Lab Details
Lab Details
Watch the following videos, then complete the required assignment. Review the document in Course Resources for instructions on accessing the videos.
Lab 1
OSCE Clinical Skills
Chest Pain
14:53
Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan?
Lab 2
OSCE Clinical Skills
Shortness of Breath
26:53
Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently in your plan?
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BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 1: Chest Pain
This video format is designed to help you prepare for objective structured clinical examinations, or
OSCEs.
You are going to observe and participate in a clinical encounter of a patient who comes to the office
with a complaint of chest pain.
As you observe the encounter, you will be asked to answer questions while the image on the screen
freezes. Such questions will allow you to practice history taking and physical examination skills as well as
your clinical reasoning skills in developing an assessment or differential diagnosis and a plan—that is, an
appropriate next diagnostic workup.
You will have time to record your findings and receive feedback.
Health History
Tell me your special concerns today.
I’m a little worried because I have been having sharp pains in my chest for the last two weeks.
What findings might be important to look for as you observe this patient?
Level of distress.
Labored breathing.
Skin color: central and peripheral cyanosis.
Respiratory rate.
Two weeks ago I was reading a story in the paper about a car crash, when I noticed sharp pains in my
left chest. I was sweating and short of breath for about 5 minutes. And my heart felt like it was racing.
What possible causes of chest pain are you considering?
Angina.
GERD.
Panic attack.
Musculoskeletal chest wall pain.
Can you tell me how severe the pain was, on a scale from 1 to 10, with 1 being very faint and 10 being
severe?
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I was 5 over 10.
Did it move into your neck or down your left arm?
No, no it was just in my chest.
How have you been since then?
I’ve had two other episodes, one of them was about 10 days ago when I was lifting some books, the
other was about 5 days ago when I was talking with my sister about our father’s death. He died 3
months ago in a car crash.
Did you have any other symptoms when you had these chest pains?
Yes, I had the same sweating and shortness of breath, with some light‐headedness during the most
recent one.
What was the level of pain?
The same, about 5 out of 10 for about 5 minutes. Then the pain just went away while I was sitting there.
I keep feeling so lost and panicked since my father died.
How are you feeling today?
Today I’m feeling fine, but I haven’t been sleeping well. It’s strange, I never felt anxious or depressed
before.
What cardiovascular risk factors do you need to consider in this patient? And which one has the highest
risk for coronary artery disease?
The risk factors are:
Family history of coronary artery disease.
Hyperlipidemia, hypertension, smoking, diabetes.
For women, preeclampsia and collagen vascular disease.
Family history conveys highest risk.
Do you have any problems with acid reflux? Or have you done any heavy lifting or strenuous exercise?
No, I’ve never had any stomach problems and I don’t really exercise much.
Do you have a history of high blood pressure? I noticed today your blood pressure was 140 over 95.
Yes, well I did have high blood pressure during my three pregnancies, I think it was about 145 over 90,
but the deliveries were fine.
What about smoking?
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When I was in my 20s I smoked about a pack a day for about 4 years.
Do you drink any alcohol?
I have 1…or 2 glasses of wine maybe 3 nights a week, more recently to help me relax.
Is there any heart disease in your family?
Yes, my brother had bypass surgery when he was 48, and my mom died of a heart attack when she was
62.
What about high cholesterol, or is there any diabetes in the family?
No, I’ve never had trouble with my cholesterol and we don’t have diabetes in my family.
You’ve given me a good picture of your symptoms, and I can see why you’re concerned. Is there
anything you think we may have missed?
No, but I can’t get away from these flashbacks about my father’s accident.
It’s common to visualize scenes like a crash with a loved one. Let’s do your physical examination, and
then we can talk more.
Physical Examination
I see your blood pressure is 150 over 95 and your heart rate is 95 today. These are both somewhat
elevated. I would like to begin by examining your lips and nails for color and then listen to your lungs.
Okay.
Examine lips and nails for cyanosis.
Okay, looks good.
Percuss then auscultate posterior lungs in ladder pattern.
Take a deep breath.
Listen to the lungs making sure to listen to the right middle lobe under axilla.
One more time.
[BREATHING IN AND OUT]
I’ll be examining the vessels in your neck, and then your heart. So please lie back with your feet straight
out.
Examine the neck first.
Assess the jugular venous pressure.
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Find the highest point of oscillation in the internal jugular vein…
…and measure the vertical distance from the sternal angle.
Palpate carotid upstroke.
The normal upstroke is brisk, smooth, and rapid, and follows S1 almost immediately.
Large bounding upstrokes indicate aortic insufficiency.
Listen for a bruit, which is a whooshing, murmur‐like sound often from atherosclerotic narrowing of the
carotid artery. A bruit sounds like this:
[BRUIT, WHOOSHING MURMUR]
Okay, I’m going to check the tapping impulse point of your heart.
Palpate the point of maximal impulse. You can do this and listen to the heart sounds by listening under
the gown without exposing the chest.
You may notice “tapping” which is timed at the beginning of systole. The point of maximal impulse may
be sustained or diffuse, meaning spread over more than one intercostal space.
Listen for S1 and S2 in each of the six listening areas: in the aortic area in the right second interspace
close to the sternum; in the pulmonic area in the left second interspace close to the sternum; in the left
third interspace; in the tricuspid area in the left fourth and left fifth interspaces; and in the mitral area at
the apex.
Use the diaphragm at the right upper sternal border and the lower left sternal border.
Use the bell at the apex.
