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You are a chest registrar seeing a 55-year-old patient in a rapid access out-patient clinic who has recently presented with cough and hemopytsis. He is a smoker and had these symptoms for just a few weeks before being sent for a chest X-ray. It shows a large lesion in the right upper zone. The patient suspects he has lung cancer, which he probably does. He wants to know why he could not have had a chest X-ray before he was sick to pick up his lung cancer.

A 65 year old male patient is brought in to your department. He is severely short of breath, sweaty and has sats of 91% on a non rebreather. He is an ex smoker and known to have IHD and suffers from LVF. The standard teaching is that Diamorphine (morphine) should be given to these patients as it is an effective treatment for the condition. You wander if that is true and if there is any evidence for this statement.

You are with a 72-year-old patient who is 15 h post emergency Type A dissection repair and CABGx1. It was a difficult operation with a long bypass time. Post-operatively he has been bleeding profusely. He has been reopened but no bleeding points have been found, and he has returned to the CICU packed and with the chest open. He has received 12 units of fresh frozen plasma and 2 pools of platelets and cryoprecipitate, but has still bled 400 ml per hour for the last 3 h. You discuss the patient with the haematologist and he tells you that they now have recombinant activated Factor VII available for use, and asks whether you would like to use it. He has no experience with this post-cardiac surgery and neither have you and you are a little anxious about the patency of the graft that you had to place, but you elect to give it and then search for reports of its use.

A young girl presents in the emergency department with right iliac fossa pain, anorexia, nausea and vomiting for the past 12hours. On examination she has significant right iliac fossa tenderness but no rebound or guarding. Her temperature is 37.3„aC and the inflammatory markers are normal. You are not entirely certain if she has acute appendicitis and would not like her to go through an unnecessary operation. You are wondering whether Ultrasound or CT is better in confirming the diagnosis of acute appendicitis.

You have been asked to perform urgent CABG on a 72 year old gentleman who has just undergone angiography for acute coronary syndrome. He had been admitted that day with chest pain at rest for 24 hours, and the Troponin T was found to be 0.95. The cardiologist has found a 30% left main stem disease and severe triple vessel disease with good LV function. He received 300mg of clopidogrel on admission. He has chest pain on minimal exertion although he has no ECG changes and his blood pressure is 140/70. The cardiologists are keen for you to get on with his surgery, but you would like to delay this gentleman's surgery 7 days, thus you decide to summarize the evidence for this decision.

You are about to perform a Coronary arterial bypass graft on a 75-year-old gentleman with good LV function. You have recently been asking your perfusionist to use a centrifugal pump for all your high risk cases, and the perfusionist asks you if you want one for this case. You say 'yes' but you are unsure if there is evidence for benefit for these lower risk patients and, therefore, resolve to search for papers on the subject after the case.

A forty-five year old abusive, intoxicated recurrent attendee complains of central chest pain of 2 hours duration. His initial ECG is normal. Your gut feeling is that he does not have an acute coronary syndrome. You are reluctant to admit him for troponin estimation at 12 hours but wonder if you ought to risk discharge without further investigation. Having heard about PAPP-A, a promising cardiac marker, you wonder if the evidence is sufficient to allow clinical use in this situation.

You are the anaesthetist assessing a 75-year-old current smoker with an exercise tolerance of only 200 yds, who is due to have coronary grafting tomorrow. You approach the surgeon to suggest that you place a thoracic epidural prior to induction. He is reluctant for you to do this as he says that epidurals can be dangerous with full heparinisation and anyway he isn't aware of any evidence that it speeds recovery. You decide to summarize the evidence for him.

A thirty six year old man is brought into the emergency department by ambulance with a suspected opiate overdose. He has pinpoint pupils and bradypnoea which is reversed by administration of naloxone. However there is no evidence of IV drug abuse such as needle track marks. You wonder if naloxone can be used to reverse and therefore diagnose any other conditions.

