Lab Details

Bates’ Visual Guide to Physical Examination

— SHORTNESS OF BREATH —

OSCE 10

• Script for Video Production

LWW_BATES_OSCE10_ShortnessOfBreath_CC2.doc

• DRAFT: CC2

January 23, 2015

revisions by DeBoy and

Lynn

For:

Wolters Kluwer

Note: All page references refer to Bates’ Guide to Physical Examination and History Taking 11th edition.

TAKE ONE DIGITAL MEDIA, 1415 Forest Drive, Annapolis, MD 21403-1424

Annapolis: 410/263-1800 • Other: 888/263/1800 Fax 800/552/2631 • [email protected] • [email protected]

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PRODUCTION TITLE: OSCE 10 Shortness of Breath CLIENT: Lippincott, Williams & Wilkins PRODUCER: Take One Digital Media DRAFT: CC2 FORMAT/LENGTH: Video / 10 minutes DATE: 1/23/15

VIDEO AUDIO

FADE IN (MUSIC)

1. TITLE SEQUENCE: Main title screen with: BATES’ Visual Guide to Physical Examination

Which transitions into the secondary screen

of the OSCE title.

Shortness of Breath

NARRATOR: (V.O.): This video format is

designed to help you prepare for objective

structured clinical examinations or OSCEs.

2. DISSOLVE TO:

WIDE SHOT – EXAMINATION ROOM

STUDENT and PATIENT (a 48-year old woman) Talk

NARRATOR: (V.O.): You are going to

observe and participate in a clinical

encounter of a 48-year-old woman who

comes to the office with a complaint of

shortness of breath. As you observe the

encounter, you will be asked to answer

questions while the image on the screen

freezes. These questions will allow you to

practice the skills of history taking and

physical examination as well as clinical

reasoning as you develop your assessment

or differential diagnosis, and a plan—that

is, an appropriate diagnostic workup.

You will have time to record your findings

and receive feedback.

3. GRAPHICS: INSERT FULL SCREEN CHAPTER HEADING: HEALTH HISTORY

STUDENT: So Mrs. Kelly, tell me your

special concerns today.

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PRODUCTION TITLE: OSCE 10 Shortness of Breath CLIENT: Lippincott, Williams & Wilkins PRODUCER: Take One Digital Media DRAFT: CC2 FORMAT/LENGTH: Video / 10 minutes DATE: 1/23/15

VIDEO AUDIO

DISSOLVE TO: TWO SHOT FREEZEPOINT: ACTION ON SCREEN FREEZES.

PATIENT: I just can’t seem to get my

breath. Of course, I’ve always been a little

short of breath when I exercise, but it’s

getting worse now. I can’t climb the steps

to my house without getting short of

breath. That’s why I’m coming to see you.

4. GRAPHIC: INSERT REASONING PANEL WITH TEXT:

QUESTION:

What clinical conditions are you considering

at this time?

NARRATOR: (V.O.): What clinical

conditions are you considering at this time?

5. CHANGE TEXT: ANSWER :

Asthma COPD Anxiety Coronary artery disease Pulmonary embolus

NARRATOR: (V.O.):

Asthma. COPD. Anxiety. Coronary artery

disease. And pulmonary embolus.

6. CUT BACK TO: WIDE SHOT OF STUDENT AND PATIENT

STUDENT: Have you been seriously sick

in any other way? Weight loss? Or fevers?

PATIENT: Well, I’m forty-eight now, and

my periods aren’t that regular. My friend at

the holistic clinic gave me some herbal

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PRODUCTION TITLE: OSCE 10 Shortness of Breath CLIENT: Lippincott, Williams & Wilkins PRODUCER: Take One Digital Media DRAFT: CC2 FORMAT/LENGTH: Video / 10 minutes DATE: 1/23/15

VIDEO AUDIO

medicine, but I don’t know what’s in it.

STUDENT: Nothing else? No other drugs?

PATIENT: Not really.

STUDENT: Tell me about some of the

things you like to do.

PATIENT: Oh my husband and I like to

hike in the mountains here in Colorado on

the weekends. I do my work as an office

manager during the week. Everything’s fine

at home. Our sons are both in college and

my husband and I are doing pretty well.

