Department of Medicine

Stanford Initiative in Bedside Medicine

The Stanford Medicine 25 is an initiative created by Abraham Verghese, MD, MACP, professor of medicine and senior associate chair for the Theory and Practice of Medicine. Dr. Verghese has had a longstanding interest in bedside medicine and in all good clinicians being able to recognize the basic phenotypic expressions of disease (which manifest as abnormal physical signs).


Abraham Verghese, MD, demonstrates one of the Stanford Medicine 25 procedures to interns and residents

Through the Stanford Medicine 25, residents and students are taught techniques and skills during workshops and while rounding on the wards at Stanford Hospital. The Stanford Medicine 25 website features videos and descriptions of each of the 25 topics. The goal of such teaching is to give physicians a repertoire of technique-dependent skills that they can in turn teach at the bedside.

The Stanford Medicine 25 employs faculty including John Kugler MD, clinical assistant professor of medicine, Jeffrey Chi MD, clinical assistant professor of medicine, and Errol Ozdalga MD, clinical Instructor of medicine in the Stanford General Internal Medicine service along with medical student Blake Charlton.


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Stanford Medicine 25: Fundamental, Technique-Dependent Physical Diagnosis Skills
1. Thyroid Exam: A good thyroid exam depends above all on knowledge of anatomy and proper technique.
2. 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.
3. 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.
4. Examination of the Liver: The liver, unlike the spleen is easily located when enlarged and its surface can be readily felt.
5. Liver Diseases, 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
11.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.
12. 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.
13. 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.
14. 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.
15. Cardiac Second Sounds: The second sounds and their variations can tell us volumes about everything from pulmonary or systolic hypertension to bundle-branch block.
16. 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.
17. 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.
18. 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.
19. 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.
20. Bedside Ultrasound: With improvement in technology, the bedside ultrasound is becoming frequent in use. Here we discuss the principles and basics of bedside ultrasound.
21. 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!"
22. 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.
23. 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.
24. 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.
25. 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.

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