Improving medical students

Archive for the ‘Diagnostic Examination’ Category

Nasopharyngeal Specimen Collection – A Guide for Medical Students

Posted by medliorator on June 8, 2010

The New York City Department of Health has prepared an excellent guide for nasopharyngeal specimen collection that describes both nasopharyngeal aspirate and nasopharyngeal swab methods.  This concise review will prove helpful for those medical students beginning outpatient medicine rotations or family medicine.

Nasopharyngeal Specimen Collection for Viral Respiratory Pathogens [NYC Dept of Health]

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Basic Lung Sound Primer

Posted by medliorator on June 4, 2010

Stethographics offers a review of commonly encountered lung sounds that includes audio samples and graphical illustrations of the following breath sounds:

  • Bronchial
  • Vesicular
  • Fine Crackles
  • Coarse Crackles
  • Wheezes
  • Rhonchi

Don’t forget to check out there brief heart sound primer.

Basic Lung Sounds [Stethographics]

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How to Approach Adolescent Athletes – Sports Preparticipation Examination

Posted by medliorator on November 30, 2009

The adolescent athlete frequently appears in clinic for sports preparticipation examination.  3rd & 4th year medical students should be prepared.  Important aspects of this assessment include:

  • cardiovascular health (hypertrophic cardiomyopathy)
  • non-cardiac issues (loss of consciousness or concussion, recovery from musculoskeletal injuries)
  • general health assessment
  • counseling
  • assessing fitness level for specific sports

Medliorate readers will benefit from the Georgia Chapter of the American Academy of Pediatrics’ Preparticipation Physical Evaluation form.  Print off a few copies for your clinic rotations in pediatrics and family medicine.  The form includes a history portion that the guardian may complete.

AAP [Georgia Chapter]

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CORE – Clinical ORthopaedic Exam for iPhone

Posted by medliorator on November 3, 2009


This reference database of ~250 clinical tests facilitates diagnosis of musculoskeletal and orthopedic disorders. It offers descriptions on how to perform each test as originally described by its author, video demonstrations (if wifi-connected), diagnostic properties (reliability and validity), and links to supporting medical references via abstracts in PUBMed.  Currently retails for $39.99

sens spec

CORE – Clinical ORthopaedic Exam from

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Forum Filter: Nurse’s Chart Notes

Posted by medliorator on May 14, 2008

Da Goddess Says:

I’d often extract major clues from patients on intake forms simply because I wasn’t “The Doctor”. Sadly, many doctors would fail to read my notes and then be surprised later, while they were scratching their heads and digging through books, when I’d point out to them what the patients told me. It would please me to no end when I’d get medical students (or that rare, totally thorough doc) at the hospital who’d actually read through ALL my notes and pick up on the clues strewn about.

The waning art of history taking [DB’s Medical Rants]

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Importance of Physical Exam

Posted by medliorator on April 2, 2008

A telling vignette from ValJones @ Dr. Val and The Voice of Reason:

One intern presented a case of a patient with “fever of unknown origin” (FUO). This particular diagnosis will make any internal medicine specialist delirious with curiosity and excitement, since it means that all the previous attempts at discerning the cause of the patients fever have failed. Generally, a fever only receives this exciting honor when it has gone on for at least 3 weeks without apparent cause.


The intern explained… every single potential cause of the fever and how he had ruled them out with tests and deductive reasoning. The attending was hanging on every word, and nodding in approval of some real zebras (rare and highly unlikely causes for the fever) that the intern had thought to consider and disprove.


I must admit that my mind wandered a bit during this long exercise, and instead I looked at the patient, smiled, and examined his thick frame with my eyes. Of course, an attending has a keen sense for wandering minds, and so to “teach me a lesson” he abruptly stopped the intern’s presentation and looked me dead in the eye. You could have heard a pin drop.


“So, Dr. Jones” he snarled. “You seem to have this all sorted out, don’t you. Apparently you have determined the diagnosis?”

“Well, yes, I think I may have.” I replied calmly.


The attending’s face turned a slightly brighter pink. “Well, then, don’t withhold your brilliance from us any longer. You’re a rehab resident, are you not?” He made a dismissive move with his right hand and rolled his eyes.


“Yes, I am.” (Snickers from the internal medicine residents.) I shot a glance at them that shut them up.


I continued, “Well, Dr. ‘Attending,’ as the intern was reviewing the potential causes of FUO, I took a look at the patient. It seems that there is a pus stain on the bottom of his right sock. I didn’t hear the intern describe the patient’s foot exam.”


The intern’s face went white as a sheet.


The attending turned to the intern with an expression of betrayal. “Did you examine this patient’s feet?”


“Well I uh… well, no.” Stammered the intern. “I guess I forgot to remove his socks.”


The attending marched over to the bedside and quickly removed the patient’s right sock, a small snow storm of dried skin flakes fell gently to the hospital floor. A festering foot ulcer proudly displayed itself to the team.

The Physical Exam Can Be Pretty Important, Part 2 [RevolutionHealth]

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Bipolar Disorder: In-Home Testing

Posted by medliorator on March 30, 2008

a company is selling a testing kit that you can use yourself, in the privacy of your own home, to see if you have genes that increase the risk of bipolar disorder.