A 60 year old man attends the ED complaining that a fish bone has got stuck in his throat. Clinical examination rules out impaction within the pharynx so you are concerned that the bone has become impacted within the oesophagus. Prior experience tells you that oesophageal abrasions secondary to ingested bones can often mimic impaction, that rigid oesophgoscopy (the definitive investigation) carries a significant mortality and morbidity rate, and that the most readily available non-invasive investigations, lateral neck and chest x-rays, are often unreliable. You wonder whether a CT scan of the neck would be a more accurate non-invasive tool?

A 23 year old female has been referred to physiotherapy with a 6 month history of temporomandibular joint (TMJ) pain without disk displacement. Based on some published evidence, the referrers commonly request electrotherapy, but you want to investigate if other forms of physiotherapy may be more beneficial.

A young adult with kidney stones amenable to extracorporeal shock wave lithotripsy (ESWL) attends for their first session of treatment and you wonder whether such patients should routinely be given opioid analgesia.

A 17 y/o patient who is otherwise fit and well attends for removal of their tonsils. The patient has no contraindications to steroid use and you wonder whether giving steroids postoperatively will improve their pain control.

A 50 year old man is found collapsed in the snow on a very cold winter's night. He is admitted to hospital unconscious with adjuvant cardiopulmonary resuscitation and a low reading rectal thermometer measures his core temperature to be 26 oC. He is in ventricular fibrillation. Should an attempt at defibrillation be made at this temperature or should he be re-warmed first and then defibrillated?

A 50 years old man attends the Emergency Department with a 12 hours history of palpitations; he complains of slight shortness of breath on walking upstairs and on clinical examination is found to be in atrial fibrillation (rate 140/min.) with a normal BP, fine bilateral basal crepitations and an otherwise normal ECG. You wonder if amiodarone increases the chances of spontaneous cardioversion back to sinus rhythm.

A 57 year old woman attends the Emergency Department with newly diagnosed atrial fibrillation of uncertain duration. You decide to treat her by ventricular rate limitation with a calcium channel blocker and wonder whether you should use diltiazem or verapamil.

A seventy-five year-old man with no significant previous medical history presents to the Emergency Department during the night with a two-hour history of typical cardiac chest pain. ECG demonstrates 2mm ST elevation in leads II, III and aVF with reciprocal ST depression in aVL. You diagnose acute inferior ST elevation myocardial infarction (STEMI). Primary angioplasty is currently unavailable and you obtain verbal consent for intravenous thrombolysis. You wonder whether the more fibrin-specific bolus thrombolytic, reteplase, confers any advantage over streptokinase, in terms of mortality and probability of reperfusion.

An 8 month old baby girl, of Eastern European parents, presents with a week long history of coryzal symptoms for which she has been taking oral antibiotics. She is pyrexial, irritable, and unwell on examination. She is admitted with a clinical diagnosis of meningitis and commenced on intravenous cefotaxime. A lumbar puncture is performed and microscopy reveals an elevated number of white cells (majority lymphocytes), low glucose, and protein of 0.9 g/l. She does not respond to conventional therapy and nothing is growing on CSF or blood culture. There is no history of contact with tuberculosis and she was vaccinated with a single dose of BCG at birth. She was an intrauterine growth retarded baby but had no subsequent problems. The possibility of tuberculous meningitis is discussed and a colleague tells you that there is contradictory evidence about the efficacy of neonatal BCG vaccination against pulmonary tuberculosis. You question the efficacy of neonatal BCG vaccination against tuberculous meningitis.

John, a 4 year old boy, has been mechanically ventilated for three days during recovery from a blunt chest trauma. According to his level of ventilator support, he is considered to be ready to be extubated. The previous patient had to be reintubated as a result of postextubation laryngeal oedema. You wonder whether corticosteroids may reduce this risk of extubation failure.

An obese, 12 year old girl comes for review in clinic. A year ago when you first saw her you gave comprehensive advice regarding dietary modification, and exercise. She has continued to gain weight with a BMI greater than the 99th centile. You arrange for an oral glucose tolerance test to be performed which shows her to be hyperinsulinaemic with fasting insulin of 20 mIU/l, and 120 min insulin of 200 mIU/l. She has normal fasting and 120 min blood glucose measurements. You wonder whether prescribing metformin may help her to lose weight.