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Uptodate sample clinical cases.doc

Sample Clinical Cases
Version 11.3
Table of Contents
1. Primary Care, Internal Medicine and Family Practice Cases
Pages 4-5
• A patient who had been prescribed venlafaxine for depression reports wanting to take the whole bottle of pills to hurt himself. Is a venlafaxine overdose particularly risky? • A patient with fatigue and difficulty concentrating comes to you after being treated with repeated courses of intravenous antibiotics for “chronic Lyme disease,” requesting further therapy. Is there evidence for, or against such therapy? 2. Cardiology Cases
Pages 6-8
• You have a patient with congestive heart failure, what is the effectiveness of using BNP (brain natriuretic peptide) as a treatment? • What is the best method to treat a patient with atrial fibrillation: rate control or • At what time should clopidogrel be given to a patient undergoing coronary artery 3. Endocrinology Cases
Pages 9-11
• In the Women’s Health Initiative, what was the effect of combined estrogen- progestin therapy on the risk of dementia? • In the Diabetes Prevention Program, both diet and exercise with metformin therapy were effective for the prevention of type2 diabetes. What are the early follow-up data for those in the metformin group? • What is the effect of obesity on the risk of cancer-related death? 4. Gastroenterology Cases
Pages 12-14
• You are caring for a 45 year old man with refractory ascites who has been managed with repeated large volume paracentesis. How effective and safe is TIPS in this setting? • You are caring for a 33 year old woman with constipation-predominant irritable bowel syndrome and are considering using tegaserod. How effective and safe is it? • You are scheduled to do a colonoscopy on a patient who is on clopidogrel. How long should it be stopped prior to the procedure? Table of Contents

5. Hematology and Oncology Cases
Pages 15-16
• What is the role of taxanes in hormone resistant prostate cancer? • What is the appropriate treatment for your 70 year-old patient with stage IV diffuse
6. Infectious Diseases Cases
Pages 17-19
• What are the therapeutic options for a 41 year-old patient with shortgut syndrome on chronic TPN who develops chills on amphotericin B for the treatment of a Candida glabrata fungemia? • Is there a safe choice for the treatment of latent tuberculosis infection in a 40 year- old respiratory therapist with a newly positive PPD who wants the shortest possible course of treatment? • Your patient with a teenage daughter calls asking if her child can get the new HPV 7. Nephrology and Hypertension Cases
Pages 20-22
• Should anticytokine therapy be used in patients with cyclophosphamide-resistant • Is an elevated cardiac troponin T levels a prediction for poor outcome in a patient with renal dysfunction and acute coronary syndromes? • Your hypertensive patient has adult polycystic kidney disease, what is the optimal 8. Obstetrics, Gynecology and Women’s Health Cases
Pages 23-25
• A 52 year-old female patient had her last menstrual period two years prior to this office visit. She is significantly bothered by hot flashes and is unwilling to take estrogen replacement therapy because of a strong family history of breast cancer and wants to know what alternatives are available? • A 60 year-old woman with osteoporosis is taking alendronate. How should she be • What is the best drug treatment for hyperemesis gravidarum? 9. Pediatrics Cases
Pages 26-28
• You have a previously normal 18-month old child hospitalized with bronchiolitis. Should she be treated with corticosteroids? • The mother of a newborn infant has heard that the AAP encourages influenza vaccine for household contacts of children younger than two years of age. She has made arrangements for herself and her husband to receive the flu shot, but wonders whether there is another alternative for her healthy six-year old son. • You are seeing an eight-month old boy for the first time and are unable to palpate his left testicle. His parents are under the impression that it is only a matter of time before the testicle descends and that there are no downsides to this wait-and-see approach. Do you agree? 10. Pulmonary and Critical Care Medicine Cases
Pages 29-31
• Your adult patient develops a chronic cough and recurrent pneumonia after an episode of choking. What is the best way to diagnosis an aspirated foreign body? What are the therapeutic options? • What is the role of the endothelin-receptor antagonist bosentan (Tracleer) in the management of patients with primary pulmonary hypertension? • Which patients with carbon monoxide poisoning should be treated with hyperbaric 11. Rheumatology
Pages 32-34
• Does the use of a cholesterol lowering “statin” reduce the risk of postmenopausal • You have a patient with Sjogren’s syndrome who is complaining of frequent urination, is • You have a patient with Wegener’s granulomatosis who has gone into remission on Cytoxan. Are the any good alternatives to Cytoxan that are recommended for maintaining remission? Primary Care, Internal Medicine and Family Practice Clinical Case #1

Question:
A patient who had been prescribed venlafaxine for depression reports wanting to take the whole
bottle of pills to hurt himself. Is a venlafaxine overdose particularly risky?

