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A 60 year old female presents to the emergency department with severe sudden onset chest pain that radiates to her back. Her exam, 12-EKG and initial cardiac enzymes are normal. The patient has an elevated creatinine at 2.0. You are concerned about an aortic dissection and wonder which test would be the best to evaluate for this suspected diagnosis.

A middle aged lady is receiving physiotherapy for her OA knee. She mentions that her husband has heard that Glucosamine tablets are great for arthritis and is thinking of buying some from a health-food shop. She asks what you think about them. Before imparting wise words, you decide to check the evidence first.

A 21-year-old male presents to the emergency department after taking few Ecstasy tablets on a night out. He is agitated, sweaty with a body temperature of 42.5°C. Reduction of the hyperthermia is initiated by stripping the patient, applying cold packs, and later using cold IV fluids and Paracetamol. Would the use of Dantrolene be of any benefit in the management of this case.

You see an elderly lady who has sustained a fractured neck of femur and remains in discomfort following administration of opiates. You wish to perform a femoral nerve block. The department's ultrasound machine is currently in use and there is no nerve stimulator. You wonder how successful a nerve block guided by anatomical landmarks will be, or whether you should wait for the ultrasound machine to be free.

A very low birth weight baby is born at 27 weeks gestation.She is now fully stable and 10 days old requiring low flow oxygen via the nasal prongs, is on full enteral feeds. Her Hb is slightly low at 13, her biochemistry is otherwise normal. Her saturation alarm limits are kept at mid 80s to low 90s, which is the local policy. Is there good evidence that this reduces complications to her eyes and future development of chronic lung disease or may actually be harmful by inducing an element of chronic hypoxia?

An adult male is brought to the Emergency Department following a significant tricyclic antidepressant overdose. While in the Emergency Department he has several seizures. You wonder whether to load with intravenous phenytoin or simply manage prolonged seizures with benzodiazepines.

Fraser is an 8-year-old boy well known to everyone in A&E and the hospital. He has severe dystonic cerebral palsy as a result of his premature birth at 26 weeks' gestation. Although he was ventilated for 5 weeks he did not develop chronic lung disease. He is gastrostomy fed and had a Nissen's fundoplication 5 years ago. He has copious secretions and a poor cough reflex. These are made worse by nitrazepam which he requires for his dystonia. Evidence from previous barium studies and swallow assessments show that he chronically aspirates his secretions. He has no symptoms of upper airway obstruction. Over the last year, he has had increasingly frequent lower respiratory tract infections, requiring admission and intra-venous antibiotics. His weight and height have fallen from the 10th to the 3rd percentile. A chest x ray shows chronic changes suggestive of underlying bronchiectasis and he is now colonised with Pseudomonas aeruginosa. Immune function and a sweat test are normal. He has not had a recent pH study or barium swallow. He awaits a CT scan of his chest. He has daily physiotherapy and regular suction and usually produces copious muco-purulent secretions. He is on maximal anti-reflux medication already. Would prophylactic azithromycin reduce his risk of further lower respiratory tract infections? Or might it increase growth of multi-resistant organisms within his sputum?

A 15-year-old girl with acute renal failure was found to have class IV systemic lupus erythematosus (SLE) nephritis on renal biopsy. A decision was taken to start her on the routine National Institute of Health protocol of pulsed methyl-prednisolone and monthly intravenous cyclophosphamide (CYC) (0.5–1.0 g/m2 of body surface area). With her post-pubertal status and the possibility of CYC induced gonadal toxicity, the question was raised as to whether she should be put on gonadotropin releasing hormone analogue (GnRH-a) therapy for ovarian protection.

As part of a bench-marking exercise in your neonatal network, the length of stay (LoS) for babies born at 30+0 to 34+6 weeks' gestation was measured over a 12-month period (only babies who were inborn and admitted within the first 24 h and had their care on the same unit were included). Corrected gestational age at day of discharge was compared between the seven units. The bench-marking results show variation of LoS in these babies from 35.5 weeks to 36.7 weeks with a network average LoS of 36.2 weeks. Although this is less than the UK mean LoS of 36.3 weeks, it is higher than the California average of 35.9 weeks.1 You decide to review the LoS in your own unit for this same defined group for the years 1995, 1998, 2001 and 2004. The median LoS for these years is fairly constant at 36.4, 36.6, 36.8 and 36.1 weeks, respectively. You note that 60% of all neonatal admissions comprise babies in this group and that they account for 6000 cot days per year. You wonder whether you can implement any changes locally to reduce the LoS, safely, for these babies.

70 years old patient has been brought in to the resuscitation area with an exacerbation of COPD. Nebulizers and steroids have been given and had little effect. You wonder if you could use intravenous magnesium sulfate to improve his airflow.

A 52 year old patient 36-hours after mitral valve repair and grafts arrests with an asystolic ECG. He had been on increasing doses of adrenaline and a TOE had shown a poor LV but no tamponade. After 2-minutes of external cardiac massage and 1mg of adrenaline you elect to perform an emergency re-sternotomy with the intention of putting the patient back on bypass. Once commencing internal massage you are surprised at the significantly better arterial pressure that you are able to achieve performing internal massage.

A 3 year old boy presents to the Emergency Department not using his left arm after a fall. He has a bruise over his left clavicle and is clinically tender over this area. X-ray reveals a mid-clavicular fracture. From your experience in adult Emergency Departments you wish to put him in a collar and cuff, however this seems to distress him. You wonder if it is necessary to immobilise him at all.

A 60yr old lady presents to A and E complaining of wrist pain following a mechanical fall. X rays reveal a Colles fracture. You wonder if manipulation of the fracture will actually improve her functional outcome?

A 39 year old man referred to the PT clinic with a 3 weeks history of low back pain. There is no history of back pain or work-related back injury. At the L4-L5 level, there is herniated nucleus pulposus without nerve root compromise as shown in the MRI images. He has limitation of lumbar spinal mobility without red flags. He is normally fit and well. He is extremely afraid that any physical activity might damage his back. You wonder how to plan a rehabilitation program that will help to reduce his fear along with pain and risk of disability.