A mother brings her 2 year old daughter to your clinic. She is concerned about her speech which she feels is poor for her age. Her daughter has failed two consecutive audiograms. On otoscopy she has signs of bilateral otitis media with effusion (OME) which you have confirmed on a previous occasion two months ago. Should you refer for insertion of grommets?
A 27 year old woman presents to the emergency department having taken a paracetamol overdose; she is not vomiting. You have been told that people with a significant overdose of paracetamol will vomit. You woner whether this is true?
A patient attends the Emergency Department with signs and symptoms consistent with a Deep Venous Thrombosis. Somebody suggests that there is a new bedside blood test, called SimpliRed, that may help to rule out the diagnosis in your patient. You know that ruling out a diagnosis is possible by having a test with a high sensitivity or negative predictive value. You wonder what evidence there is to suggest that SimpliRed fulfils these criteria?
A 76 year old male is brought in to A&E in a collapsed state. He has a history of ischaemic heart disease. He is agitated, tachypnoeic and sweating profusely. His neck veins are distended and there are widespread coarse crepitations in his chest. He has a diminshed oxygen saturation. You make a clinical diagnosis of acute cardiogenic pulmonary oedema. In addition to vasodilator treatment and opiates, you wonder whether you should administer non-invasive positive pressure ventilation (NIPPV).
Midazolam does not reduce emergence phenomena in children undergoing ketamine sedation.
A 4 year old boy presents to the emergency department with a 4cm laceration to the thigh. This requires cleaning and layered suture closure. You decide to sedate him using Ketamine IM. You are successful and close the wound. However, while he is recovering he appears to be experiencing unpleasant hallucinations. You wonder whether a small dose of midazolam given with the ketamine would have prevented this.
A 25 week gestation male infant, birth weight 520g, is transferred ex-utero to your Neonatal Unit for intensive care. On day 19 he remains ventilator dependent and is hypoxic on 60-95% oxygen. The Oxygenation Index (OI: a measure of respiratory failure) is 18. Chest X-ray shows clear lung fields. Echocardiogram by a senior Paediatric Cardiologist shows evidence of pulmonary hypertension. In view of these findings it is felt that a pulmonary vasodilator may help. You discuss entering the INNOVO Trial (a multicentre RCT of addition of inhaled nitric oxide (inNO) to babies with severe respiratory failure) with the parents, who agree and the baby is entered into the control (no addition of inNO) arm. In spite of this, parents ask for "everything" (including inNO) to be tried. Reluctantly you agree and inNO is administered as per the trial protocol (you inform the trial co-ordinators). The baby does not improve, and dies 24 hours later. Was it reasonable to administer inNO to this baby?
A 12 year old boy is admitted to the paediatric intensive care unit after a motor vehicle collision, where he sustained a severe closed head injury. He lost consciousness at the scene and was intubated in the Emergency Department for a Glasgow Coma Score of 8 and no gag reflex. The boy has no history of seizure activity in the past or at the scene. Your local "Traumatic Brain Injury Protocol" recommends that he receive phenytoin for seizure prophylaxis. You have recently cared for a child who nearly died from phenytoin hypersensitivity syndrome and would like to know if there is a good indication for the drug.
A 16-month-old boy with stage IV neuroblastoma and hypoalbuminaemia presented with a left sided haemorrhagic pleural effusion. He subsequently developed generalised oedema. You wonder if there was a role of albumin infusion in correcting hypoalbuminaemia and colloid osmotic pressure (COP), in order to treat the extravasation of fluid into tissue spaces.
Chiropractice may be an effective treatment in infantile colic
Mrs A. presents with her 6-week-old baby complaining of his excessive and uncontrollable crying behaviour, particularly in the evening and at night. The child is otherwise healthy, thriving and has a normal weight gain. Following questions regarding the pattern of crying, and associated signs, it is apparent that the child is exhibiting typical colic behaviour. There are clear signs that the continual and excessive crying behaviour is impairing the mother-child relationship, and you consider the child might be at increased risk of harm (or neglect). In discussing the treatment options, Mrs A. tells you that her chiropractor has offered to treat her baby for the excessive crying behaviour. She herself has been treated by this chiropractor in the past for back pain, and it is obvious she has considerable confidence in him. She asks your advice.
Does melatonin help children with learning disabilities sleep?