Answer:
• Search on venla
• Select Venlafaxine

• Go to topic “Pharmacology of antidepressants”

• Point out the author/date

• Go to outline
• Under section OTHER ANTIDEPRESSANTS choose Venlafaxine –ANSWER
• The answer – one study suggested that venlafaxine overdose may be as or more
dangerous as overdose with some tricyclic antidepressants. A second study showed a high rate of seizures with overdose. We conclude that venlafaxine should be avoided in patients at high short-term risk for overdose.
• Scroll down to the 9th paragraph in this section and click on reference 12 to show Medline

• Go to outline

• Click on venlafaxine to show drug database

• Go to outline
• Select graphic Side effects of antidepressants
Primary Care, Internal Medicine and Family Practice Clinical Case #2

Question:

A patient with fatigue and difficulty concentrating comes to you after being treated with repeated
courses of intravenous antibiotics for “chronic Lyme disease,” requesting further therapy. Is
there evidence for, or against such therapy?

Answer:
• Search on “lyme”

• Choose Lyme disease

• Narrow search results by selecting the Treatment modifier

• Select topic “Late Lyme disease: Neurologic and cognitive manifestations”

• Point out the author/date

• Go to outline

• Under section MANAGEMENT, choose section Lack of effect of additional antibiotics –
The answer – two additional trials showed no benefit on neurologic symptoms
from repeated courses of antibiotics. We conclude that additional antibiotics are not
indicated.

• Click on reference 30 to show Medline abstract (2003)

• Click on ceftriaxone to show drug database

• Go to outline and show graphic: Antimicrobial therapy in Lyme
Cardiology Clinical Case #1

Question:
You have a patient with congestive heart failure, what is the effectiveness of using BNP (brain
natriuretic peptide) as a treatment?

Answer:
• Search on BNP
• Choose “BNP (Brain natriuretic peptide)”

• Select the first topic, Brain and atrial natriuretic peptides in left ventricular
dysfunction

• Point out author/date

• Go to the outline

• Click on heading NESIRITIDE IN DECOMPENSATED HF--ANSWER
In next paragraph (Effects in HF) BNP (nesiritide) is an effective treatment and
has a role as a therapeutic agent. Nesiritide, given by intravenous infusion,
produces significant reductions in pulmonary capillary wedge pressure (PCWP),
right atrial pressure, and systemic vascular resistance; and significant increases in
cardiac index and stroke volume index. These benefits are evident at one hour and
are sustained throughout the infusion period.

• Click on Reference 1 to show Medline abstract

• Click on the drug name Nesiritide to show drug information

• Go to outline

• Under GRAPHICS, select BNP and survival in CHF

Cardiology Clinical Case #2

Question:
What is the best method to treat a patient with atrial fibrillation: rate control or rhythm control?

Answer:
• Search on A F
• Choose the first option, AF (Atrial fibrillation)

• Narrow search by choosing modifier Treatment

• Choose the second option, Rhythm control versus rate control in atrial fibrillation:
clinical trials

• Point out author/date

• Go to the outline

• Click on CLINICAL TRIALS
This section discusses the four randomized trials comparing these two approaches to management.
• Scroll through trials to the topic of RECOMMENDATIONS (you may use the outline too)--
The data from these trials, particularly AFFIRM and RACE, confirm that
both rate and rhythm control are acceptable approaches, depending upon
the specific clinical circumstances.

• Click on reference 1 & 2 in the first paragraph under RECOMMENDATIONS to
show the Medline abstract

• To show the drug database, click on warfarin in the Anticoagulation paragraph
under RECOMMENDATIONS

• Go to the outline

• Under GRAPHICS, show Rhythm v rate control AF AFFIRM
Cardiology Clinical Case #3

Question:
At what time should clopidogrel be given to a patient undergoing coronary artery stenting?

