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A 22 year old male presents to you in Accident and Emergency complaining of sudden onset of shortness of breath and right sided pleuritic chest pain. He has clinical signs in keeping with a pneumothorax and is not currently tensioning. You request a plain PA erect chest radiograph which shows a small right tided pneumothorax. After aspirating 200ml of air, you repeat the chest radiograph which shows no improvement in the pneumothorax. Can you rely on the x-ray ?

A 60 year old male presents to the emergency department with substernal chest pain. He is a smoker, has hypertension and has never been diagnosed with coronary artery disease. EKG does not show an acute myocardial infarction and initial cardiac enzymes are negative. Aspirin and sublingual nitroglycerin have relieved his pain.

A patient presents with headache and transient visual loss. He is diagnosed with pseudotumor cerebri. Conservative therapy fails. Could sinus stenting be an alternative treatment?

A 65 year old man presents to the ED with a large, fresh upper GI bleed. He has a history of NSAID use and complains of increasing indigestion over the last few months. You think some of this may be due to the fact he drinks 35 units of alcohol a week. On examination, he has no stigmata of chronic liver disease and is unwell with a BP of 80 systolic and tachycardia of 140. In view of his history and lack of positive examination findings you feel that the most likely diagnosis is a bleeding peptic ulcer. You wonder if there is any evidence to support the use of iv terlipressin in non variceal upper GI bleeds.

A 21 year old man attends the emergency department complaining of cardiac sounding chest pain. He has no risk factors for ischaemic heart disease but admits to recent cocaine abuse. His ECG reveals appears ischaemic. You wonder if nitrates or benzodiazepines, in combination or alone, compare at resolving chest pain and clinical outcome.

A 2 year old is brought to the emergency department with a first presentation of fitting secondary to febrile illness. She has been fitting for >30 minutes. You obtain intravenous access and wonder if lorazepam or diazepam would be best at terminating the fit safely.

An eight year-old girl was seen in an epilepsy clinic with a diagnosis of left cerebral hemi-atrophy with right hemiparesis and complex partial seizures. Eight months previously, she was on 800mg sodium valproate and 12.5mg lamotrigine and still having 18 seizures a week. She then spent seven weeks as an inpatient under specialist observation. A ketogenic diet was recommended and commenced five months ago. Since then she has less seizures, but has a major episode requiring midazolam every two weeks. Her seizures now involve intermittent paraesthesia on the left side. Her medication has been decreased to 400mg sodium valproate and 5mg lamotrigine. The patient is struggling with the diet (particularly the Liquigen medium chain triglyceride) and urinary ketones have been ranging from trace to high. The current plan is to continue with the diet, increase the valproate to 500mg and gradually take her off the lamotrigine.

A seven year old child with a known history of asthma presents with a 24h history of exacerbation of wheeze. He has been using his salbutamol inhaler with little benefit. You prescribe a ß-agonist by nebuliser but wonder if it would have been cheaper and more effective to administer this drug via a spacer (holding chamber).

A seven year old boy with moderately well controlled asthma since his last admission 10 months ago presents to the Emergency Department with an acute exacerbation. You ask the nurse to administer salbutamol and ipratropium 5mg and 0.25mg as a nebuliser. She questions the value of adding an anti-cholinergic, despite your theoretical knowledge that the mechanism of action of both drugs should be additive you are left wondering about the clinical evidence to support this.

An 18 month old child attends the department with a limp. You question the mother of the child who explains that the child has fallen down three stairs at home. X-ray reveals a transverse tibial fracture. Further inquiry is unrewarding, and you wonder whether the prescence of the fracture alone is sufficient to support a diagnosis of non-accidental injury.

A 78 year old male is brought to the Emergency Department having had a syncopal episode at home witnessed by his wife. He collapsed to the floor whilst standing, losing consciousness for 30 seconds and fully recovering within 5 minutes. He did not report chest pain or breathlessness. His presenting ECG shows no evidence of ischemia and he has no abnormalities on physical examination. Should this gentleman have delayed cardiac markers measured in order to rule-out an acute myocardial infarction?

You are on your ward round and you see a fit 51 year old gentleman 3 days post right upper lobectomy. He has an air leak. He asks why he is not allowed to go to the toilet or go for a walk with the physiotherapist like everyone else on the ward. You tell him that the only way to resolve the air leak is to use suction. He mumbles that it is probably making it worse. You resolve to search the literature to see if he is right.

A call comes over your urban emergency department dispatch radio about a 25 year old man involved in a high speed motor vehicle crash, multiple injuries, depressed mental status, and your estimated time from the scene is 6 minutes. The paramedics want to use RSI to intubate, and you say bag-valve-mask, we will intubate in the ED. They arrive with the patient using BVM, angry with you. You want to show them why BVM is better.

A 475g baby girl born at 24 weeks and 2 days gestation by emergency cesarean section following maternal pre-eclampsia, develops hypotension in the first 48 hours of life. She is given inotropic support with dopamine, dobutamine and adrenaline.

A pleasant elderly gentleman presents to the emergency department following a recent return from the Indian subcontinent. He is nauseated, feels tired and is clearly jaundiced. His blood tests confirm a hepatitis, and further tests confirm that this is secondary to a viral hepatitis infection. There is NO evidence of paracetamol overdose. A few hours later, you are called to see him as he has become increasingly confused. He is encephalopathic, and repeat bloods show he is developing a coagulopathy. You diagnose acute liver failure, and institute supportive measures. Your colleague states that you should start him on N-acetylcysteine (Parvolex), but you tell him not to be silly, as there is no paracetamol involved. However, he insists that N-acetylcysteine will still be beneficial. You wonder if there is any evidence behind his words.

You are the RMO in A&E and are seeing a gentleman with suspected cardiac chest pain. He is still in significant pain despite taking his GTN spray and you decide to give him some morphine. Soon after, his blood pressure drop to 70/40, and you need to give naloxone to reverse the effect of the opiate. Fortunately, his blood pressure comes up again, but the episode has left you with concerns. You wonder if giving an opiate is the best thing to do for analgesia in these patients.

A 77-year old woman presents to the Accident and Emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a "3-in-1" block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound (US) has been used as an alternative to nerve stimulators (NS) in this setting.

A 38 year old man presents with one week history of jaundice. He admits to drink alcohol excessively of about 10 units per day for the last 10 years. Clinical examination reveals jaundice, spider naevi over chest and tender, palpable hepatomegaly with no clinical signs of ascites. Hepatitis screen and septic screen are negative . A diagnosis of alcoholic hepatitis is made. You wonder whether early commencement of steroids would improve his short term survival.

Is Gabapentin effective as an adjuant in reducing postoperative pain and opioid requirement?

A previously healthy sixty year-old lady presents with a thirty-minute history of left-sided chest discomfort, also felt in the left arm. Examination and initial ECG are normal. You refer her for troponin testing at 12 hours but recognise that this strategy has three major limitations: (1) The patient may be unnecessarily alarmed or receive inappropriate treatment for what turns out to be an erroneous diagnosis; (2) The patient's condition has not been diagnosed in the initial 12-hour period, when intensive guided therapy may have been most beneficial; (3) troponins merely mark myocardial necrosis and cannot inform you as to whether the patient has an unstable coronary atheromatous plaque. Having heard a rumour about brain natriuretic peptide (BNP) as an early cardiac marker, you wonder if it would help to avoid such disadvantages in this clinical situation.