You are a junior doctor in the neonatal intensive care unit. A preterm neonate has a loud murmur with bounding femoral pulse. Echocardiogram shows a haemodynamically significant patent ductus arteriosus. He is ventilated, but is otherwise well and has been tolerating full enteral feeds for a few days. A decision is made to commence intravenous Ibuprofen. You wonder whether oral Ibuprofen could be used and whether this would be as safe and efficacious as the intravenous route.
A multi disciplinary team working with diabetic and non diabetic patients who have had a lower limb amputation. A challenging area for the team is whether the diabetic patients can mobilise/weightbear after a partial foot resection. Situations have arisen in the past where consultant teams have had opposing views over the weightbearing status of the patient; non weight bearing or partial weight bearing with appropriate footwear.
Use of Magnetic Resonance Imaging for the diagnosis of acute appendicitis in children
A 7 year-old boy presents to the emergency department with acute onset abdominal pain. His symptoms are not entirely classical for acute appendicitis but you are concerned this could be the start of its presentation and refer him to your surgical colleagues. The surgical registrar on call asks you to arrange an abdominal ultrasound for him which is carried out whilst he is waiting for a hospital bed. Unfortunately the report is returned as “unable to visualise the appendix”. The surgical team say they will adopt a “wait and watch” approach but his parents are unhappy with this as their son is in pain and ask you if there are any other investigations that can be performed. You are reluctant to request an abdominal CT due to radiation exposure and wonder if there is any evidence for the use of MR scanning in diagnosing appendicitis in children as you have seen it used to diagnose appendicitis in pregnant women.
A 58 year old woman with a history of DVT attends A&E with pleuritic chest pain. She is haemodynamically stable with normal saturations, ECG and chest x-ray. D-dimer is positive. You would like to rule out a pulmonary embolism. You wonder whether it would be safe to discharge the patient home overnight before the CTPA, which is booked for tomorrow morning.
A 42-year-old man is brought to the ED with a single stab wound to the left lateral aspect of his chest and a systolic blood pressure of 85 mmHg. He is alert, well perfused and anxious but talking to you. Appropriate management is underway to stabilise his condition; should this include early restrictive intravenous fluid resuscitation prior to definitive surgical intervention?
A 29 year old male postman is referred from the acute knee clinic to physiotherapy 4 weeks following a clinically diagnosed ACL rupture. He feels his knee is regularly giving way and asks whether rehabilitation will ease and prevent his recurrent instability.
39 year old male presents to the medical facility at an international air show having spent the day on grass and concrete watching the air show. Clinically he presents with significant confusion, disorientation, tachycardia, tachypnoea, and absence of sweating. On initial assessment he is found to have a rectal temperature of 41.2 degrees and HR of 118. Following rapid assessment he is taken to the decontamination shelter where he is taken through the tent which is spraying cool water - he is passed along the tent twice and following this his rectal temperature is 39.3 degrees. He returns to the P1 (resuscitation) area and cooling and treatment continues with fine mist water spraying (plant sprayers), blow by air and IV fluids. After 1 hour of treatment his core body temperature has returned to normal and he is alert and orientated.
The subsegmental pulmonary embolus: Should all clots be treated equally?
A 36 year-old gentleman presented with pleuritic chest pain to the emergency department of St Vincent’s Hospital, Melbourne. He was low-risk for pulmonary embolism with a modified Well’s score of 0 but had a raised d-dimer of 0.7 mcg/ml. A CT pulmonary artery scan (CTPA) was performed, showing a subsegmental pulmonary embolus . He was subsequently admitted to hospital for anticoagulation and investigation of underlying risk factors. The prospect of systemic anticoagulation for three months was unappealing for him. He was otherwise clinically well and was a young person with an active lifestyle. This raised the question of whether the use of oral anticoagulation was justified in this gentleman, or whether the potential harm would outweigh the benefits.
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.
The use of bedside ultrasound in diagnosing retinal detachment in Emergency Department.
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.
Are patients who have used chewing gum at an increased risk of aspiration during sedation?
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?