Answer:
• Search on stent
• Choose the first option, Stent deployment, Coronary artery

• Choose the first option under Related Topics, Antithrombotic therapy following
intracoronary stent implantation

• Point out author/date --Donald Baim is an UTD cardiology co-editor-in-chief

• Go to the outline

• Under heading RECOMMENDATIONS, select Clopidogrel--ANSWER
The recommendations confirm that CREDO suggests giving clopidogrel at least 6 hours before stenting, if possible. It is then pointed out, however, that, if the patient must have coronary artery surgery within the next few days, clopidogrel will increase the bleeding risk.
• Select Reference 34 to show Medline abstract (2002)
• To show drug database, choose clopidogrel

• Go to outline

• Under GRAPHICS, select Clopidogrel outcome stenting
Endocrinology Clinical Case #1

Question:
In the Women’s Health Initiative, what was the effect of combined estrogen-progestin therapy on
the risk of dementia?

Answer:

• Search “hrt”
• Choose HRT (Estrogen replacement therapy)

• Select Estrogen and cognitive function

• Point out authors/date

• Go to the outline
• Under heading ESTROGEN AND DEMENTIA , click on Clinical trial data –ANSWER
It had been thought that estrogen would decrease the risk of dementia, but it
has been reported that combined estrogen-progestin therapy does not have
global cognitive benefits in older, non-demented postmenopausal women.
Additionally, after a mean follow-up of four years, HRT was associated with an
increased risk of dementia.

• Click on reference 33 in the second paragraph to show a Medline abstract

• Click on (show figure 3)

• Go to the outline

• Go to the GRAPHICS section

• Show figure ERT and treatment of Alzheimer (from a different study). Estrogen doesn’t
help symptoms in women who already have Alzheimer’s. Endocrinology Clinical Case #2

Question:
In the Diabetes Prevention Program, both diet and exercise with metformin therapy were
effective for the prevention of type2 diabetes. What are the early follow-up data for those in the
metformin group?
Answer:

• Search “type 2 dia”

• Choose Type 2 diabetes mellitus

• Click on Narrow search results, then click on the Prevention modifier

• Choose the topic Prediction and prevention of type 2 diabetes mellitus

• Point out the authors/date

• Go to the outline

• Under the heading PREVENTION, click on Metformin – A NSWER
Metformin appears to be effective in reducing the risk of type 2 diabetes in patients with IGT, although it is less effective than diet and exercise.
• Click on reference 10 to show a Medline abstract (2002)

• Click on metformin to show the drug database

• Go to the outline

• Go to the Graphics section – show the figures
Endocrinolo gy Clinical Case #3

Question:
What is the effect of obesity on the risk of cancer-related death?

Answer:

• Search Obe
• Choose Obesity

• Select the 1st topic Health hazards associated with obesity

• Point out the authors/date

• Go to the outline
• Under the heading MORBIDITY, click on Cancer – ANSWER
Certain forms of cancer occur with increased frequency in obese men and women Obesity also increases the likelihood of dying from cancer.
• Click on reference 60 to show a Medline abstract (2003)

• Go to the outline

• Go to the Graphics section – show the figures/picture
Gastroenterology Clinical Case #1

Question:
You are caring for a 45-year old man with refractory ascites who has been managed with
repeated large volume paracentesis. How effective and safe is TIPS in this setting?

Answer:

• Search on "Refrac as”
• Select Refractory ascites

• Choose the only topic: "Treatment of diuretic-resistant ascites in patients with
cirrhosis"

• Go to outline

• Under heading THERAPEUTIC OPTIONS, select Transjugular intrahepatic
portosystemic stent-shunt—ANSWER
§ This section highlights studies discussing TIPS and effective treatment option. In summary, TIPS has great promise in the treatment of diuretic-resistant ascites.
• Scroll though the following paragraphs for details on trials/studies.

• Show the SUMMARY section

• Select Reference 31 in SUMMARY paragraph to show Medline abstract

• To show drug database, within Transjugular intrahepatic portosystemic stent-shunt heading,
show "lacutlose" (paragraph 8)

• Go to outline

• Under GRAPHICS, click on table "Child's Pugh Classification"
Gastroenterology Clinical Case #2

Question:
You are caring for a 33 year old woman with constipation -predominant irritable bowel syndrome
and are considering using tegaserod. How effective and safe is it?

