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Problem-based Learning & Finding the Evidence: Case 3: Sandy Jones -- It’s too painful to write


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Case 3 : Sandy Jones -- It’s too painful to write

Resources for this case include:

Textbook Suggestions (look left)

Featured Resources:  ACP Journal Club  

National Organizations

PubMed Search Tips -- Quickly Getting to the Evidence on Treatment

Drug Information Resources

Lab Test Resources

DDX Resources

Point of Care Resources


Two key textbooks for the background on RA are Harrison's & Cecil Medicine.

A very nice section on RA and it signs, symptoms, & manifestations. 

Check out the section on RA for details on epidemiology, genetic factors, clinical course, & more.

Featured Resource

ACP Journal Club

Now that you have finished EBMI, you can see how this resource is unique and very valuable for drilling down to the Number Needed to Harm or Number Needed to Treat.  It does not cover all topics, yet, so you have to be selective about the topics you search there - primarily internal medicine topics, but if it has the answer you need, you're a head of the game.  Try it out.  (Remember, with synthesized resources, limit to to most important terms because their depth is not as great as PubMed's.)

Perhaps this week, one topic to try is  rheumatoid arthritis.  See what develops - perhaps an analysis of a very recent Cochrane systematic review on RA.  

Quick comment about the search - be sure to use the box for the Journal Club and not the top search box which searches the entire site.



Check out the various topics in the tiles.  You might find some helpful info on rituximab & methotrexate or TNF.

National Organizations

National & Government Organizations

Guidelines and concensus statements, while not always a systematic review, review the existing literature and are considered a high level of evidence. 

This week, the key organization to know is the American College of Rheumatology.  It provides resources for health professional education and research including publishing guidelines on treatment & diagnosis.

PubMed Search Tips: Quickly Getting to the Evidence on Treatment

Find the Evidence about Treatment #1

With your EBMI skills firmly intact, you have options for using that knowledge in your PubMed Searching.  What's the highest level of evidence for treatment studies?  Usually a randomized controlled trial (unless a systematic review or meta-analysis is available).

PubMed Tip #1:  Search for rheumatoid arthritis drug therapy (or use other terms more appropriate for your query) & apply filters to narrow down the 30K articles.

  • Randomized controlled trial
  • English
  • Age:  19 - 44

Find the Evidence about Treatment #2

PubMed Tip #2: Use Clinical Queries to find Systematic Reviews 

From the main PubMed page, look in the center column "PubMed Tools" for the Clinical Queries link.


Once there, enter the search terms you want - it is always best to be as specific as possible.

Find the Evidence about Treatment #3

Tip #3:  Cochrane Library: Database of Systematic Reviews - cut to the synthesis with this resource, whether it is an overview or systematic reviews about using corticosteroids or Tocilizumab or herbal therapy for arthritis.

  • Search using the disease and depending upon your questions, use terms like 
    • treatment, therapy, drugs, or specific names of the drugs.
    • There are lots of results for this type of search unless you specify a drug name.

Drug Resources

Drug Resources

Some of your questions for this case include better understanding of the medications used or potentially used.  This information could come from a variety of resources, from textbooks to Google searches.  However, the following two resources  have the seal of approval from the UCSD Healthcare System.  It is a good idea to get used to using one of them.

In either of these resources look up information by specific drug (e.g., salsalate or rantidine or adverse effects of steroids) or use the disease to find a list of drugs for that diagnosis (Micromedex).

Lab Tests Info

Looking up information about the results of lab tests are mostly background questions.  The following resources are easy to use tools to find very reliable information about the normal values, reference ranges, and more.

Clinical Reasoning Tool & Diagnostic Resources

Need to work on the DDX for the case?  

Symptoms and differential diagnostic information is often buried in a number of our resources.  However, a few tools (both online and for your smart phone/PDA) have special tools to help with this process.

Passing along a Tip from Dr. Gates regarding a DDX & Symptom Checker 

Dr. Gates has found a very helpful text within Access Medicine - Symptoms to Diagnosis: An Evidence Based Guide.  Presented through a series of cases of patients complaining of a specific issue, then walks you through buiding the DDX and prioritizing it, and making the diagnosis.  Unlike the interactive tools that give you list, this text helps explain the thinking process. Topics include a variety of non-specific complaints from low back pain to weight loss to GI bleeding, to abdominal pain.  Check out Chapter 1 as an overview of the diagnostic process.  

The books we have include one that helps explain the thinking process (Symptom to Diagnosis) with topics that include a variety of non-specific complaints from low back pain to weight loss to GI bleeding, to abdominal pain.  One book has a list of mnemonics (Collins' book) as well as the symptom info.  Another book (Syed & Rasul's book) is organized by body areas and the last one (DDX of Common Complaints) focuses on the most common symptions and presents the way a doctor might pursue to diagnosis (images & tests).

Also listed below are some of the interactive DDX tools and their advantages.

Online Look-up Tools

Old Friends - Point of Care Tools

The three point of care tools - DynaMed, eMedicine and Up to Date each have some unique things for this case.  If you haven't checked out DynaMed yet, this case might be a good time to do so.