Saturday, October 13, 2012

Stanford Medicine 25 - Stanford University School of Medicine

Welcome to the Stanford Medicine 25 website. Remember, this site is NOT the Stanford Medicine 25; it is only a map to a territory, one that must be explored in person! The Stanford Medicine 25 consists of hands-on sessions in small groups. You can't substitute for that, and we don't try to. However, this site provides a place to go to remind ourselves of what we have learned, or are about to learn in a hands-on session.

Why the Stanford Medicine 25?

• We recognized that after a med school physical diagnosis course, there is little emphasis on these skills in the 3rd and 4th years of medical school or in an internal medicine residency.
• In the absence of a high-stakes clinical bedside final exam (as opposed to a high-stakes multiple choice exam), there is little impetus for people to learn and master bedside skills—truth is, you can be board certified in internal medicine and no one hasreally ascertained that your technique in doing an ankle reflex allows you to accurately say a reflex is truly absent. (You will be surprised how most 'absent' reflexes become 'present' when you learn good technique.) Does it matter? It does to us.
• In observing students and residents perform physical diagnosis maneuvers at the bedside, we observe that though they know the theory, their technique may prevent them from eliciting the sign reliably.
• We find a real hunger among our residents in internal medicine to sharpen their skills at the bedside.
• Many diseases (almost all of dermatology for instance) are diagnosed by bedside exam. In neurology for example, even if the CT and MRI reveals a lot to you, only your exam can tell you what the functional consequence is in terms of motor or sensory loss or cognitive deficit.
• For evidence-based medicine fans, a cautionary note here: we are not trying to prove anything, but we do want to be sure that when people write in the chart "reflexes intact" or "cranial nerves intact" or "S1 and S2 heard, no m or g" that it is not a form of fiction, but represents an accurate observation.


Thyroid Exam
A good thyroid exam depends above all on knowledge of anatomy and proper technique.

Gait Abnormalities
Abnormal gaits are commonly seen in the hospital and elsewhere. Many of them should be recognizable on sight and it would be a shame to subject a person to a CAT or MRI for lack of recognition. We review a number of abnormal gaits and their disease associations.

Examination of the Spleen
An enlarged spleen can be easily missed. It is a prime example of how technique matters and even with the best technique, the spleen is not easily felt.

Examination of the Liver
The liver, unlike the spleen is easily located when enlarged and its surface can be readily felt.

Liver Disease, Head to Foot
Many if not most of the signs of liver disease are paradoxically to be found outside the abdomen. The clinician needs to be able to elicit and recognize these signs and here we review them from head to foot.

Ascites & Venous Patterns
The simple act of observing venous patterns and the direction of venous flow on the abdomen can help us to differentiate inferior vena cava obstruction from portal hypertension from portal hypertension. The techniques for detecting ascites are reviewed here.

Knee Exam
The knee is one of the most common causes of joint pain. A good knee exam helps us to rule out serious conditions such as a septic or inflammatory joint space and can also help make an accurate anatomical diagnosis of ligament or meniscus injury.

Shoulder Exam
Careful examination of the shoulder can provide valuable information and help the physician determine when image studies may or may not be helpful.

Lymph Node Exam
Do you know what a "shotty" lymph node is? Do you keep your nails neatly trimmed? Learn this and other tips from our experts and watch them perform a meticulous lymph node exam.

Deep Tendon Reflexes
Subtle changes in your technique can elicit an otherwise absent deep tendon reflex. Having a proper reflex hammer helps. Here we review those subtle techniques to improve on this import exam skill.

Cerebellar Exam
A number of signs and symptoms correlate with cerebellar disease and the clinician needs to be able to elicit them from head to foot.

Fundoscopic Exam
When it comes to an ophthalmoscopic exam there's more to it than meets the eye! Here we take a look at the various ophthalmoscopes available to internists and review their proper use.

Pulmonary Exam
The pulmonary exam is more than simple auscultation--in fact percussion and inspection often tell you much more than auscultation. Knowing the normal boundaries of percussion and the surface anatomy is critical.

Precordial Movements
Palpation is a critical part of the cardiac exam. The size and the character of the PMI (PMI) can speak volumes and predict the presence of an S3 or 4.

Cardiac Second Sounds
The second sounds and their variations can tell us volumes about everything from pulmonary or systolic hypertension to bundle-branch block.

Neck Veins & Wave Forms
Identifying an elevated jugular venous pulse will almost always affect your management of a patient. An understanding of waveforms can help you recognize everything from canon "a" waves of complete heart block to "ventricularization" of the "v" wave in tricuspid regurgitation.

BP & Pulsus Paradoxus
An accurate and reproducible blood pressure reading is a basic clinical skill. We review that skill and discuss how to test for pulsus paradoxus.

Ankle Brachial Index
Measuring an ankle brachial index is a simple skill that can be done at the bedside and give you helpful information about a patient's peripheral circulation. This technique is reviewed here.

The Hand in Diagnosis
The hands are a window to the body, and changes in the hands are linked to a plethora of illnesses. Recognizing these phenotypic expressions of disease is a basic clinical skill.

Bedside Ultrasound
With improvement in technology, the bedside ultrasound is becoming frequent in use. Here we discuss the principles and basics of bedside ultrasound.

Rectal Exam
A rectal exam is important to help rule out prostate issues, diagnosing causes of perirectal pain and looking for distal rectal masses. As the saying goes, "If you don't put your finger in, you will put your foot in!"

Pupillary Responses
The pupillary response requires a complex integration of nerve fibers. An abnormal pupillary response can be a harbinger for disease or simply a benign process. We review the physiology behind this reflex and discuss situations where it will be abnormal.

Involuntary Movements
There are many types of involuntary movements and the diagnosis rests on observation and knowledge of the types of involuntary movements and their causes.

Internal Capsule Stroke
A stroke within the internal capsule leads to a unique number of physical exam findings. We review these changes and compare them with strokes in other locations.

The Tongue in Diagnosis
Changes in the tongue occur in many situations. Systemic disease such as amyloidosis or lymphoma will affect its size and color. Localized infections may suggest underlying immune disorders. Nutritional deficiencies will cause abnormalities.