Answer:

• Search on “irt bo”
• Select "Irritable bowel syndrome"

• Narrow search by selecting the “Treatment” modifier

• Choose the 3rd title, “Tegaserod in the treatment of irritable bowel syndrome"

• Point out the author/date
• Go to outline

• Select CLINICAL TRIALS—ANSWER
§ Tegaserod reduces pain and discomfort in the abdominal area, and reduces
• Click on reference 6 to show Medline abstract

• To show drug database, click on tegaserod
Gastroenterology Clinical Case #3

Question:

You are scheduled to do a colonoscopy on a patient who is on clopidogrel. How long should it be
stopped prior to the procedure?

Answer:

• Search on colonos
• Select colonoscopy

• Narrow search by typing “clopid”

• Choose Clopidogrel

• Select remaining topic Gastroenterologic procedures in patients with disorders of
hemostasis

• Point out authors/date

• Go to outline

• Under heading ASPIRIN, NSAIDS AND OTHER ANTIPLATELET DRUGS, choose, Class
III agents—A NSWER
When patients are on both clopidogrel and aspirin as is currently recommended, clopidogrel should be discontinued, if possible, at least five days before the procedure. Discontinuation of clopidogrel for a shorter duration may increase the risk of bleeding, albeit by only a small amount.
• Show Reference 16 (not 15,16) to show Medline abstract

• Click on clopidogrel to show drug database
• Go to outline

• Under GRAPHICS, highlight one
Hematology and Oncology Clinical Case #1

Question:
What is the role of taxanes in hormone resistant prostate cancer?

Answer:

• Search HRPC
• Select HRPC (Hormone refractory prostate cancer)

• Choose Chemotherapy in hormone resistant prostate cancer

• Point out the authors/date

• Go to the outline
• Go to Recommendation—ANSWER
2nd paragraph= A combination regimen employing estramustine and a taxane, such as docetaxel, or single agent docetaxel, is a reasonable choice, either as second line therapy in men with symptomatic HRPC, or as first line treatment in men with asymptomatic disease who have a good performance status.
• For specific information related to taxane therapy with docetaxel, go to outline.
• Under heading SINGLE AND MULTIAGENT CHEMOTHERAPY REGIMENS IN HRPC, select Docetaxel (reviews the results of several trials that have examined docetaxel alone or with
vitamin D (Calcitriol).

• Click on docetaxel to see the drug database

• Click on Reference 46 to see a Medline abstract in 3rd paragraph

• If interested, show studies involved in topic EMP (estramustine) plus docetaxel
Hematology and Oncology Clinical Case #2

Question:
What is the appropriate treatment for your 70 year-old patient with stage IV diffuse large B-cell
non-Hodgkin's lymphoma?

Answer:

• Search on DLBCL
• Click on DLBCL (Diffuse large B cell lymphoma)

• Select Narrow search

• Choose the Treatment modifier

• Choose "Treatment of aggressive and highly aggressive non-Hodgkin's lymphoma"
• Point out authors/date

• Go to the outline

• Under heading THE AGGRESSIVE LYMPHOMAS, select Older patients—ANSWER
Scroll through to the 6th paragraph in this section.
We therefore recommend standard dose CHOP, if tolerated, with growth factor
support to maintain the relative dose intensities of doxorubicin and
cyclophosphamide, as preferred therapy for elderly patients. However, given the
relatively poor prognosis with this treatment, patients should be encouraged to enroll
in a clinical trial specifically designed for elderly patients whenever possible.

• Click on Reference 96 to show Medline abstract
• Select any of the drugs in the paragraph above to show the drug database
• Go to outline

• Highlight any of the graphics
Infectious Diseases Clinical Case #1

Question:
You want to start treatment for Lyme disease in a 20 year-old college student with skin lesions
suspicious for erythema migrans. Should you give a dose of parenteral ceftriaxone before starting
doxycycline and how long you should treat?

