Using UNMC's Online Resources to Address Clinical Questions
by Cindy Schmidt, M.D., M.L.S.
Published December 2015, Revised July 2019
Warning:
If you are using Internet Explorer, please STOP now! Open another internet browser (we recommend Firefox), go to --
http://library1.unmc.edu/gots/tutorial/sb1n
-- and continue working on the tutorial in the new browser.
Instructions:
1. Use the Arrow icons below this instruction panel to go forwards and backwards in the tutorial.
Avoid working ahead of the instructions. Deal only with the information on one panel before clicking the "forward" arrow to move to the next.
2. You do NOT have to complete this tutorial miniseries in one sitting.
-- and selecting the needed 'chapter.'
3. If the page or chapter menu jitters, right-click on the instruction panel header and select the refresh/reload option. This will correct the problem.
We hope that this tutorial will help you learn to find needed resources, and the relevant information within those resources, quickly. Only read all of the information retrieved if you find it fascinating and have lots of free time!
The specific objectives of the tutorial series are listed below:
1. After being presented with a learning issue, students will identify an information resource likely to be useful from among 8 frequently used resources -- ProceduresConsult, Online journals/Ebooks finder, AccessMedicine, UpToDate, MedlinePlus, PubMed with GetIt!@UNMC buttons, Clinical Pharmacology, and LexiComp.
2. After identifying a resource appropriate for their learning issue, students will use the library’s website to navigate to the needed resource, conduct a search in the resource, and identify needed information.
3. Students will conduct keyword and MeSH-based searches of PubMed. The constructed searches will make appropriate use of operators (AND, OR, NOT), asterisks*, parentheses (), quotation marks "", and article type filters.
4. Students will be aware of the methods that can be used to contact librarians when they are faced with resource or access questions, need search training, or want a librarian to conduct a literature search for them.
The referral note tells you that Sarah Pilger, is a 16 year-old, obese female, who didn't realize she was pregnant until one week ago. The date of Sarah's last menstrual period (LMP) suggests that Sarah is in the middle of her second trimester.
Before Sarah learned that she was pregnant she had been on a low calorie diet. She hasn't gained any weight during the pregnancy. Dr. Pham Li, Sarah's family practitioner, wants you to recommend the best diet and ideal pregnancy weight gain for Sarah. Dr. Li asks that you continue seeing and counseling Sarah throughout her pregnancy.
height: 5’6”
weight: 210 lb.
last menstrual period: approximately March 30, 2019, suggesting a gestational age of 24.5 weeks, but menstrual periods have always been irregular.
Fundal height: 27 cm.
Ultrasound scheduled for September 16, 2019
Meds: prenatal vitamins prescribed September 13, 2019.
When you call Sarah out of the waiting room you see that, as expected, she is an obese, white teenager. She is accompanied by her mother, who introduces herself as Pat Pilger. Sarah and Pat look worried.
They tell you that they are having a hard time concentrating and are worried they will forget everything you tell them. They ask you to write down anything that they will need to remember. They tell you that Sarah had an ultrasound exam on Monday. It showed signs that Sarah's baby has an infection that could be very dangerous for the baby. Sarah has had a blood test, but the results aren't back yet.
The ultrasound also showed that the baby's legs are short compared to it's head. The doctor told them that this is a sign of borderline growth retardation and might be due to the infection. However, they are wondering whether Sarah's recent diet might have affected the baby.
You ask Sarah about her weight and diet history. She tells you that she was never thin, but she gained 50 pounds in 2018, the year of her parents' divorce. She stopped weighing herself in January 2019 (nine months ago), when she weighed 210 pounds. She continued to eat a lot of junk food after the January 'weigh-in' and may have gained more weight before she started dieting in late April.
In late April, her Mom was offered a new job in Omaha. Pat says that the job opportunity was excellent and also had two other advantages. 1) It brought Pat back to Omaha, where her mother, Sarah's grandmother, still lives, and 2) it removed Sarah from the influence of her boyfriend. Pat disliked the boyfriend and had discovered that Sarah and the boyfriend had been sexually active.
Sarah also began exercising and working hard in the community garden.
Sarah didn't weigh herself during the course of her low calorie diet. Her 210 pound weight in January had been depressing enough. She hadn't wanted to know how much weight she gained after January.
Sarah thought her legs and arms had slimmed down a bit during the diet, but her torso hadn't followed suite. The reason for the lack of torso slimming is obvious now, but she really hadn't considered the possibility she might be pregnant. Dieting had always made her menstrual cycles irregular.
1) fetal brain shows
a) mild ventriculomegaly
b) several, tiny areas in the brain parenchyma are consistent with intraparenchymal calcifications.
2) abdomen shows some ascites.
3) The thickness of fetal subcutaneous fat is reduced.
4) Placental thickness is increased.
5) Some of the fetal measurements are:
Biparietal diameter: 62 mm
Abdominal circumference: 175 mm
Femur length: 37 mm
What do you need to learn to be a clinical nutritionist who can provide excellent care to Sarah?
Perhaps some of the following are among the learning issues that occurred to you:
1. How were the fetal measurements obtained?
2. How severe is the 'borderline' growth retardation?
3. What gestational age is suggested by a fundal height of 27 cm?
4. What are the recommendations for pregnancy-related weight gain in obese pregnant women? Do these recommendations vary for pregnant adolescents?
5. Could Sarah's poor nutrition prior to her pregnancy and her severe diet (and probable weight loss) during the first trimester of her pregnancy have contributed to the growth retardation or other ultrasound findings?
6. What fetal infections can cause intracranial calcifications and ascites?
Before moving to episode 2 in this tutorial series, please complete the pre-test at http://unmc.libwizard.com/sarahsbabymne
When working on the pre-test questions, please, do not labor over the questions or consult any resource for help. Just give us your best response based on your current knowledge.
We expect most students to spend less than 7 minutes answering the pre-tutorial survey questions.
The data we obtain from the pre- and post-tutorial tests will allow us to better focus our educational efforts for your class and for future classes.
When you submit your answers to the pre-test you will be provided a link to episode 2 of the tutorial series. The format of tutorial 2 is a bit different, you will need to click a "Start Tutorial" button. Two windows will appear. Please, resize the narrow instruction panel/window so that it is as long as possible and can sit adjacent to the resource window.