Scenarios wanted! Please add your favorites! [Click on "Easy Edit", above]

Information about each scenario can include, but need not be limited to:

• the case
  
• the PICO'd question
  
• type of question/preferred study design
• suggested search strategies
• teaching tips

_______________________________________________
Case: The patient is a 73-year-old white woman who was admitted to the hospital with heart failure. She is a compliant patient and seldom misses her medications. On admission, her medications were furosemide 40 mg po qd, enalapril 20 mg po bid, simvastatin 10 mg po qd, and aspirin 325 mg po qd. She usually functions at a NYHA class II level, but she now has had two admissions for congestive heart failure in the past 4 months. On this admission, a myocardial infarction has already been ruled out and she remains in sinus rhythm. She has normal renal function with a serum creatinine of 0.7 mg/dL. The patient is particularly concerned about staying out of the hospital because she is very active in her community, lives alone, and has no one to care for her pets and plants. The resident asks the team if digoxin would help shorten her hospital stay or keep her from being readmitted. You are asked to do a PubMed search and bring the answer to morning rounds.
P female, 73, heart failure with history of MI
I digoxin
C
O reduce length of stay or likelihood of readmission
T therapy
T RCT

SEARCH Strategy: heart failure, congestive ANd digoxin AND hospitalization
clinical queries

TEACHING Tips: have go to MeSH to look at length of stay, move up to tree to Hospitalization which would include all terms we are interested in
_______________________________________________
Case: An 18 year old male with no significant past medical history is brought to the Emergency Department by Life Flight after a high-speed motorcycle accident. He was in excellent health before the accident. He is admitted to the SICU in a non-responsive state with multiple severe injuries, including multiple fractures and head trauma. After two days in the SICU, the patient is still in a coma from the traumatic brain injury.

The resident also notes that the patient has been started on dexamethasone, which is commonly used to control cerebral edema in cases of multiple head trauma, and asks you if there is good evidence that steroids will help his overall outcome and reduce the risk of death. As the two of you are walking out of the unit, you meet his parents, and they ask you what their son’s “chances of returning to his normal self” are after being in a coma for two days.

P brain injury, head trauma
I dexamethasone, steroids
C none
OImprove mortality, other outcomes
T Therapy
T RCT

SEARCH Strategy: (brain injury OR head trauma) AND (dexamethasone OR steroids OR corticosteroids)
Clinical queries: therapy/narrow

TEACHING Tips: talk about including both head injury terms as well as broadening the search out with steroids and corticosteroids

_______________________________________________
Case: Patient is a 73 year old female in good health with normal cholesterol levels and no chronic diseases. However she comes to the clinic because she is starting to notice that she is forgetting things more often and having problems balancing her checkbook and playing brain teaser games with her grandchildren. Her husband says he hasn’t notice anything different about her. But she’s fearful that she might be “getting Alzheimer’s Disease”. She said her neighbor told her that Lipitor is supposed to help with the symptoms or maybe even prevent Alzheimer’s disease. She wants your advice. Would this help? You recall a few patients complaining about memory problems while on statins but don’t know the data on reducing the risk of AD or associated cognitive symptoms. You tell her you’ll get back to her. You ask her about any other medications she might be on and she tells you that she is taking Sporanox for a toe nail infection.

P - elderly, female with memory loss and possible cognitive problems
I - Lipitor or statins
C- none
O - prevent Alzheimer's Disease or dementia; improve cognitive function
T- therapy/prevention
T-RCTor cohort study

TEACHING Tips: Use of MeSH to check drugs under statins- Pharmacological Action; use the Tree structure to use a broader term for Alzheimers (Dementia...Cogniive Disorders); use MeSH for cohort studies (everyone looks under limits!); use of textword "prevent" to get at the subheading.
_______________________________________________

Case: The patient is a 68-year-old AA male who has well-controlled hypertension, hyperlipidemia (on a statin) and GERD. He has a h/o MI 2 years ago with a reduced ejection fraction (EF) of 30% (i.e. left ventricular dysfunction). His functional status is NYHA Class III CHF. He is on aspirin, Atenolol, and an ACE-Inhibitor at the time of admission. He expresses concern that, given the state of his heart, he will not survive to see his grandson graduate from law school in 3 years. However, he also states that the quality of his life is important to him, specifically he does not wish to spend time in the hospital or live his life if he cannot be active and interact with his family. Your attending tells you that the implantation of a cardiac defibrillator can decrease all cause mortality in these kinds of patients. However the resident says that ICD have significant costs and risk associated with them. They both turn to you and ask you to gather the current evidence so they can help the patient make a good decision.

P - elderly male, history of myocardial infarction, reduced ejection fraction of 30%
I - ICD
C- none
O - quality of life, mortality
T- therapy
T-RCT

SEARCH Strategy: myocardial infarction AND (ejection fraction OR "Ventricular Dysfunction, Left"[MeSH]) AND implantable defibrillator
Then use Therapy-->Narrow Clinical Query

TEACHING Tips: reduced ejection fraction doesn't map, using MeSH Database search ejection fraction and choose ventricular dysfunction, left (this is the main issue). use clinical queries to find relevant studies

_______________________________________________

Case: In elderly patients with normal LDH and signs of cognition problems, does Lipitor or other statins reduce the risk of Alzheimers disease or dementia?

P cognition problems, normal cholesterol
I lipitor or other statins
C
O reduce alzheimers risk
T therapy, prognosis
T RCT or cohort

SEARCH Strategy: alzheimers disease AND Delirium, Dementia, Amnestic, Cognitive Disorders
to get at types of studies use therapy narrow clinical query or AND in cohort study to above strategy

TEACHING Tips: use MeSH Database to move up the tree to include more than just Alzheimer disease
_________________________________________________________________________________

AB is a 16 year old female who was diagnosed with a rare, highly aggressive cancer last year. She has been undergoing intensive chemotherapy for several months and seems to be in remission. But the treatment has left her overwhelmed and depressed. It will take the insurance company 6 weeks to approve visits to a psychiatrist. In the meantime she is feeling worse and falling into a deep funk. Her parents ask you for help and suggest that Prozac might help her. They tell you they have seen this advertised in magazines. You, however, are aware of the controversy with SSRIs and need to carefully review the evidence before responding to her parents.

Teaching Tip: good example of why it's important to check DETAILS; good example of how MeSH doesn't always map correctly (SSRI); good use of limits and clinical queries
____________________________________________________________________________________

You are a medical student rotating in the ED. This is the first day of the rotation. The first case is a 34 year old male complaining of lower abdominal pain, nausea and vomiting. The team suspects appendicitis and asks you as the new student which is the better diagnostic tool – a scan or an ultrasound? You are overcome with a feeling of uncertainty and a strong urge to review the literature and find some impressive evidence to bring back to your Chief.

Teaching Tip: good example of Boolean, mapping and clinical queries
____________________________________________________________________________________

You are evaluating a 27 yo female who has trouble with migraines. She has daily headaches and is known to overuse abortive medications. She currently uses ibuprofen and if that doesn't work she uses Imitrex. She has tried nortriptyline 25mg before bedtime for the past month without success for prevention. She has no other medical problems and is not taking other medications & is not pregnant. VS are normal.

Teaching Tip - good scenario for generating a variety of clinical questions