Answer:
• Search lyme
• Click on Lyme disease
• Choose the fourth title “Treatment of Lyme disease”

• Point out author/date

• Go to outline

• Under the heading CHOICE OF ANTIMICROBIAL THERAPY, select Early localized
disease—ANSWER
q Scroll down to the fourth paragraph that begins with “Several studies have now appeared addressing the optimal duration of therapy…” The answer is that you don’t need ceftriaxone and you can give doxycycline for a much shorter time than previously thought 10 to 14 days instead of 21 to 28 days.
• Click on Reference 8 to show Medline abstract

• Click on doxycycline to show the drug database
• Show the last sentence of the paragraph where the author makes his recommendation and says that he has changed his practice. [shows that we get the author to commit to a
course of action]

• Go to outline

• Show graphic/table
Infectious Diseases Clinical Case #2

Question:
Is there a safe choice for the treatment of latent tuberculosis infection in a 40 year-old
respiratory therapist with a newly positive PPD who wants the shortest possible course of
treatment?
Answer:
• Search ltbi
• Choose LTBI (Latent tuberculosis infection)
• Click on the second title “Treatment of latent tuberculosis infection in HIV-negative
patients”
• Point out author/date
• Scroll to the last sentence in the second paragraph to highlight the newly included “…recommended treatment regimens for LTBI were further revised in 2003.”
• Go to outline
• Under heading LTBI THERAPY REGIMENS, choose RZ no longer recommended —
• “…but liver toxicity observed most prominently in HIV-negative individuals led the ATS and the CDC to recommend against using this regimen in any patients except if an
experienced clinician deems that the benefits outweigh the risks and if other regimens
cannot be used.”
• Click on Reference #3 in the paragraph under the bullets for Medline abstract
• Scroll down, and click on rifampin to show drug database
• Go to outline
• Select Revised regimens to treat LTBI to show a graphic
Infectious Diseases Clinical Case #3

Question:
Your patient with a daughter in college calls asking if it is safe for her child to travel to Singapore
because of SARS. What do you tell her?
• Search sars
• Click on SARS (Severe acute respiratory syndrome)

• Choose the topic review Severe acute respiratory syndrome (SARS)

• Go to outline

• Point out author/date

• Under the heading EPIDEMIOLOGY click on Number of cases –ANSWER
• Second paragraph: “By July 7, no new cases…” The one case in Singapore is described but
• Click on Reference # 13 to show a reference to a Website. Mention that this directly links
in the online version of UpToDate
• Go to outline and choose TREATMENT

• Click on ribavirin to show drug database

• Also click on reference # 36 to show a Medline abstract.
• Click on graphic SARS CXR progression and also CDC SARS case definition
Nephrology and Hypertension Clinical Case #1

Question:
Should anticytokine therapy be used in patients with cyclophosphamide-resistant Wegener's
granulomatosis?

Answer:

• Search weg gran

• Choose on Wegeners granulomatosis

• Click on Narrow Search Results and modify the search results by clicking on Treatment

• Click on second topic review Alternative agents in the treatment of Wegener's
granulomatosis and microscopic polyangiitis
• Point out authors/date (Note: Highlight Bud Rose and well known nephrology author and one
• Under RESISTANT AND FREQUENTLY RELAPSING DISEASE, click on
Cyclophosphamide resistant disease—ANSWER
True cyclophosphamide resistance, which is defined as the presence of active disease affecting a major organ despite optimal doses of daily cyclophosphamide and corticosteroids, is rare in Wegener's granulomatosis and some experts feel that they have never seen such a patient.
• Under RESISTANT AND FREQUENTLY RELAPSING DISEASE, click on outline Cytokine

• Scroll through the two bullets for Etanercept and Infliximab. These two drugs are
standard therapies among patients with Wegener's granulomatosis.
• Click on Etanercept to show drug database

• Show reference #12 in first paragraph for Medline abstract

• Under RESISTANT AND FREQUENTLY RELAPSING DISEASE, choose
Recommendations
Nephrology and Hypertension Clinical Case #2

Question:
Is an elevated cardiac troponin T levels a prediction for poor outcome in a patient with renal
dysfunction and acute coronary syndromes?

Answer:

• Search card trop

• Click on Cardiac troponin T

• Narrow search results by typing renal fail

• Click on renal failure

• Click on topic review "Troponins; creatine kinase; and CK isoforms as biomarkers of
cardiac injury"

• Point out author/date

• Under TROPONINS, select Use in renal failure--ANSWER
• In the second paragraph, the results of study ref number 44 (GUSTO-IV trial) shows that,
despite false positive elevations of cTnT in patients with renal failure, increased cTnT levels are a good biomarker of cardiac injury across the spectrum of renal dysfunction.
• Show reference #44 for Medline abstract

• Scroll down to the 4th paragraph. There is a list of three different topic reviews
that address heart disease and/or the use of different cardiac enzymes in patients
with renal failure. Click on see, “Serum enzymes in patients undergoing dialysis”

• Scroll down to the paragraph starting with Creatine kinase

• To show drug database, click on Vitamin A.