STUDENT: Have you ever had any

breathing problems before?

PATIENT: No. Well, I did have some

asthma as a child for a year or two.

STUDENT: Have you ever been a smoker?

PATIENT: No.

STUDENT: Have you ever been to doctors

about this shortness-of-breath problem?

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PRODUCTION TITLE: OSCE 10 Shortness of Breath CLIENT: Lippincott, Williams & Wilkins PRODUCER: Take One Digital Media DRAFT: CC2 FORMAT/LENGTH: Video / 10 minutes DATE: 1/23/15

VIDEO AUDIO

PATIENT: No, but I have wondered if it’s

from hormones.

STUDENT: Tell me more about what it’s

like.

PATIENT: Well, sometimes I just can’t get

my breath. It’s like…like I just can’t keep

doing what I’m doing, like I have to

concentrate on breathing, making sure I’m

doing it right, do you know?

7. TWO SHOT

STUDENT: What would happen if you

didn’t do that—concentrate on it?

PATIENT: Doctor! Please! I have to take a

deep breath right now. (takes a breath)

There!

STUDENT: Did you feel like you could

really take in all the air with lungs just

now? Like you got it all in?

PATIENT: No. I didn’t. That’s the worst

thing about it.

STUDENT: Am I making you nervous here

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VIDEO AUDIO

with what we’re doing right now?

PATIENT: Well, how would you like it if

you couldn’t get your breath? Wouldn’t you

concentrate on things? Make sure you were

getting enough air?

STUDENT: Well, I suppose I would.

PATIENT: Thank you.

STUDENT: Do you think that it could be

that you were always a little nervous?

PATIENT: Well, maybe a little.

STUDENT: Even as a child?

PATIENT: Yes, I guess so.

STUDENT: Were you afraid of things?

PATIENT: No. Except sleeping alone. That

I couldn’t do as a child.

STUDENT: Did you worry about things?

PATIENT: No more than anyone else.

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VIDEO AUDIO

STUDENT: How about now? What do you

worry about now?

PATIENT: Breathing is my biggest worry

now. That’s why I’m here.

8.

WIDE SHOT

STUDENT: Do you ever worry about the

health of your two sons?

PATIENT: Doctor! That gives me a strange

feeling when you ask about that! You don’t

think anything’s wrong with them, do you?

STUDENT: No, no. But when you do

worry, do you get sweaty? Does your heart

race?

PATIENT: Of course. Wouldn’t your heart

race if you were worried about your sons?

And yes, I do get sweating, too.

STUDENT: Did you say that your shortness

of breath has gotten worse lately?

PATIENT: Yes. That’s why I came.

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PRODUCTION TITLE: OSCE 10 Shortness of Breath CLIENT: Lippincott, Williams & Wilkins PRODUCER: Take One Digital Media DRAFT: CC2 FORMAT/LENGTH: Video / 10 minutes DATE: 1/23/15

VIDEO AUDIO

STUDENT: Tell me about that.

PATIENT: I don’t know why, but it’s

gotten worse about every day for the last

month. It’s worse today than it was

yesterday. (takes a deep breath)

9. INTERCUT CLOSE-UPS OF STUDENT AND PATIENT

STUDENT: Are you still doing your job?

Are you still hiking?

PATIENT: Yes.

STUDENT: I wonder why it’s getting

worse?

PATIENT: I don’t know. My husband says

I’m more irritable and I haven’t been

sleeping that well. You’ve got to find out.

You’ve got to do something.

Otherwise…otherwise.

STUDENT: Otherwise what?

PATIENT: If people can’t breathe…you

know what happens to them.

STUDENT: Are you feeling depressed?

PATIENT: Yes, yes I have to say. Yes. I’m

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VIDEO AUDIO

still doing everything I’m supposed to do,

but it’s getting harder and harder.

STUDENT: Are you thinking of killing

yourself?

PATIENT: Doctor! How can you say such a

thing? (cries a little)

STUDENT: Are…are you losing weight?

PATIENT: Yes, yes. I just don’t feel like

eating.

STUDENT: Are you having trouble

concentrating?

PATIENT: Yes. I can hardly do my work. I

don’t know if I can work for much longer.

