Hi Dr. Stogen, I was wondering if I could present this new patient to you outside of the room. >> That would be great. >> Okay, this is a three month old infant male who presented to the emergency department with his mother for a history of three days of cough, nasal congestion, decreased oral intake, and difficulty breathing. On my initial assessment, he was febrile to 101.2 degrees Fahrenheit, was tachycardic, was tachypneic with a respiratory rate in the upper 30s. And his oxygen saturation was 92% on half of a liter by nasal cannula. On my physical exam, on pulmonary exam, he did have bilateral wheezing and I did note that he had some increased work of breathing with subcostal and intercostal retractions. I did not hear any rales, however. The ED gave him some IV fluids and started him on the nasal cannula oxygen, but did not get a chest X-ray. So my question for you is do you think that this patient merits a chest X-ray to evaluate for bacterial pneumonia. >> Well, it certainly sounds like bronchiolitis because it is that season, and obviously, we're seeing plenty bronchiolitis right now. But I think it's a really good question on whether or not we have to order a chest X-ray. And I think this is a great learning opportunity that we can go to the literature and try to see what the evidence shows. >> I agree. >> Have you ever been able to go to the literature and find out what the evidence shows by formulating a question ahead of time? >> Yes, I think so. >> Have you ever heard of the PICO format? Yeah, doesn't PICO stand for Patient Intervention Comparison and Outcome? >> Why yes, it does, so why don't we go through each one of those and try to define our question using our patient. So who is our patient? >> So an infant male, three-month old. >> Exactly. >> Previously healthy. >> And that's going to be important because a lot of the studies are going to take into account whether or not the person is healthy or has comorbidities. >> Okay. >> So what do you think our intervention is in this case? >> So we placed him on oxygen, but the intervention I was wondering about is the chest X-ray. >> Exactly, so we want to know whether or not a chest X-ray is going to be important to get. And for our comparison group, what would our comparison group be? >> I think infants with bronchiolitis who did not receive a chest X-ray. >> Exactly, who were just diagnosed with, let's say, just the history and just the physical like we typically do. >> Okay. >> Now what outcome would we be looking for in this case? >> I guess one outcome would be whether or not they received antibiotics for pneumonia? >> Absolutely, that would definitely be one of them. >> Or how long they were hospitalized? >> Exactly, so that would be an outcome on whether or not a chest X-ray made a difference. But what else would be an outcome for us in this particular circumstance? >> Which diagnosis you made from the chest X-ray. >> Right, whether or not the chest X-ray actually made a difference in the diagnoses. So if you put those together your patient, your intervention, your comparison, and your outcome, what is your question going to be? >> My question would be in a healthy infant male, does a chest X-ray change our diagnosis? >> Exactly, when compared to just a regular diagnosis with using a history and physical exam. >> Okay. >> So I know that we're really busy on rounds and we have to see the rest of the patients right now, but why don't you look that up and find an answer and let me know later on in the afternoon. >> Okay, great. >> All right, thanks. >> Thank you.