• Hit the Back button in the tool bar

• Go to outline

• Show a graphic
Nephrology and Hypertension Clinical Case #3

Question:
Your hypertensive patient has adult polycystic kidney disease, what is the optimal blood pressure
goal for him?
Answer:

• Search poly kid

• Choose polycystic kidney disease

• Narrow search results by typing hypert

• Select hypertension

• Click on "Hypertension in polycystic kidney disease"
• Point out authors/date (Note: Bud Rose)
• Under TREATMENT, click on Blood pressure goal. The authors review the different
studies regarding optimal blood pressure among those with hypertension.
• Scroll down to Recommendations—ANSWER
A blood pressure goal of less than 120/80 mmHg is reasonable among ADPKD patients with hypertension
• Show reference #15 for Medline abstract

• To show drug database, click on enalapril
Obstetrics, Gynecology and Women’s Health Clinical Case #1

Question:

A 52 year-old female patient had her last menstrual period two years prior to this office visit. She
is significantly bothered by hot flashes and is unwilling to take estrogen replacement therapy
because of a strong family history of breast cancer and wants to know what alternatives are
available?
Answer:

§ Search on “hot flashes"
§ Select "hot flashes"
§ Narrow search by choosing the Treatment modifier
§ Click on “Treatment of menopausal symptoms in women not taking estrogen”
§ Point out author/date
§ In the introduction, select reference 1 to show a Medline abstract
§ Go to outline
§ Under heading VASOMOTOR INSTABILITY, click on Selective serotonin reuptake
inhibitors which give an overview of different SSRIs as an alternative therapy to estrogen—
ANSWER
The selective serotonin reuptake inhibitors (SSRIs) also relieve the symptoms of vasomotor instability. Scroll through the information regarding the 5 drugs therapies as well as alternative complementary medicine therapies.
§ Either scroll through paragraphs or go to outline
§ Review the RECOMMENDATIONS section, highlighting Vasomotor instability--ANSWER
In this section a recommendation for use of the SSRI class of drugs is given, with common examples of specific drugs, doses, and duration of therapy. We now use the SSRI class of drugs as the first choice.
§ Click on the drug name sertraline to show the drug database
• Go to outline and click on Alendronate prevents bone loss to show a graphic
Obstetrics, Gynecology and Women’s Health Clinical Case #2


Question:

A 60 year-old woman with osteoporosis is taking alendronate. How should she be monitored?
Answer:

• Search on “Alend”

• Select “Alendronate”

• Choose “Clinical use of the bisphosphonates in osteoporosis"

• Go to outline
• Under heading ALENDRONATE, click on Monitoring the response to therapy—
Because follow-up measurements of bone density at a single site may be misleading, we prefer to measure at both the spine and hip. We prefer an approach that combines measurement of biochemical markers of bone turnover with measurement of bone density. Both bone density and a marker of bone turnover are measured at baseline, followed by a repeat measurement of the marker in three months.
• To show drug database, click on alendronate.

• Select Reference 37 to Medline abstract

• Go to outline
• *If time allows, under RELATED TOPICS, select "Overview of the management of
osteoporosis in women" and show more detailed discussion under DRUG THERAPY—
“Monitoring the response to therapy”
Obstetrics, Gynecology and Women’s Health Clinical Case #3

Question:
What is the best drug treatment for hyperemesis gravidarum?

Answer:
• Search on hyper gravi

• Choose “Hyperemesis gravidarum”

• Choose the first most relevant topic, “Hyperemesis gravidarum”
• Point out the author/date (1st author is European, showing our International scope of
• Go to outline
• Under TREATMENT choose Summary Of Safety And Efficacy Studies--ANSWER
The bullets under this topic highlight the various drug treatments. • Click on Reference 49 to show Medline abstract

• Click on dicyclomine, to show the drug database.