STUDENT: There must be something that’s

making you sad.

PATIENT: There is, there is. It’s my

husband. He has to have an operation, and

I’m so afraid he’ll die.

STUDENT: Tell me more about that.

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VIDEO AUDIO

PATIENT: He’s older than I am. I always

dated older men, I can’t tell you why.

Anyway, he’s ten years older, and he was a

smoker, and now, he has to have the heart

operation.

10. INTERCUT MEDIUM SHOTS OF STUDENT AND PATIENT

STUDENT: It sounds like his operation is

really worrying you. I’m going to ask you a

few more health questions, and we can get

back to how you’re feeling now. So you

mentioned that your heart races. Have you

ever had any heart problems before?

PATIENT: No, just this racing, like

palpitations. But it’s just when I feel short

of breath.

STUDENT: Are you having skipped beats

or rapid beats?

PATIENT: No, my heart just goes fast. I

checked my pulse yesterday and it was

about 130 for a while.

STUDENT: Do you have chest pain?

PATIENT: No, no chest pain.

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VIDEO AUDIO

STUDENT: How about pain when you take

a deep breath?

PATIENT: No, I haven’t had that.

STUDENT: Have you had any recent

infections, such as a sinus infection or a

cough?

PATIENT: No, not really.

STUDENT: Uh, have you coughed up any

blood? Or had any swelling of your calves?

PATIENT: No, if I had, I would have been

here much sooner!

STUDENT: How about any recent car or

plane trips?

PATIENT: No, we like to stay right here in

the mountains.

11. WIDE SHOT OF STUDENT AND PATIENT

STUDENT: Have you ever had any

problems with your thyroid? Too much

thyroid hormones can cause palpitations,

sometimes with symptoms being like

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VIDEO AUDIO

sensitive to heat, changes in hair and skin,

weight loss, tremor, or even diarrhea.

PATIENT: No, I’ve never had thyroid

problems, and the heat has never bothered

me. My hair and skin are fine. But I have

lost about five pounds.

STUDENT: How is your appetite?

PATIENT: I’ve always had to eat three

meals a day or I feel really tired. Right now

I just don’t feel like eating that much

though.

STUDENT: Let’s talk about your

medications. You mentioned that you are

taking an herbal medicine. Are you taking

any other medicines, either over the counter

or prescribed?

PATIENT: No, just a multivitamin.

STUDENT: What about birth control?

PATIENT: I’ve never wanted to take the

pill. I have an IUD.

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VIDEO AUDIO

STUDENT: How about drugs like cocaine,

amphetamines, heroin?

PATIENT: Never. They can ruin your

family life and kill you.

STUDENT: How about your family

history? Any problems with heart or lung

disease?

PATIENT: No, my family is really, pretty

healthy.

12. TWO SHOT

STUDENT: Just to summarize, it sounds

like you’ve been a little nervous your entire

life, but you’ve handled it well, carried on

well. Seems like you’ve done well at work,

and it sounds like you have a good

marriage, and your sons are doing well.

Your husband may have always been the

source of your strength; someone you could

rely on; someone who could reassure you.

But now he has to have a heart operation,

and the roles are reversed a little, with you

reassuring him more; perhaps taking care of

him more in the future? And as that

happened, your nervousness and your

shortness of breath have gotten worse, and

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PRODUCTION TITLE: OSCE 10 Shortness of Breath CLIENT: Lippincott, Williams & Wilkins PRODUCER: Take One Digital Media DRAFT: CC2 FORMAT/LENGTH: Video / 10 minutes DATE: 1/23/15

VIDEO AUDIO

you’ve gotten depressed.

PATIENT: Yes, yes, yes. That’s just what’s

been happening.

STUDENT: Is there anything we missed?

PATIENT: No, I think you understand. But

what shall I do?

STUDENT: We’ll talk more in a few

minutes to see how we can help you. Let’s

turn to your physical exam.

13. GRAPHICS: INSERT FULL SCREEN CHAPTER HEADING: PHYSICAL EXAMINATION STUDENT USES HAND SANITIZER.

NARRATOR: (V.O.): With the patient’s

health history in mind, and after good hand

hygiene, you are ready for the physical

examination.

