonders whether a nitrous oxide and oxygen gas combination would be a safe analgesic choice in this patient.

A 55 year old male with no cardiac history presents for chest pressure with onset of about 2 hrs ago, now resolved. You question if new sensitive troponin assays will be able to more accurately rule in or rule out an acute myocardial infarction when compared with standard troponin assays.

A 24 year old man presents to the ED complaining of having injured his knee earlier that evening in a football match. He is in a significant amount of pain so you prescribe him diclofenac. A medical student asks why you prescribed diclofenac rather than ibuprofen, given its higher risk of gastro-intestinal complications. You inform the student that diclofenac is a better analgesic than ibuprofen but wonder if there is any evidence to support this.

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient undergo another investigation, such as an MRI, there and then?

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient undergo another investigation, such as an MRI, there and then?

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient undergo another investigation such as a CT scan there and then?

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient undergo another investigation, such as an MRI, there and then?

A 3-month-old child is seen in clinic because of a rapidly enlarging birthmark on his back. On examination it is seen to be a strawberry naevus measuring 45×25 mm. The parents want to know how much further it will enlarge and when it is likely to settle. A straw poll of staff at grand round reveals that it is reckoned that maximum size should be achieved by 13 months (median) and resolution should have occurred in half the cases at 5 years (median).

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient undergo another investigation, such as an MRI, there and then?

You see a 9-year-old girl with stable cystic fibrosis in your outpatient clinic and review her treatment regime with regard to lung function. Over the last 4 months she has been on nebulised recombinant deoxyribonuclease (rhDNase) 2.5 mg once daily, but her lung function has not shown any improvement. She has also had one pulmonary exacerbation requiring intravenous antibiotics over this period. You are aware that although rhDNase is widely used in the management of lung disease in cystic fibrosis, approximately 50% of patients may gain no clinically significant benefit,(Fuchs, Ballman, Suri 2001) and studies have shown that response after a 3-month trial of therapy is a good predictor of longer term response (Davies, Suri 2004) Given that your patient may be a poor responder to rhDNase, you wonder if treatment with nebulised hypertonic saline would improve pulmonary outcomes.<br><br>

A 13 year old boy presents to the Emergency Department with a three hour history of a severe throbbing headache. He has taken nasal sumatriptan two hours previously and has obtianed little relief, he is currently extremely uncomfortable. He is a known migraine sufferer and has had two other episodes in the last month. After history and clinical examination, a diagnosis of migraine is made. You wonder if the use of an opioid would be appropriate to resolve his symptoms.

A 9 year old girl presents to the Emergency Department with a 2 hour history of a severe throbbing headache that she has described to be at the 'back of her head'. She has experienced headaches in the past, but is unsure if she has always felt it in the same place. After history and clinical examination, a diagnosis of occipital migraine is made. You wonder if you should refer her to neurology for investigation.

A 12 year old girl presents to the Emergency Department with a one hour history of a severe throbbing headache and an episode of nausea and vomiting 20 minutes previously. She is a known migraine sufferer, and her last episode was one week ago. After history and clinical examination, a diagnosis of migraine is made. You wonder whether Chlorpromazine would be effective in relieving her symptoms.

A 9 year old girl presents to the Emergency Department with a 2 hour history of a severe throbbing headache and two episodes of vomiting since the onset. She is a known migraine sufferer, who has had several similar episodes with associated nausea and vomiting in the past. After history and clinical examination, a diagnosis of migraine is made. You wonder if referral to neurology is necessary to rule out underlying aetiology.