• Under GRAPHICS, highlight the algorithm, showing treatment of nausea and vomiting in
pregnancy based upon results of a systematic review is now available Pediatrics Clinical Case #1

Question:
You have a previously normal 18-month old child hospitalized with bronchiolitis. Should she be
treated with corticosteroids?

Answer:
• Search bronchio

• Select Bronchiolitis

• Choose Bronchiolitis in children

• Point out author/date

• Go to outline
• Under TREATMENT, under Corticosteroids, click on Recommendations—ANSWER
§ We do not recommend the routine use of corticosteroids in healthy infants
hospitalized with a first episode of mild to moderate bronchiolitis.
• Click on Corticosteroids, prednisolone, and/or prednisone to demonstrate the pediatric

• Click on reference 10 under Helium oxygen therapy paragraho to show Medline abstract.
Pediatrics Clinical Case #2
Question:

The mother of a newborn infant has heard that the AAP encourages influenza vaccine for
household contacts of children younger than two years of age. She has made arrangements for
herself and her husband to receive the flu shot, but wonders whether there is another alternative
for her healthy six-year old son.

Answer:
• Search flu vac
• Choose Flu vaccine (Influenza vaccine)
• Select Meningococcal; influenza; smallpox; rotavirus; and combination vaccines in children.
• Point out author/date
• Go to outline

• Under INFLUENZA VACCINE, choose Preparations--ANSWER

• The underlined paragraph indicates that that the trivalent live-attenuated, cold-adapted
vaccine (T-CAIV) is administered intranasally and was licensed by the FDA in June 2003 for
use in healthy individuals older than five years of age.— Translation- It is safe for the 6
year old to take the flu vaccine and it may be taken within the nose.

• In the paragraph below the underlined paragraph, click on reference 12 to demonstrate

• Click on influenza vaccine to show drug database
• Go to outline

• Under INFLUENZA VACCINE, choose Dosing. Click on (show table 2) to show
influenza vaccine dosage by age. Point out the dosing schedule for T-CAIV below the link. Pediatrics Clinical Case #3

Question:
You are seeing an eight-month old boy for the first time and are unable to palpate his left
testicle. His parents are under the impression that it is only a matter of time before the testicle
descends and that there are no downsides to this wait-and-see approach. Do you agree?

Answer:

• Search cryptor

• Choose Cryptorchidism.

• Choose Undescended testes (cryptorchidism)
• Point out author/date
• Go to outline
• Under NATURAL HISTORY, the bullet points give information related to fertility in boys
• Scroll down to the last paragraph in that section—ANSWER
§ … because spontaneous descent rarely occurs after the child is
six months of age, the optimal time for surgical correction as
soon as possible after he is six months of age.
• Click on reference 31 to demonstrate Medline abstract.
• Go to outline
• Choose SUMMARY AND RECOMMENDATIONS . The second paragraph highlights
additional complications of undescended testicles and the benefits of orchiopexy. Pulmonary and Critical Care Clinical Case #1

Question:
Your adult patient develops a chronic cough and recurrent pneumonia after an episode of
choking. What is the best way to diagnosis an aspirated foreign body? What are the therapeutic
options?

Answer:
• Search on “FBA ”

• Click on Foreign body aspiration

• Select “Airway foreign bodies”

• Point out author/date (highlight European author for scope of authorship)
• Go to outline

• Under heading “PRESENTATION AND DIAGNOSIS,” select subsection on adults –ANSWER
• The diagnosis of FBA in adults is complicated and frequently overlooked. Thus, in adults, a FB may be noted unexpectedly during fiberoptic bronchoscopy performed for symptoms of endobronchial disease, such as chronic cough, hemoptysis, asthma not responding to therapy or recurrent / nonresolving pneumonia.
• Show Reference 2 for Medline abstract

• Scroll through the text to the second paragraph under Technical aspects, and click on
Midazolam to show the drug database.