14. DISSOLVE TO: WIDE SHOT - EXAMINATION ROOM

PATIENT IS IN A GOWN, SITTING ON THE EXAM TABLE.

THE STUDENT FINISHES TAKING THE PATIENT’S TEMPERATURE.

FREEZEPOINT: ACTION ON SCREEN

FREEZES.

STUDENT: Your blood pressure is 135

over 80, which is good. Your heart rate is

88, just a little fast. Your respiratory rate is

normal at 20, and your temperature is

normal. Your palms are a little sweaty. Are

you okay?

PATIENT: Well, I’m wondering what you are going to find, but I’m okay.

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VIDEO AUDIO

15. GRAPHIC: INSERT REASONING PANEL

WITH TEXT:

QUESTION:

What regions of the physical

examination are important in this

patient?

NARRATOR: (V.O.):

What regions of the physical examination

are important in this patient?

16. CHANGE TEXT: ANSWER:

Vital signs Head and neck Heart and lungs Brief neurological examination

NARRATOR (V.O): Vital signs. Head and

neck. Heart and lungs. Brief neurological

examination.

17. DISSOLVE TO: TWO SHOT As STUDENT talks to the PATIENT who is sitting up on the table. LOWER THIRD GRAPHIC: INSERT TEXT:

Examine the eyes

Student has patient look at him/her, then has patient follow finger from eye level up about a foot, then down to neck level, looking for lid lag, or rim of white sclera above iris as finger moves down. This will not be present.

STUDENT: First, I want to check your

eyes.

STUDENT: I can see that there is no stare,

which we sometimes see with thyroid

problems. Can you look at my finger? Can

you follow my finger up…and down?

18. CUT TO: TWO SHOT

As STUDENT examines:

STUDENT: Everything checks out so far. Now I’m going to check your thyroid.

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VIDEO AUDIO

LOWER THIRD GRAPHIC: INSERT TEXT: Examine the thyroid gland Patient takes a sip of water and holds it in her mouth, camera focuses on anterior neck. Camera focuses on butterfly shaped thyroid moving up then down in neck as patient swallows.

STUDENT: Could you take a sip of water for me please, and swallow?

PATIENT: Okay.

19. DISSOLVE TO: TWO SHOT

Student examines posterior lungs in ladder pattern starting at bases, can just show lower lung fields. LOWER THIRD GRAPHIC: INSERT TEXT: Examine the lungs

NARRATOR: (V.O.): Examine the lungs.

PATIENT: (Takes a deep breath in) STUDENT: Out. PATIENT: (Takes a deep breath out)

20. DISSOLVE TO: TWO SHOT

With patient with head at 30 degrees and drape folded back in diagonal from right shoulder across to above left nipple, show student examining just upper right sternal border, upper left sternal border, and down to the 3rd left interspace. LOWER THIRD GRAPHIC: INSERT TEXT: Examine the heart

NARRATOR: (V.O.): Examine the heart.

21. DISSOLVE TO: TWO SHOT

With the head of bed a little to about 15 degrees and with correct draping, just show student listening to the RUQ then moving

NARRATOR: (V.O.): Examine the

abdomen.

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VIDEO AUDIO

across to the LUQ LOWER THIRD GRAPHIC: INSERT TEXT: Examine the abdomen

22. DISSOLVE TO: TWO SHOT

As STUDENT performs biceps jerk on both sides LOWER THIRD GRAPHIC: INSERT TEXT: Perform biceps jerk

NARRATOR: (V.O.): Perform biceps jerk

on both sides.

23.

DISSOLVE TO: TWO SHOT

As STUDENT performs knee jerks on both sides. These should be normal, not too reactive. LOWER THIRD GRAPHIC: INSERT TEXT: Test knee and ankle reflexes

NARRATOR: (V.O.): Test knee and ankle

reflexes.

24.

DISSOLVE TO: TWO SHOT

As STUDENT examines: LOWER THIRD GRAPHIC: INSERT TEXT: Check for tremors

NARRATOR: (V.O.): Check for tremors. STUDENT: Could you hold your arms out like this with your wrists up? STUDENT: Great, I don’t see any tremor.

