Download PICO

Write up cases
All students must complete one of the following cases and send to Dr. Colford and Dr.
Shaheen by the Friday after the dayback session.
To complete a case, you must consider the facts given. If you are seeking other clinical
information about the case, consider what clinical information might be helpful in your
discussion and then say how knowing that information might affect your clinical decision
making. It is expected that you use search strategies in pubmed and at least one other data
base (Up to Date, EMedicine, and Wikipedia are not library data bases) to find appropriate
original data. You should write an assessment and plan using a persuasive style to convince
the reader of your diagnostic or therapeutic strategy and include your references from at
least 2 of the sources used. You must include the planned discussion with the fictional
patient in your essay.
Overall Learning Objectives:
1. Improve understanding of pathophysiology of disease
2. Integrate basic science into the clinical years with microbiology, pathology, and/or
pharmacology
3. Integrate radiologic findings into history where appropriate
4. Create asynchronous learning opportunities with on-line learning tools
5. Learn clinical reasoning by creating clinical questions and using resources such as pubmed, google scholar, and Cochrane data base to find primary data that address the
clinical scenario
6. Learn how to use and fill out a PICO worksheet in the context of a clinical case-see
Page 2
7. If you would prefer, a student can use his/her own case from his/her own clinical
experiences. However, the case and clinical question must be approved by the course
director.
PICO Worksheet
Name:
Date:
__________________________________________________________________
Clinical Question:
Study category:
therapy
diagnosis
harm
PICO:
Patient, population, or problem being addressed
What are the characteristics of the patient or population?
What is the condition or disease?
Intervention being considered which could include:
exposure, diagnostic test, prognostic factor, therapy, patient perception
What do you want to do with this patient? Treat, diagnose, observe?
prognosis
Comparison intervention or exposure
Relevant most often when looking at therapy questions.
What is the alternative to the intervention? Placebo, different drug, surgery?
Outcomes of interest
What are the relevant clinical outcomes of interest to you and your patient?
Morbidity, death, complications?
Focused, Well-Built Question:
Thanks to Texas Tech for use of their PICO worksheet
Case 1
58 year old Caucasian female with asthma has been on and off prednisone over the last year and on a
moderate dose of an inhaled corticosteroid. She comes for an annual exam. Her mom had osteoporosis
and she asks you about her risk for it. She has never broken a bone.
Physical exam: Height unchanged from last year. BMI 24.
Meds- Fluticasone/salmeterol 250/50 1 puff bid
Singulair 10 mg daily
Fluticasone nasal spray daily
Omeprazole 20 mg daily
Prednisone currently tapering from 40 mg daily to off.
Labs: TSH, PTH, Calcium, phosphorus, alk phos, and Vitamin D are normal
What will you recommend to this patient and why? Discuss you search strategies and your clinical
question. Write about your discussion with the patient.
Case 2
66 year old female with history of hypertension and hypercholesterolemia presents with shortness of
breath and dizziness. She reports the gradual onset of these symptoms over the last 3-4 weeks. She
has no history of Coronary artery disease or diabetes and denies chest pain. She has noticed significant
palpitations. She denies other medical problems but does feel a little sweaty today. Denies diarrhea,
chest pain, pedal edema, rheumatic heart disease.
PMH: Hypertension on HCTZ 25mg po QD and lisinopril 40mg QD
Hypercholesterolemia for which she takes simvastatin 40mg daily
Allerg: none
SH: She is married, drinks 2 glasses of wine/night, no drugs, no tobacco. She exercises regularly on the
hills at Governor’s Club by walking.
FH: Dad had palpitations too. Mom is 90 and lives alone still. Sister has “thyroid problems’
ROS: NC
Physical exam;
BP: 105/75 HR nurse notes it is irregular and gets 110, Temp is 99, RR 20, pulse ox 99%, weight 190#
and 5ft 7” tall
HEENT: normal
Neck; Normal
Cor: Irregular irregular rhythm, tachycardic rate
Lungs: CTAB
Abd: soft non-tender, non distended
