by Cynthia M. Schmidt, M.D., M.L.S.
Published December 2015
Updated July 2019
You should complete the first and second episode of this tutorial miniseries before beginning this third episode.
Warning:
If you are using Internet Explorer, please STOP now! Open another internet browser (we recommend Firefox) and go to --
http://list.unmc.edu/gots/tutorial/sb3u
-- and continue working on the tutorial in the new browser.
Remember:
It's September 16, 2019. You've begun conducting a prenatal ultrasound examination on Sarah Pilger, an obese, pregnant, 16-year-old. Sarah's LMP suggests a gestational age of 24.5 weeks. Sarah just learned she was pregnant last week. This is her first ultrasound exam.
Sarah's ultrasound examination findings are:
1) fetal brain with:
a) mild ventriculomegaly
b) several, tiny areas in the brain parenchyma that are consistent with intraparenchymal calcifications.
2) fetal abdomen enlarged by ascites.
3) subnormal thickness of fetal subcutaneous fat.
4) placental thickness slightly above normal.
5) fetal measurements including:
Biparietal diameter: 62 mm
Abdominal circumference: 175 mm
Femur length: 37 mm
Sarah's ultrasound findings may have raised additional learning issues. Perhaps these are among the learning issues that would occur to you:
#4. What conditions might result in fetal intracranial calcifications, mild ventriculomegaly, and fetal ascites?
#5. What might produce an increased placental thickness?
#6. Do the fetal measurements correspond to the 24.5 week gestational age suggested by Sarah's LMP?
What conditions can cause "intracranial calcifications, ventriculomegaly and ascites?
When you need to build a differential diagnosis list, you will want to use either (a) a resource that has been specifically designed to produce a differential diagnosis list or (b) a resource that allows a relatively robust search in which several different symptoms, signs, or concepts can be included in a single search.
Resources that can handle a multi-concept search include --
1) UpToDate
2) AccessMedicine
3) PubMed and other literature databases that index the journal literature.
When the previous tutorial episode ended, you were using the UpToDate article on the right-hand side of the screen (you may need to login with your UNMC Net ID to see the article). You might as well continue using UpToDate to search for conditions that can cause intracranial calcifications, ventriculomegaly and ascites.
Search UpToDate for either --
fetal "intracranial calcifications" ventriculomegaly ascites
The quotes around "intracranial calcifications" tell the search engine that you only want to find articles in which the words -- intracranial -- and -- calcifications -- are next to each other and in the order shown.
There are several articles in the list of results that may be of interest (the "Congenital Cytomegalovirus" and "Congenital Toxoplasmosis" articles, for instance). However, for now just click on the --
"Overview of TORCH infections"
-- article.
You'll find that TORCH includes toxoplasmosis ("T"), Other ("O"), rubella ("R"), cytomegalovirus ("C"), and Herpes ("H") .
Which of the TORCH infections can cause intracranial calcifications?
Hint:
Click inside the UpToDate article's text. Use Control f (Windows users) or Command f (Mac users) to create a "find on page" box. Look for instances of the word calcification. If your "find on page" box has a "highlight all" option, use it.
According to this UpToDate article, what congenital infections might cause the intracranial calcifications seen in Sarah's baby?
Before you check the differential diagnosis in a second resource, a word about UpToDate's mobile app. The UpToDate app is available for your iPhone, iPad, or Android device. It is free to you through the Nebraska Medicine license.
If you'd like to install the app:
If you are working on a small screen, you may have to click on the "Menu" icon to find the "Register" link
Every 1-3 months, you will receive an e-mail notice that your subscription is ending. When this happens. Go to the Library's homepage-->Clinical Resources -->UpTodate--> login with your UNMC Net ID if asked to do so. Click on the UpToDate "Login" link (if necessary) and sign in with your UpToDate username and password. This will renew your access.
You have used UptoDate to create a differential diagnosis list. As information resources are produced by imperfect humans, it's always best to check multiple resources when possible.
A second resource that can handle a multi-concept search is AccessMedicine. AccessMedicine's extensive e-book collection includes basic science, basic clinical medicine, and more advanced clinical medicine texts.
To reach AccessMedicine:
In the future, you can reach the library's homepage by going to any unmc.edu page and clicking the "Library" link at the bottom of the "Quick Links" list in the lower right-hand corner of the page.
The quotes around --"intracranial calcifications"-- tell the search engine that you want to find the two terms in a phrase ( immediately adjacent to each other and in the specified order).
When the search results appear, click on the link to the "Congenital Fetal Infections>Symptoms & Signs (Table 15-9)" chapter in CURRENT Diagnosis & Treatment: Obstetrics & Gynecology.
To scan the chapter quickly for relevant terms (calcification, ascites, etc.):
1) Click on the "Print" icon below the chapter title.
2) When the "Print" dialog box appears, click on the "Cancel" button. The whole chapter pop-up will still be present.
3) Enlarge the whole chapter pop-up as needed and click inside the pop-up.
4) use your browser's "find on page" feature (control-f on Windows computer, command-f on Macs) to find instances a term of interest, e.g. --
calcification
If the find-on-page feature includes a "Highlight all" option/button check to be sure it's been selected/activated.
Does the information you've obtained from AccessMedicine confirm the differential diagnosis list suggested by the UpToDate article?
The following questions cover the major points of this tutorial episode:
Which of the following is true of both UpToDate and AccessMedicine (a,b, or both (c))?
The tutorial interface for episode 4 is a bit different. After you click the "Start Tutorial" link, two windows will appear. Resize the two windows so that the instruction window is as long as possible and fits next to the resource window on the right.
http://list.unmc.edu/gots/tutorial/sb4u