25.

GRAPHICS: INSERT FULL SCREEN CHAPTER HEADING: DIAGNOSTIC CONSIDERATIONS

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VIDEO AUDIO

FULL SCREEN GRAPHIC: INSERT REASONING PANEL WITH TEXT:

QUESTION:

List your diagnostic considerations in order of importance and explain your rationale.

ADD TEXT:

Press pause and list your answers. Resume when you are ready to receive feedback.

(KEEP ON SCREEN FOR 3 seconds)

FREEZEPOINT ON THIS GRAPHIC.

NARRATOR: (V.O.): List your diagnostic considerations in order of importance and explain your rationale.

NARRATOR: (V.O.): Press pause and list your answers. Resume when you are ready to receive feedback.

26. CHANGE TEXT:

Consideration 1: Anxiety disorder

One of the most common disorders in primary care

Lifetime population prevalence is 5–10%

CHANGE TEXT:

Excessive anxiety and worry that is difficult to control and that causes clinically significant distress and impaired functioning for at least six months

Restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance

Over half of patients with generalized

anxiety have co-existing depression or

NARRATOR: (V.O.): Anxiety disorder.

Anxiety is one of the most common

disorders in primary care, with a lifetime

population prevalence of 5 percent to 10

percent.

This patient displays many of the features

of generalized anxiety disorder specified by

the 5th edition of the American Psychiatric

Association’s Diagnostic and Statistical

Manual of Mental Disorders, namely:

excessive anxiety and worry that is difficult

to control and that causes clinically

significant distress and impaired

functioning for at least six months.

Although her duration of symptoms is only

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PRODUCTION TITLE: OSCE 10 Shortness of Breath CLIENT: Lippincott, Williams & Wilkins PRODUCER: Take One Digital Media DRAFT: CC2 FORMAT/LENGTH: Video / 10 minutes DATE: 1/23/15

VIDEO AUDIO

other anxiety disorders such as phobias

or panic disorder

CHANGE TEXT:

Use brief, well-validated screening tools

for anxiety and depression such as the

GAD-2, GAD-7, and PHQ-2

Also screen for substance abuse

a month, she has at least three of the

following required symptoms:

restlessness, being easily fatigued, difficulty

concentrating, irritability, muscle tension,

and sleep disturbance. It is important to

pursue possible related depression,

especially in women, as present here, since

over half of patients with generalized

anxiety have co-existing depression or other

anxiety disorders such as phobias or panic

disorder. Brief well-validated screening

tools for anxiety and depression consisting

of 2 to 7 questions such as the GAD-2,

GAD-7, and PHQ-2, are useful adjuncts for

office practice. Screening for substance

abuse is also important due to its high

correlation with anxiety disorders.

27. CHANGE TEXT:

Consideration 2: Personality disorder

Patients are often problematic in office settings

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s

culture

Is pervasive and inflexible

Has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment

NARRATOR: (V.O.): Personality disorder.

Patients with personality disorders are often

problematic in office settings. These

disorders are characterized in the DSM IV-

TR by “an enduring pattern of inner

experience and behavior that deviates

markedly from the expectations of the

individual’s culture, is pervasive and

inflexible, has an onset in adolescence or

early adulthood, is stable over time, and

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Patients have dysfunctional interpersonal coping styles that disrupt and destabilize their relationships

Involve unusual cognition, affect, and impulse control

CHANGE TEXT:

Odd and eccentric (paranoid, schizoid, schizotypal)

Dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic)

Anxious or fearful (avoidant, dependent, obsessive-compulsive)

leads to distress or impairment.”

These patients have dysfunctional

interpersonal coping styles that disrupt and

destabilize their relationships, including

those with health care providers that involve

unusual cognition, affect, and impulse

control.

Personality disorders fall into three

categories: odd and eccentric (paranoid,

schizoid, and schizotypal); dramatic,

emotional, or erratic (antisocial, borderline,

histrionic, and narcissistic); and anxious or

fearful (avoidant, dependent, and obsessive-

compulsive).

Although this patient is anxious, this

disorder is unlikely since she has had stable

intimate relationships and a stable work

history.

