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University Library, University of Illinois at Urbana-Champaign

FOUNDATIONS: Molecules to Populations

Case 1

A 2-year-old is brought to your office by her mother who is concerned that she has been pulling at her left ear since late last night and has a fever of 101.3°F. She has had recurrent bouts of these symptoms, the last of which was 9 months ago. Each time, the symptoms resolved with one "shot." She is alert and interactive. She has some evidence of mucoid discharge from her nares bilaterally.

Suspected Otitis Media

Diagnosis Question
HINT: Don't believe a red eardrum. By itself, redness of the TM has a 15% positive predictive value for diagnosing AOM. Use pneumatic otoscopy, which is the standard of care for diagnosing AOM. Tympanometry is an alternative to pneumatic otoscopy. Of course, you still need to look in the ear.

Therapy Question
HINT: All children <6 months of age with otitis media should be treated with antibiotics. Patients from 6 months to 2 years should receive antibiotics if the diagnosis is suspected and the patient meets high-risk criteria (moderate-to-severe ear pain, fever >39°C, immunosuppressed). In patients 6 months to 2 years, observation is an option if they meet low-risk criteria (fever <39°C, mild otalgia, immunocompetent, unilateral AOM, and follow-up assured within 48–72 hours). Patients with proven AOM who are older than 2 years may be observed rather than treated with antibiotics as long as they meet low-risk criteria. Analgesics should be given to all patients. There's also the option of providing a "backup" antibiotic prescription (endorsed by the American Academy of Pediatrics) for the patient to start if the symptoms are persisting longer than 2 to 3 days.

Case 2

A 14-year-old female comes into the office with a chief complaint of headache. She says the headache began after her soccer game yesterday. She recalls striking her head against an opponent when trying to head the soccer ball. During the remainder of the game, she began to feel a headache, and the harder she ran, the more "woozy" she felt. She denied any loss of consciousness, vomiting, visual symptoms, or neck pain. Today, she also has poor concentration and feels excessive fatigue.

Suspected concussion

Diagnosis Question
HINT: Concussion is defined as a disturbance in brain function caused by trauma to the head. It does not require loss of consciousness or amnesia. Lightheadedness, disorientation, and nausea, etc. after head injury are all possible signs of concussion. Symptoms of postconcussion syndrome may include headaches, difficulty concentrating, "dizziness," lightheadedness, nausea, fatigue, irritability, anxiety and depression. Symptoms generally resolve but may be long lived, especially in those over age 50, who may never return to baseline.

Therapy Question
HINT: "Cognitive rest" after a concussion may need to include avoidance of reading, computer games, TV, Internet, smartphone use, homework, school attendance, and driving. Here's the simple idea: the brain is hurt, so don't overuse it too early. Prevention of concussions is best accomplished by education of athletes and coaches, and by early recognition of more minor symptoms. Mouth guards do not have any proven benefit in preventing concussion, and helmets do not lessen the incidence of concussions; they just prevent more severe traumatic brain injuries. (As one of our colleagues has noted, "All that padding just means that you can hit harder.")

Case 3

You are called to the emergency department (ED) to examine a 40-year-old man with fever (temperature of 39°C) and headache. His past history is remarkable only for a splenectomy secondary to trauma at age 10. He is not allergic to any antibiotics. Upon examination you note that he has meningeal signs. Nondilated fundal examination shows sharp disc margins, and he is neurologically intact with a nonfocal examination.

Suspected meningitis

Diagnosis Question
The combination of Kernig and Brudzinski signs carries a sensitivity and specificity of 5% and 95%, respectively. Thus, the great majority of patients do not manifest these signs when they have meningitis, and they are useless to rule out meningitis. The sensitivity and specificity of nuchal rigidity (stiff neck) is 30% and 68%, respectively. In adults, the classic triad of fever, nuchal rigidity, and altered mental status was found in only 46%, with 85% having fever, 70% having neck stiffness, and 67% having mental status changes.

Treatment Question
HINT: If the preponderance of initial clinical and laboratory data indicate that bacterial meningitis is likely and the LP cannot be done immediately, draw blood cultures and administer dexamethasone and appropriate antibiotics. You won't change the CSF culture results (in most cases) if you give a single dose of antibiotics before the LP. However, it is considered prudent to do the LP within 2 hours of administering IV antibiotics. The standard of care for suspected meningitis is to administer antibiotics within 30 minutes of the patient presenting to the ED.

ACTIVITY 1 - Develop a PICO

Individually you will:

  • Open the EBM 2021 Worksheet.
  • Select one case out of the three and develop a PICO question related to diagnosis or treatment.
  • Save your work as you go.


Activity 2 - Breakout Room Groups

In your groups you will:

  • Select a REPORTER  - REPORTER is responsible for recording responses in a Group worksheet
  • Record your Group name (Zoom room) on the Group worksheet (REPORTER)
  • Enter names and emails of group members in worksheet (REPORTER)
  • Share and discuss the PICO questions you each created
  • As a Group, select one of the cases for your Group and record the case number on the Group worksheet(REPORTER)
  • Create a Group PICO (feel free to use or tweak a PCIO that someone in the group created) (REPORTER)

Individually you will:

  • Search for "evidence" that addresses your Group PICO in a Clinical Tool of your choosing;
  • Fill in the worksheet table 1 to address details about what you found.
  • Search for "evidence" in PubMed; find 1 or 2 articles that best address your Group PICO
  • Fill in the worksheet table 2 with details about your search strategy and citations for articles that you found.

As a Group you will:

  • Share and discuss Secondary Literature that you found in Clinical Tools.
  • Select 1 resource that you all agree provides quality evidence for the Group PICO;;
  • Record the selection and rational in Table 3. (REPORTER)
  • Share and discuss the Article literature that you found in PubMed.
  • Select 1 article that you all agree provides quality evidence for the Group PICO.
  • Copy & paste citation into Table 4. (REPORTER)
  • Discuss the quality of the article and respond to prompts in Table 5. (REPORTER)

As a Group:

  • Work with the Reporter to complete the final document for submission, either during the session of after if you don't get through all the steps.
  • Reporter will email the completed Group worksheet to by 5:00 PM Thursday, July 14th.
  • Acknowledge the hard work of your Reporter.

PubMed Walkthrough