Listen to and palpate the abdomen.
The following findings may be heard in the cardiac auscultation of this patient. Can you identify these
heart sounds?
[HEARTBEAT]
S4 is a low pitched diastolic sound reflecting changes in ventricular compliance, best heard with the bell
with the patient in a left lateral decubitus position. It may be present during ischemia or in the setting of
hypertension.
Identify these heart sounds.
[HEARTBEAT]
Mitral regurgitation is a holosystolic murmur reflecting mitral valve dilatation, best heard at the apex
that may radiate to the axilla and lower left sternal border. It may occur with transient ischemia.
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Assess congestive heart failure (CHF) in patients with extensive myocardial infarction that compromises
cardiac output due to decreased stroke volume or heart rate. Which findings on the cardiac exam have
the best evidence for congestive heart failure?
Rales, an elevated JVP, and an S3 consistently predict heart failure.
[HEARTBEAT]
S3 is a low‐pitched diastolic sound reflecting changed ventricular compliance, best heard with the bell
with the patient in a left lateral decubitus position.
Palpate the ankles for edema.
Diagnostic Considerations
List your diagnostic considerations in order of importance and explain your rationale.
Press pause and list your answers. Resume when you are ready to receive feedback.
Angina. This woman has stress‐induced non‐exertional chest pain. Recent evidence shows that women
present with more subtle symptoms of cardiovascular disease. She has cardiac risk factors of
hypertension, past smoking, preeclampsia, and family history.
Panic attack. She had stress related symptoms and flashbacks to the recent death of her father in a car
accident. She has suggestive anxiety, chest pain, and diaphoresis.
GERD. Her alcohol intake has recently increased. She has some reflux symptoms but her symptoms are
not triggered by meals and she does not report heartburn.
Musculoskeletal chest wall pain. There is no history of chest pain triggered by movement of the upper
torso or related exercise, and no notation of chest wall tenderness.
Dissecting aortic aneurysm. There is no asymmetry of blood pressures noted and no history of pain
shooting into the neck, up the side of the head, or into the back.
Diagnostic Workup
List 5 next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready to receive feedback.
EKG. About 80% of patients with an acute MI have an initial EKG that shows evidence of new infraction
or ischemia, if read correctly. However, among patients mistakenly discharged from the emergency
department, up to 50% have normal or non‐diagnostic EKG findings.
Stress echo. This is the test of choice for women with atypical chest pain. The echocardiography stress
test has a sensitivity of 90% and specificity of 79% for women, and 85% and 96% for men.
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Consider a trial of a proton pump inhibitor for 4‐6 weeks for possible GERD.
Chest x‐ray may be helpful to look for widened mediastinum, which can be evidence of aortic dissection.
Behavioral therapy—to learn management strategies for anxiety and panic disorder.
Summary
In sum, this is a 50‐year old school counselor with three episodes of left substernal chest pain over the
prior two weeks, rated 5 to 10 in intensity, with associated sweating and shortness of breath.
The first episode was precipitated by reading about a car crash, the cause of her father’s recent death.
The patient had hypertension during pregnancy and a brief smoking history in her 20s.
There is a strong family history of coronary artery disease. Her mother died of a myocardial infarction at
age 62 and her brother had a coronary bypass at age 48.
There is no history of diabetes. Her physical examination is unremarkable except for her blood pressure
of 150 over 95.
The differential diagnosis includes angina, especially suspect due to her symptoms, history of
hypertension during pregnancy, and family history. It also includes panic attack, GERD, musculoskeletal
chest pain, and dissecting aortic aneurysm.
The diagnostic workup includes an EKG, stress echo, trial of a PPI, chest x‐ray, and behavioral therapy.
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Bates’ Visual Guide to Physical Examination
— SHORTNESS OF BREATH —
OSCE 10
•
Script for Video Production
LWW_BATES_OSCE10_ShortnessOfBreath_CC2
•
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 • david@take-one.net • liz@take-one.net
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mailto:david@take-one.net
mailto:liz@take-one.net
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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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
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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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: 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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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
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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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: 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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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: 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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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
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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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: 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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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
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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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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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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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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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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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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>Lab rubric
and ) into yellow cells only in column F.
Average 2 4 0
Submission does not relate to the topic. %
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Instructor Guidelines: First enter scores (between
0
4
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Inappropriate
Below
Average
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Score
Weight
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1
3
The entry is on topic and includes content to support the unit Learning Objectives.
Submission does not relate to the topic.
Answers some question/topics with some content linked to only one unit Learning Objective.
Answers all questions with some content linked to at least two unit Learning Objectives.
Answers all questions with opinions/ideas creatively, clearly, and completely with obvious support of all unit Learning Objectives.
60%
0.0
The entry demonstrates critical thinking by supporting opinions with example and explanations.
Answers some question/topics with some clearly stated opinions. No example is provided.
Answers all questions with opinions and ideas that are stated clearly. At least one example is provided.
Answers all questions with opinions/ideas creatively, clearly, and completely. More than one example is provided.
20
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10%
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Poor spelling and grammar are apparent. Does not use APA style formatting when needed.
Uses Standard English with rare errors and misspellings. Minor errors in APA style formatting.
Consistently uses Standard English with rare misspellings. Appropriate mechanics and APA style formatting.
100%
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Low
High
3.5
4.0
18
90%
2.5
3.49
16
80%
89.99%
1.7
2.49
14
70%
79.99%
0.0
1.00
69.99%