28. CHANGE TEXT:

Consideration 3: Asthma or COPD

Asthma

Chronic inflammatory airway disease

Wheezing, chest tightness, and cough

that limit activity

NARRATOR: (V.O.): Asthma or COPD.

Asthma is a chronic inflammatory airway

disease that typically presents with

difficulty breathing but also wheezing, chest

tightness, and cough that limit activity.

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VIDEO AUDIO

Symptoms are intermittent, often

triggered by cold, exercise, or

environmental allergens

Diagnosis rests on confirmation of

reversible airway obstruction during

bronchodilator testing during spirometry

or methacholine challenge during

pulmonary function tests

CHANGE TEXT:

COPD

Airway obstruction is progressive and

irreversible

80% is related to tobacco smoke and

20% to other occupational exposures

Distant breath sounds, hyperresonance,

and delayed expiration markedly

increase the likelihood of diagnosis

Diagnosis rests on spirometry and further

pulmonary function testing

CUT TO SHOTS OF STUDENT AND

PATIENT TALKING

Symptoms are intermittent, often triggered

by cold, exercise, or environmental

allergens. On examination wheezing and

accessory muscle use may be present.

Diagnosis rests on confirmation of

reversible airway obstruction during

bronchodilator testing during spirometry or

methacholine challenge during pulmonary

function tests.

In COPD, airway obstruction is progressive

and irreversible. Roughly 80 percent is

related to tobacco smoke and 20 percent to

other occupational exposures.

On examination, distant breath sounds,

hyperresonance, and delayed expiration

markedly increase the likelihood of

diagnosis. Diagnosis rests on spirometry

and further pulmonary function testing.

Asthma or COPD are unlikely in this

patient as her symptoms were initiated by

news of her husband’s operation and not

clearly exertional, and because she has

associated sweating and loss of

concentration, no history of smoking, and a

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normal lung examination.

29. CHANGE TEXT: Consideration 4: Hyperthyroidism

Anxiety, palpitations and diaphoresis, weight loss

Lid lag

Heat intolerance, increased appetite, elevated systolic blood pressure with a widened pulse pressure

Tachycardia (heart rate > 90)

Stare (or eyelid retraction from proptosis), goiter, tremor

CHANGE TEXT:

Commonly caused by Graves’ disease

Other causes include toxic multinodular goiter and destructive subacute, postpartum, or silent thyroiditis

NARRATOR: (V.O.): Hyperthyroidism.

This patient presents with several features

of hyperthyroidism: anxiety, palpitations

and diaphoresis, and weight loss. Her

overall clinical picture, however, makes this

diagnosis unlikely. She lacks lid lag, present

in almost all cases, as well as the common

findings of heat intolerance, increased

appetite, elevated systolic blood pressure

with a widened pulse pressure, tachycardia

(heart rate > 90), stare (or eyelid retraction

from proptosis), goiter, and tremor, which

markedly raise the likelihood of diagnosis.

Nevertheless, because of her weight loss,

further testing is warranted. The most

common cause of hyperthyroidism is

Graves’ disease, an autoimmune process

involving TSH receptor antibodies that

stimulate secretion of T4 and T3. Other

causes include toxic multinodular goiter and

destructive subacute, postpartum, or silent

thyroiditis.

30. CHANGE TEXT: Consideration 5: Pulmonary embolus (PE)

New episodes of anxiety, shortness of

NARRATOR: (V.O.): Pulmonary embolus.

This patient has new episodes of anxiety

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breath, hormone preparation

Mortality as high as 60%

Onset ranges from subtle dyspnea to catastrophic syncope, hemoptysis, chest pain, and hypotension

Onset is acute

Pleuritic chest pain, calf or thigh

swelling and pain, tachypnea

Findings of right heart failure (jugular venous distention and an accentuated S2 pulmonic closure sound)

coupled with shortness of breath, and she is

taking an unknown plant hormone

preparation, raising the remote but

potentially fatal possibility of pulmonary

embolism. New or worsening dyspnea is

one of the hallmarks of PE, which carries a

mortality as high as 60 percent. Onset

ranges from subtle, with only mild dyspnea,

to catastrophic, with syncope, hemoptysis,

chest pain, and hypotension. Onset is acute,

within seconds, which is not evident here.