A girl aged 3 years and 6 months has neurofibromatosis with significant visual impairment and mild to moderate learning difficulties. She has always been difficult to settle to sleep and has frequent nocturnal wakenings. A sleep programme with specific behavioural management techniques has been used as have sedative medications such as Trimeprazine, which caused deterioration in concentration and daytime sleepiness. Should she be tried on Melatonin?
Is silver nitrate the best agent for management of umbilical granulomas?
A mother brings her two-week-old baby to your clinic. The child has a small umbilical granuloma but is otherwise well. Should you use silver nitrate to cauterize the granuloma?
Does dexamethasone improve blood pressure in hypotensive ill neonates?
A 25 week gestation baby, birth weight 695g is ventilated for respiratory distress syndrome. Invasive blood pressure monitoring at 2 hours of age showed a mean of 23-25 mmHg. The blood pressure did not improve over the next 24 hours, in spite of three intravenous boluses of 0.9% saline and concurrent infusions of dopamine and dobutamine at 15 ug/kg/min. A colleague suggests that dexamethasone might help to improve the baby's blood pressure.
Intravenous or intramuscular/subcutaneous naloxone in opiod overdose
A 30 year old male who is a known opioid addict is brought to the emergency department after an overdose of heroin, with a GCS of 3, a respiratory rate of 4 breaths per minute, and pinpoint pupils. You are aware that many addicts self-discharge on reversal of opioid intoxication (possibly due to precipitation of acute withdrawal symptoms), and that because naloxone has a shorter duration of action than most opioid agonists, there is a risk of harm to the patient if he becomes renarcotized away from the hospital. You wonder if use of the intramuscular or subcutaneous route reduces this risk by prolonging the duration of action of naloxone.
Does iron have a place in the management of breath holding spells?
A 2 year old child is seen in the out patients department with a history of breath holding spells for the last three months, occurring about 3-4 times per week. These are causing her mother a great deal of concern. You consider whether or not a course of iron would reduce the frequency of these attacks.
You are a junior doctor working in a neonatal intensive care unit. You are about to take blood from a baby born at 34 weeks gestation who is now 24 hours old and not being ventilated. The neonatal sister suggests you give the baby some oral sucrose before the procedure as analgesia. You have never used sucrose before and are uncertain whether there is any real evidence behind its efficacy.
An 18-year-old male presents after having been stabbed with a 9inch screwdriver 1cm below the left nipple. On arrival he is tachycardic at 125 bpm with a blood pressure of 110/75. This settles with two litres of normal saline to a pulse rate of 85 bpm and a blood pressure of 129/82. He is fully alert. His chest X-ray reveals the presence of a pneumopericardium. He has no other injuries.
You are called to see a young adult male who is accompanied by two members of Her Majesty's Customs and Excise. They tell you that he is under suspicion of trying to smuggle drugs into the country and that he may have done this by ingesting packets of cocaine. Physical examination is unremarkable, but abdominal radiography does reveal multiple, oval foreign bodies in the bowel. You know that such 'body packers' might well develop intestinal obstruction and/or get potentially fatal cocaine toxicity from leakage of the contents of these packages in their bowels. You wonder whether to simply leave the patient as he is and observe him for signs of obstruction and/or pending cocaine toxicity, intervene conservatively and do the latter as well, or whether to do something more aggressive to remove the packages from the patient's intestines.
A 25 year old man who has been involved in an RTA is brought into your department by the paramedics. He has signs of cord transection and is complaining of low back pain. You wonder if a logroll to examine his back is appropriate.
A 25 year old male attends A&E after a fight in which he sustained a laceration to the eyelid. There are no signs of intra-occular injury. You clean and suture the wound and wonder whether you should cover the wound with prophylactic antibiotics as you have recently seen a case of peri-orbital cellulitis associated with an eyelid wound.
A 20 year old man is brought into the emergency department having been hit by a high-speed vehicle while crossing the road. He has a large haematoma to the head and is confused and combative. Plain radiographs of his cervical spine are normal, as are radiographs of his chest and pelvis. You request a CT brain scan and a CT of his upper cervical spine, as you have heard that plain radiographs can miss injuries in this area. The radiologist does not agree that this is indicated as the plain radiographs of the cervical spine appear normal. You wonder if there is any evidence to support your request.