Evidence based medicine scenario Example
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EVIDENCE B
ASED
MEDICIN
E SCENARIO
(67)
BY:
HA
TE
M M
OH
AM
MA
D H
US
SA
I N
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AGENDA
1- Scenario
2- Background
3- PICO and foreground question.
4- search terms and strategy.
5- visited sites.
6- answers
7- conclusion
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SCENARIOA 22-year-old male presents to the emergency
department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (38°C; 100.5°F), pain on palpation at right lower quadrant (McBurney's sign), and leukocytosis (12 x 10^9/L or 12,000/microlitre) with 85% neutrophils.
You suspect acute appendicitis and advice the patient to undergo appendectomy but he asks if there is more definitive diagnostic test to diagnose acute appendicitis?
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BACKGROUND
What is the diagnostic tests for acute appendicitis and which is suitable for this case?
What is the gold standard for acute appendicitis?
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BACKGROUND
- Combination between diagnostic tests and clinical findings is
required for accurate diagnosis of acute appendicitis.
- There is many diagnostic tests including laboratory and
imaging tests.
- 35% of wrong diagnosis for acute appendicitis result in
appendectomy for normal appendix is accepted percent !
- The world search for a definitive diagnostic test for acute
appendicitis and also the patient in my lucky scenario .
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BACKGROUND ANSWERS- Gold Standard is exploratory laparotomy
(Histological result from the surgery).- Imaging diagnostic tests is suitable to decrease –
VE appendectomy rates.- One Size doesn't fits all rule . - Our case is for adult non complicated patient
with high Alvarado score ensure high possibility to have acute appendicitis.
- According to our Scenario and background question answers, we choose CT scan test to compare with the gold standard.
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PICO
PICO: (Diagnosis)
P: 22 year old male with suspected Acute Appendicitis
I: CT scan on abdomen and pelvic
C: exploratory laparotomy (Histological result from the
surgery).
O: Diagnosis of Acute appendicitis
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FOREGROUND QUESTION
“In adult male with suspected acute appendicitis is CT scan on abdomen and pelvic, as compared with exploratory laparotomy (Histological result from the surgery), will diagnose Acute appendicitis? “
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SEARCH TERMS AND STRATEGY
Search terms used alone and/or in combination using
Boolean strategies:
Acute Appendicitis. right lower quadrant pain
Appendectomy McBurney's sign
Diagnostic test Abdominal pain
Computed tomography (CT).
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VISITED SITES
1. Cochrane
2. UpToDate
3. Best Practice
4. National Guide lines clearing house
5. Essential evidence plus
6. Dynamed
7. Trip database
8. Sum Search
9. Pubmed
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ANSWERS SUMMARY
- Appendicitis may be diagnosed clinically; however, imaging
increases sensitivity and specificity for diagnosis.
- In general, CT is the most accurate imaging study for evaluating
suspected appendicitis and alternative etiologies of right lower
quadrant abdominal pain.
- higher accuracy was reported when IV contrast is used in the CT
scan . However, if IV contrast is contraindicated, non-contrast
enhanced CT has been shown to have sensitivity of 96%,
specificity of 99%, and accuracy of 97%.
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CONCLUSION
- There is no unique test for diagnosis of acute appendicitis as we
should combine between clinical and laboratory findings with
imaging test to decrease negative appendectomy rates.
- CT scan has high sensitivity and specificity for evaluating suspected
acute appendicitis .
- CT scan should be used in patients presenting with unclear findings.
- If there is contraindication to contrast media enhanced CT is used.
- Ultrasonography is recommended if CT scan is unavailable or
contraindicated.
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THANK YOU FOR YOUR ATTENTION