Over 40 percent of patients have pleuritic

chest pain, calf or thigh swelling and pain,

and especially tachypnea, also absent in this

patient. Large PEs can produce findings of

right heart failure like jugular venous

distention and an accentuated S2 pulmonic

closure sound. Clinical suspicion in this

patient is low, but it is important to consider

this diagnosis in patients with dyspnea.

31.

GRAPHICS: INSERT FULL SCREEN CHAPTER HEADING: DIAGNOSTIC WORKUP

CHANGE TEXT TO READ:

QUESTION:

List 5 next steps in your diagnostic workup.

ADD TEXT:

NARRATOR (V.O.): List 5 next steps in your diagnostic workup.

NARRATOR (V.O.): Press pause and list

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Press pause and list your answers.

Resume when you are ready to receive feedback.

(KEEP ON SCREEN FOR 3 seconds)

FREEZEPOINT ON THIS GRAPHIC.

your answers.

Resume when you are ready to receive feedback.

32. CHANGE TEXT: Diagnostic Workup 1: Cognitive behavioral therapy (CBT)

The best of the nonpharmacologic therapies for treating generalized anxiety Gives patients a set of coping skills to reduce triggers and symptoms of anxiety Strategies include education, relaxation exercises, coping skills training, cognitive restructuring, imagery exposure, and stress management Combining CBT with pharmacotherapy is superior to either treatment alone

NARRATOR (V.O.): Cognitive behavioral

therapy. Clinical trials show that cognitive

behavioral therapy (CBT) is the best of the

nonpharmacologic therapies for treating

generalized anxiety.

CBT gives patients a set of coping skills to

reduce triggers and symptoms of anxiety.

CBT strategies include education,

relaxation exercises, coping skills training,

cognitive restructuring, imagery exposure,

and stress management. Evidence shows

that combining CBT with pharmacotherapy

is superior to either treatment alone.

33. CHANGE TEXT: Diagnostic Workup 2: Trial of medication

Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are effective treatments for anxiety SSRIs: side effects are weight gain,

NARRATOR (V.O.): Trial of medication.

Both selective serotonin reuptake inhibitors

(SSRIs) and benzodiazepines are effective

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sexual dysfunction, insomnia, nausea, and diarrhea Benzodiazepines: significant risks of dependence and tolerance Tricyclic antidepressants are a third option, but have risks of cardiac arrhythmias

treatments for anxiety, but both have

disadvantageous side effects. For SSRIs

these include weight gain, sexual

dysfunction, insomnia, nausea, and

diarrhea. Benzodiazepines carry significant

risks of dependence and tolerance.

Tricyclic antidepressants are a third option,

but have risks of cardiac arrhythmias.

34. CHANGE TEXT: Diagnostic Workup 3: O2 saturation and

spirometry

Pulse oximetry helps identify hypoxemia when the oxygen saturation falls below 90% Oxygen saturation can be high even when the pO2 is considerably lower These tests are helpful in the initial assessment of asthma and COPD These tests have a limited role in the assessment of a pulmonary embolus (PE)

NARRATOR (V.O.): O2 saturation and

spirometry.

In an office setting, pulse oximetry, which

measures the oxygen saturation of

hemoglobin, helps identify hypoxemia

when the oxygen saturation falls below 90

percent, particularly in smokers and patients

with COPD or known lung disease.

However oxygen saturation can be high

even when the more important indicator of

oxygenation, the pO2, measured by arterial

blood gas, is considerably lower due to the

S-shape of the oxyhemoglobin dissociation

curve. Currently these tests, plus

spirometry, are helpful in the initial

assessment of asthma and COPD, but have

a limited role in the assessment of a PE.

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35. CHANGE TEXT: Diagnostic Workup 4: CBCd, complete

metabolic panel, TSH, D-dimer

CBCd considered since patient reports weight loss TSH is reasonable since it is the most sensitive measure of thyroid function In patients with suspicious clinical findings, free T4 and T3 should also be obtained For possible PE, current protocols recommend a sequential workup that begins with assessing clinical probability with a validated scoring system

CHANGE TEXT:

Contrast-enhanced helical CT scanning or ventilation-perfusion (V/Q) scanning is reserved for patients with abnormal D- dimer levels

NARRATOR (V.O.): CBCd, complete

metabolic panel, TSH, D-dimer.