Rectal: Heme Negative
Ext: no edema, no clubbing
EKG shows:
http://www.ecglibrary.com/af_fast.html
PS please ignore the “76 yo man with breathlessness”
Chest xray looked something like this:
http://www.healthcare.uiowa.edu/InternalMedicine/////Education/Clerkship/Inpatient/documents/Rea
dingCXRs.pdf
Note: this xray is for a much thinner male patient than our plump hypertensive woman but gets at the
point (left atrial enlargement)
If you can’t see this and would like a on-line tutorial that is awesome on reading chest xrays I would go
to http://www.med-ed.virginia.edu/courses/rad/cxr/
Since the patient is hemodynamically stable, you elect to manage her as an outpatient.
Develop your clinical questions and search the literature. State what you will discuss and how with the
patient.
Case 3
46 year old African American female with history of sarcoid on daily prednisone presents with a 4 day
history of headache that she rates as 8/10.
Medications: Prednisone 20mg daily for the last three weeks but has been on chronic prednisone for
the last one year at doses from 5-40mg
Omeprazole 20mg daily
fluticasone 220mcg 2 puffs BID
PEX: VS; 155/80, 100, 20, Temp 100.5
No papillaedema. No meningeal signs.
Lungs: Bibasilar crackles, no wheezing
Abd: Soft NT ND, No spleen palpated but liver is 2 cm below costal margin and soft
Ext: Slight peripheral edema that patient feels is unchanged.
The characteristic pathologic finding of sarcoid is:
This is known as a non-caseating
granuloma
A chest x-ray of stage I disease can be shown showing hilar adenopathy. Note the loss of the
normal A-P window and the widening of the mediastinum at the area of the SVC entering into
the right atrium. This is characteristic of hilar adenopathy. (note: This patient has more than
stage 1 disease or she wouldn’t be on steroids)
http://images.google.com/imgres?imgurl=http://www.nlm.nih.gov/medlineplus/ency/images/e
ncy/fullsize/1613.jpg&imgrefurl=http://www.nlm.nih.gov/medlineplus/ency/imagepages/1613.
htm&usg=___VM4IBDAobCQcVjbWlLhEC8kAYc=&h=306&w=226&sz=8&hl=en&start=2&um=1&i
tbs=1&tbnid=pP4CIOwz_gu15M:&tbnh=117&tbnw=86&prev=/images%3Fq%3Dchest%2Bxray%
2Bsarcoid%26um%3D1%26hl%3Den%26rls%3Dcom.microsoft:en-us%26tbs%3Disch:1
Devise an appropriate clinical question and search for answers. Write about any discussions you
will have with your patient.
Case 4:
57 year old male smoker with stage 1 HTN presents with painless hematuria. He has no
history of flank pain and no dysuria. He has a history of DVT and takes Coumadin. His INR is 2.0.
Meds: 1) warfarin 5mg alternating with 7.5mg 2) HCTZ 25mg po QD
Labs: 1+ protein and 3+ blood on urine dip. Microscopy below
Creatinine is 1.1 and other labs are normal.
PEX: VSS afebrile; No abnormalities found on exam
Devise a clinical question and search for the answers. Write about any discussion that you will
have with the patient.
Case 5
68 year old white female presents with bilateral peripheral edema, mild shortness of breath worse with
exertion. She has also noticed that she feels better sleeping in her recliner because she was waking with
shortness of breath. She has longstanding hypertension that has not been ideally controlled.
Meds: Atenolol 50mg po QD
Asa 81m g QD
HCTZ 25mg po QD
omeprazole 20mg QD
VS: 155/85, 112, 98.6, pulse ox 90% on RA
Neck: JVP estimated at 10cm H20
COR: RRR normal S1 and S2 with an S3 heard at the apex. No S4 is heard. No murmurs
Lungs: Bibasilar crackles
Ext 2+ edema
An Echo shows an EF of 30%. Nuclear stress testing shows no reversible changes with stress.
Devise a clinical question and search for the answers.
Case 6
75 year old woman with poorly controlled diabetes and hypertension presents with fever, pleuritic
chest pain, and cough productive of yellowish-green sputum and occasionally blood tinged sputum. She
has some shortness of breath. She is a non-smoker but occasionally drinks alcohol.
Meds:
Metformin 500mg po BID
Glipizide ER 2.5mg QD
Lisinopril 20mg QD
HCTZ 25mg QD
Metoprolol XL 50mg QD
ASA 81mg QD
Simvistatin 20mg QD
PEX: VS 100/75, RR 28, pulse ox 91%, HR 111, T= 38.6
HEENT: rhinnorhea
NECK: Supple NT No JVD
Cor: RRR no murmurs or rubs, S4 is present
Lungs: Bibasilar crackles worse on the left and half way up with bronchial breath sounds and scattered
wheezes. There is egophany present on the left
Chest xray shows:
This x-ray shows that the heart border is well visualized on the left but that there is a clear left sided