Psynome™ – tests for two mutations of the GRK3 gene that are associated with bipolar disorder.


Psynome2™ –tests for gene mutations in the Promoter L allele gene that predicts patient response to serotonin-based drugs, the most commonly prescribed drug therapies in psychiatry today. These tests are useful to your doctor in making a timely and accurate diagnosis of your condition and prescribing the right medication. The tests can be ordered individually or combined.


In order to know if the test is worth anything, you would have to do some kind of study that shows that the people who get the test, do better in the long run. It is one thing to be able to tell whether the mutations are present. In is another thing to show that the knowledge makes a difference in the outcome of the treatment.


Previous efforts have failed to show clinical utility, even if they are useful in a research setting. Any proposed test will have to meet a high standard before it will make any sense to put it into use. Even then, it is doubtful that it would make sense for a person to do it at home.

In-Home Test for Bipolar Disorder [The Corpus Callosum]

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Diagnosing a Spider Bite

Posted by medliorator on March 27, 2008

Poisonous spider bites are extraordinarily rare; wounds blamed on spiders are extraordinarily common. I have seen dozens of patients who thought they had been bitten by a spider, and I have never made a diagnosis of an actual spider bite.

  • Spider bites are exceedingly rare. Studies have shown that the number of spider bites attributed to spiders far exceeds the number of poisonous spiders living in that area.
  • If you did not see a spider bite you, then it is very unlikely that you were bit by a spider.
  • Spiders do not come out at night to bite you. They are, in fact, reluctant to bite, even when provoked.
  • Very few spiders in the US (some would say only one spider, the brown recluse) are likely to cause a necrotic wound.
  • The black widow spider is also a poisonous spider, but it releases a neurotoxin that causes abdominal pain and paralysis. It does not cause a necrotic skin wound.

Spider Bite (?) [The Derm Blog]

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How to Take a Sexual History

Posted by medliorator on February 22, 2008

#1 Dinosaur hitting it out of the park…

Here’s my strategy:

All female patients get asked, “What do you use for birth control?”One set of answers is simply the method: the pill, the diaphragm, condoms, etc. The natural next question is, “How is that working for you?”


Another answer is, “Nothing.” Although there are several possibilities, in real life they divide themselves by whether or not the patient continues explaining on her own. Here’s how the first set of answers usually plays out:

  • “Nothing; I’ve had my tubes tied.”
    • Response: “Cool. Do you also use condoms to protect against STDs?” etc.
  • “Nothing; my husband’s been fixed.” (Vasectcomy)
    • I tell women whose husbands are considering it, “It’s great; you won’t feel a thing.”)
  • “Nothing; I’m trying to get pregnant.”
    • Response: “How long? Have you ever been pregnant?” etc. (fertility issues)
  • “Nothing; I’m not in a relationship right now.”
    • Response: “Ok. What do you use when you do have sex?” (also presents the opportunity to find out how she feels about the lack of a relationship.)

Best answer I’ve ever heard: ::glaring daggers at me:: “I have a 2-year-old. I don’t have sex.” (No response)


there’s the second group of women who say, “Nothing,” and then fall silent.


Here’s what I usually say:

“Female partners?”

If the patient is a stupid teen (or 20-something) the answer is usually a disgusted, “Eeew! No.”
Response: “So how do keep from getting pregnant when you have sex?”
The answer is usually something like, “He pulls out,” or, “I don’t know,” etc.
Note: these patients are usually pregnant.


males starting about age 14 are asked, “Do you use condoms when you have sex?” thus forcing the explicit answer, “I don’t have sex.”

Getting a Simple Answer [Musings of a Dinosaur]

Posted in Clinical Rotations, Diagnostic Examination, How-To | Comments Off on How to Take a Sexual History

Rectal Exam Insights

Posted by medliorator on February 9, 2008

I always felt… that the most gentle and least humiliating way to do a rectal exam is with the patient curled up on his/her side, and covered except for the target orifice. it behooves one fully to explain exactly the reasons for such a transgression. So here are some:

  • In evaluating a patient with bowel obstruction, it’s useful to determine if there’s air in the rectal vault.
  • By revealing localized pain on the right, it can help in the diagnosis of appendicitis.
  • With a pelvic abscess from any source, it can determine the feasibility of trans-rectal drainage. (Yes, it’s possible to do it without a radiologist, and there’s still a place for it.) In fact, under some unusual circumstances, such an abscess, followed for “ripening,” can be drained digitally and yuckally, right there in the bed.
  • Rectal exam can stimulate the bowels to move, in a post-op patient (hopefully not in an instantaneous fashion.)
  • Among the most important: it predicts successful resection of rectal cancer with the ability to re-connect the colon without colostomy. (If I can feel the tumor on rectal exam, I won’t be able to resect with a margin safe for anastomosis.)
  • The exam helps to judge how extensive a rectal tumor is; how large, and how fixed in position. The need for pre-op radiation is determined, in part, this way.
  • When that very low stapled anastomosis becomes too tight (which they sometimes do), it can be permanently fixed with a single digital dilatation.
  • Some anal fistulae track up into areas that can be felt & mapped out by a rectal exam.
  • In addition to routine evaluation of the prostate, there are some circumstances wherein prostate massage is therapy.

That’d Be Up The Butt, Bob [Surgeonsblog]

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