Since this patient reports weight loss, obtain

a complete blood count with differential to

assess any anemia related to her

perimenopausal status and a complete

metabolic panel. Checking the TSH is also

reasonable since it is the most sensitive

measure of thyroid function and is almost

always suppressed in hyperthyroidism. In

patients with suspicious clinical findings,

free T4 and T3 should also be obtained. For

patients with possible PE who are

hemodynamically stable, current protocols

recommend a sequential workup that begins

with assessing clinical probability with a

scoring system like the Wells criteria and

D-dimer testing for fibrin fragments. In this

patient probability is low so D-dimer testing

is optional. Contrast-enhanced helical CT

scanning or ventilation-perfusion (V/Q)

scanning is reserved for patients with

abnormal D-dimer levels.

36. CHANGE TEXT: Diagnostic Workup 5: EKG and rhythm strip

Can be considered in patients reporting racing of the heart and palpitations

NARRATOR (V.O.): EKG and rhythm

strip.

An EKG and rhythm strip can be

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If symptoms persist or worsen, further cardiac workup should be pursued Women with coronary artery disease present with atypical symptoms

considered since the patient reports racing

of her heart and palpitations. If her

symptoms persist or worsen, further cardiac

workup should be pursued. She has no

cardiac risk factors and her history is

atypical for coronary artery disease, but

women with coronary artery disease present

with atypical symptoms.

37. CUT TO:

FULL SCREEN GRAPHIC:

SUMMARY

DISSOLVE TO:

MONTAGE OF SHOTS

NARRATOR (V.O.): This patient is a 48-

year-old married office manager with a one-

month history of intermittent difficulty

breathing in, accompanied by racing of her

heart and sweatiness, irritability, insomnia,

and a 5-pound weight loss. She has always

tended to worry. Her increased symptoms

have been triggered by learning that her

husband needs an operation. She is

physically active and has no symptoms of

infection and no history of smoking or

cardiac or pulmonary disease. On physical

examination she appears anxious with

sweaty palms. Her respiratory rate and heart

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FULL SCREEN GRAPHIC CHANGE TEXT IN OVERLAY: Diagnostic Considerations (Differential Diagnosis)

Anxiety disorder Personality disorder Asthma or COPD Hyperthyroidism Pulmonary embolus

CHANGE TEXT: Diagnostic Workup

Cognitive behavioral therapy Trial of medication O2 saturation and spirometry CBCd, complete metabolic panel, TSH, D-dimer EKG and rhythm strip

rate are normal. She has no stare or lid lag

and her thyroid, heart, lung, and lower

extremity examinations are normal. She has

no tremor.

Diagnostic Considerations include: Anxiety

disorder, personality disorder, asthma or

COPD, hyperthyroidism, and pulmonary

embolus.

The diagnostic workup includes: Cognitive

behavioral therapy, medication, O2

saturation, spirometry, CBCd, complete

metabolic panel, TSH, D-dimer if indicated

and EKG with rhythm strip.

38. GRAPHICS: FULL SCREEN:

References/Acknowledgments: Bickley L, Szilagyi P. Ch 5, Behavior and Mental Status; Ch. 7, Head and Neck; Ch 8, Thorax and Lungs; and Ch 9, Cardiovascular System. Bates’ Guide to Physical Examination and History Taking, 11th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2013. Agnelli G, Becatrini C. Acute pulmonary embolus. N Engl J Med 2010:363:266–274.

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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV- TR). Washington, DC: American Psychiatric Press, 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing, 2013. McDermott MT. In the clinic. Hyperthyroidism. Ann Intern Med 2012:157:ITC-1–ITC-16. Panetteri PA. In the clinic. Asthma. Ann Intern Med 2007;146:ITC6-1–ITC 6-16. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092–1097. Stein PD, Beemath A, Matta F et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med 2007;120:871.

U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;151:784–792.

39.

DISSOLVE TO: Closing credits.

40. FADE OUT

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