infiltrate. Since the heart border is well defined, it is likely a left lower lobe pneumonia and this is
confirmed by the posterior location of the pneumonia on the lateral film and the loss of the second
diaphragmatic border on the lateral film.
Devise a clinical question and search for the answers
Case 7
Ms. Smith is a 59 year old Caucasian female who presents for alcohol abuse. Her husband brings her in
and reports that she is drinking heavily. The patients confirms this and is reticent to quit drinking but
acquiesces to an outpatient alcohol treatment program. She reports significant swelling in her
abdomen, shaking, leg swelling, and has noticed brown urine and yellow eyes.
Meds: None
Allerg: None
PMH: G3P3, One is physically disabled in a group home. The other 2 live locally and she reports
occasionally strained relationships.
SH: No tobacco, Drinks 1 bottle of vodka daily. No drugs. Married, was a homemaker.
FH: No alcohol or drug problems but she says that they don’t discuss health issues in her family. She
denies domestic violence in the family.
ROS: negative.
PE: Thin white female in NAD, weight is 104#, down 8 pounds from previous annual exam 1 year ago.
HR is 110 RR is 18 and she is afebrile. She seems irritable, impatient, and speech seems slightly
pressured.
HEENT: PERRLA, Conj pink, Slight jaundice to sclera, OP clear, no lesions
Neck: Supple, No LAN, No TM
Cor: RRR s1 s2 no murmurs
Lungs: CTA and Percussion
Abd: Mildly distended, NT, ND +BS, Liver is palpated 4 cm below costal margin. Probable ascites, and
prominent venous markings on her abdomen.
Ext: No CC, 1+edema both feet.
Neuro: Intention tremor. Is shaky with gait and it is slightly wide based. More difficulty with turning.
Finger to nose testing reveals dysmetria (passing object and then readjusting and coming back to object
when trying to touch it). No asterixis Motor is 5/5. Sensory is intact to light touch. Reflexes: patient is
diffusely hyperreflexic.
Labs: White cells 11.1 normal diff, HCT is 34 with MCV of 101, Platlets are 88.
GGTP is 388, Alkaline phosphatase is 250, AST is 440 and ALT is 250. Albumin is 2.2 and PT is 13.9 (up to
11.5 is normal) . Total Bili is 3.0.
Alcohol screen is positive with a level of 323mg/dL with common parlance 0.3.
Drug screen is negative.
You send her first for an ultrasound of her liver. It shows:
Portal hypertension and macronodular cirrhosis. There is also an enlarged spleen and moderate
amounts of ascites.
She then underwent a liver biopsy that shows significant fatty infiltrate and periportal fibrosis consistent
with cirrhosis
Images from www.md.huji.ac.il/mirror/webpath/LIVER.html
Devise a clinical question:
Case 8
55 year old male with complaints of severe knee pain and swelling that came on acutely
PMH: Hypertension, Pseudogout, asthma, recurrent tooth abscesses for which he is on penicillin
Meds: Enalapril, HCTZ, ASA, albuterol prn, and PCN VK and ibuprofen for a recent tooth abscess
Allerg: NKDA
SH: Occasional EtOh, no drugs, Married for 35years.
FH: Mother died of CAD, father of prostate cancer.
PEX: 140/80, 100, 37.1, 20 In significant pain
HEENT: normal
NECK: supple No LAN, No thyoidmegaly
COR: RRR s1s2 normal
Lungs: CTA
Knee: Swollen, warm, tender to touch, does not let MD flex/extend knee
To diagnose this you do a tap of the fluid in the knee which shows:
Develop a clinical question and research the answer.
Case 9-EXAMPLE-Thanks to Nate Montgomery
Mr. S is 59 year old Med/Surg nurse who comes to clinic asking if he should have a PPD placed for
routine TB screening. He grew up in Korea and did receive the BCG vaccine as a child. He thought he
should not have to have a PPD and could just have chest xrays if he started to cough. He has never been
treated with antibiotics for TB and cannot remember whether he has had a positive PPD in the past or
not. He has chronic medical problems of GERD, BPH and high cholesterol. He take omeprazole,
simvastatin and tamsulosin daily.
The patient has a PPD placed and returns in 48 hrs. You measure the distance between the dots and it is
15 mm.
Ask a specific clinical question and search for the answer and discuss below.
Case 9
Clinical question 1: “Amongst patients with a history of BCG vaccination, what are the senstivity and
specificity of PPD testing in evaluating TB infection?”
Pubmed search strategy:
MESH terms : “BCG vaccine”, “PPD/tuberculin test”, and “specificity”