• Go to outline
• Under GRAPHICS, select show figure FBA complicated by pneumonia
Pulmonary and Critical Care Clinical Case #2

Question:

What is the role of the endothelin-receptor antagonist bosentan (Tracleer) in the management of
patients with primary pulmonary hypertension?
Answer:
• Search “bose” or “tracl”
• Select “Prognosis and treatment of primary pulmonary hypertension”
• Point out author/date (Dr. Rubin is an international authority on pulmonary
• Go to outline
• Under the heading VASODILATORS, select “Endothelin receptor antagosist,
subsection on Bosentan—ANSWER
• Bosentan has been approved by the United States Food and Drug Administration for use in patients with pulmonary hypertension and has been found to be a beneficial treatment for both PPH and congestive heart failure. • Click on reference 53 to show Medline abstract (2002)
• To show drug database, click on Bosentan
• Go to outline
• Under GRAPHICS, highlight Treatment of PPH
Pulmonary and Critical Care Clinical Case #3
Question:

Which patients with carbon monoxide poisoning should be treated with hyperbaric oxygen, and
how strong is the evidence?
Answer:

• Search CO pois
• Select CO poisoning (Carbon monoxide poisoning)

• Select “Carbon monoxide poisoning”

• Go to outline
• Under the heading MANAGEMENT, choose “Hyperbaric oxygen”—ANSWER
In the 5th paragraph: (show figure 4)=chart/algorithm for using HBO. There is no solid answer in identifying patients who will benefit from HBO, but most authorities favor HBO in the presence of COHb >40 percent, loss of consciousness, or in pregnant women with COHb >20 percent or evidence of fetal distress.
• In couple paragraphs above, show Reference 24 to show Medline abstract

• Go to outline

• Under GRAPHICS, select one
Rheumatology Clinical Case #1

Question:
Does the use of a cholesterol lowering “statin” reduce the risk of postmenopausal osteoporotic
fractures?

Answer:

• Search statin
• Choose Statins (3rd option)
• Narrow search results by typing Osteop
• Click Osetoporosis
• Choose most relevant topic Overview of the management of osteoporosis in
• Point out authors/date
• Under heading, POTENTIAL NEW THERAPIES choose Statins--ANSWERS
The first paragraph provides the answer: there was no difference between statin and non-statin users. …the Women's Health Initiative Observational Study of over 93,000 postmenopausal women ages 50 to 79 years (7846 of whom were statin users) reported that clinical fracture rates and bone mineral density levels were not significantly different between statin users and nonusers after four years of follow-up. • Click on reference 46 of this section to show a Medline abstract (2003)
• Scroll up to the Recommendations section, and click on one of the drugs to show our drug

• Under the Graphics heading, choose Alendronate prevents bone loss
Rheumatology Clinical Case #2

Question:

You have a patient with Sjogren’s syndrome who is complaining of frequent urination, is there
any relationship between the two?

Answer:

• Search Sjo
• Choose Sjogren’s syndrome
• Narrow search with Urinary frequency (or you may just go to topic)
• Click on Clinical ma nifestation of Sjogren’s syndrome
• Point out the author/date
• Go to the outline
• Under the heading EXOCRINE GLAND INVOLVEMENT, click on Genitourinary
• Click on blue link to (see "Interstitial cystitis" below)

• Under heading Interstitial cystitis — ANSWER
• The presence of such urinary symptoms was twenty-fold higher in those with SS (4.0 versus 0.2 percent in controls). Translation: yes, there is a relationship between SS and urinary frequency. • Point out underlined/ updated content • In the Fatigue paragraph below, click on reference 40 to show a Medline abstract
• Go to the outline
• Go to the graphics section
• Under Pathology Click on figure Lip gland biopsy to show a graphic
Rheumatology Clinical Case #3

Question:
You have a patient with Wegener’s granulomatosis who has gone into remission on Cytoxan. Are
the any good alternatives to Cytoxan that are recommended for maintaining remission?

Answer:

• Search Weg
• Choose Wegener’s granulomatosis
• Narrow search results by clicking on Narrow search then select the Treatment
modifier.
• Choose Treatment of Wegener’s granulomatosis and microscopic polyangiitis
• Point out the authors/date
• Under the heading MAINTENANCE THERAPY, click on Recommendations --ANSWER
• Recommendations — Yes, there are other alternatives. Once complete
remission is achieved, cyclophosphamide is discontinued and either
methotrexate or azathioprine is initiated.
• Point out underlined/ updated content • Click on cyclophosphamide or any of the highlighted drugs to show the drug database
• Click on reference #4 to show current Medline abstract

Source: http://ntuml.mc.ntu.edu.tw/news/up/sample_clinical_cases.pdf