Limits: humans, English.

Results: 29 articles, including two studies specifically addressed the clinical question.
o
Bugiani M et al. “Tuberculin reactivity in adult BCG-vaccinated subjects: a crosssectional study.” Int. J. Tuberc. Lung Dis. 2003; 7: 320-6.

A cross-sectional study performed in Italy, which compared PPD results in
4987subjects who had close contact with individuals with infectious TB 2-6
months prior to the study (TB exposure group), 4962 BCG-vaccinated subjects
without known TB exposure (BCG vaccine group), and 5000 subjects who were
not BCG-vaccinated and had no known TB exposure (control group). Whereas
the median diameter of induration was 13 mm in the TB exposure group, it was
only 4 mm in the BCG vaccine group and 0 mm in the control group. Using 12
mm of induration as a cutoff, this study found that the PPD tests had a sensitivity
of 74.6% and a specificity of 98.8%. These values would correspond to a
positive likelihood ratio of 62.2. Hence, this study supports interpreting the
patient’s 15mm of induration as a positive result.
o
Wang L et al. “A meta-analysis of the effect of Bacille Calmette Guerin vaccination on
tuberculin skin test measurements.” Thorax. 2002; 57: 804-9.

A meta-analysis of 26 articles evaluating the effect of BCG vaccination on PPD
results in patients without TB. This study found that subjects previously
vaccinated with BCG were initially more likely to have positive PPD results,
even when 15 mm of induration was set as the cut off for a positive result.
However, this increased reactivity was lost if more than 15 years had elapsed
since vaccination (37.6% of subjects vaccinated with BCG had 10 mm of
induration, compared to 47.8% of subjects not vaccinated).
Given that treatment of TB is dictated by public health algorithms, I next performed a search to review
these protocols.
Clinical question 2: “Amongst asymptomatic patients with a positive PPD, what are recommended
treatment guidelines?”

MESH terms: “Practice guidelines”, “PPD”, “asymptomatic”

Limits: humans, English

Results: 1 article- Sharmu et al. J. Fam. Pract. 2006; 55: 163-5.
Assessment and Plan
The patient is a 59 year old healthcare worker who received BCG vaccination as a child and is
now presenting to discuss PPD testing. His most recent PPD had 15 mm of induration.
BCG-induced enhancement of PPD skin testing is limited to the first 15 years after vaccination
(Thorax. 2002; 57: 804-9). Moreover, cross-sectional studies have demonstrated that patients with a
remote history of BCG vaccination have a median diameter of induration of just 4 mm. When a 12 mm
cutoff is used for positive results, the specificity of PPD testing is high, with only very rare false positive
from BCG vaccination (Int. J. Tuberc. Lung Dis. 2003; 7: 320-6.). Given that had 15 mm of induration
and given that he was vaccinated more than 50 years ago, the patient’s PPD result should be interpreted as
positive. It should be noted that as a healthcare worker, he is at increased risk of acquiring TB, meaning
that his pretest probably of infection was higher, as well.
Accordingly, the next step in the patient’s management is to enter the TB management algorithm
(J. Fam. Prac. 2006; 55: 163).. First, he will have a chest x-ray. If it is normal, the patient will INH for
9 months. If the chest x-ray shows evidence of an active TB infection, we will need to collect sputum
samples for culture. While those results were pending, he would need to take a four-drug combination
with isoniazid, ethambutol, rifampin, and pyrazinamide. On the other hand, if the chest x-ray shows
evidence of an old TB infection, the next step is sputum culture. If negative, the patient would likewise
be treated like patients with a normal chest x-ray, receiving one drug, INH, for 9 months. On the other
hand, if sputum culture is positive, the patient would be treated like patients with active TB, receiving
four drug therapy.
Conversation with patient
In speaking to the patient, I would validate the reasoning behind his skepticism and acknowledge
that a history of BCG vaccination can influence PPD test interpretation. However, I would explain that
this increased PPD reactivity decreases with time. After 15 years, patients who have received BCG
vaccination are no more likely than unvaccinated patients to have a false positive PPD result. As a result,
the size of the response he experienced would be atypical without a history of TB infection. I would also
emphasize that, as a healthcare worker, he is at increased risk of acquiring TB. As a result, the only safe
approach is to interpet his PPD should as positive. I would emphasize that this interpretation promotes
his own safety and the safety of his patients and contacts.
Next I would explain to the patient that public health agencies have determined a series of next
steps that should be taken with any patient who has a positive PPD. Since he has had a positive test, he
should start taking these steps, the first of which is a chest x-ray. I would explain that the results of chest
x-ray, may or may not require that he provide a sputum sample for culture. Either way, there are basically
two possible final outcomes. Either, he will take on pill, INH, for nine months, or he will take four drug
combination. I would emphasize that I will keep him updated as results become available, and should he
have any questions, I am available.
Works Cited
(1) Bugiani M et al. “Tuberculin reactivity in adult BCG-vaccinated subjects: a cross-sectional
study.” Int. J. Tuberc. Lung Dis. 2003; 7: 320-6.
(2) Wang L et al. “A meta-analysis of the effect of Bacille Calmette Guerin vaccination on
tuberculin skin test measurements.” Thorax. 2002; 57: 804-9.
(3) Sharma U et al. “What is the recommended approach to asymptomatic patients who develop a
reactive PPD?” The Journal of Family Practice. 2006; 55: 163.