Medical Student US education

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Comparison of Stanford 25 Physical Exam and Ultrasound Evaluation
Courtesy of Dr. Chris Fox (University of Irvine Medical Center)

 From The Stanford 25                                                                      Physical Exam with PortableUltrasound Devices

Fundoscopic Exam:  Using an ophthalmoscope to examine the fundus (the retina, vessels and nerves in the back of the eye) can help assess the condition of blood vessels throughout the body, diagnose neurologic problems and provide clues to systemic diseases from heart valve infection to AIDS. We use ultrasound to look at the anterior and posterior chambers.  This provides information about retinal detachment, detached vitreous bodies, lens dislocation, globe ruptures, foreign bodies, optic neuritis, and widened optic nerve sheath in setting of increased intracranial pressure.
Pupillary responses: This session covers how the pupils constrict and dilate to light and respond to distant and near vision, as well as the best ways to elicit these findings. The responses can indicate trauma to the eye, and neurological disease and other conditions. Ultrasound can see the pupil constrict under a closed eyelid when light is applied to the contralateral open eye (assessing for APD). Enables pupillary exam despite large periorbital hematomas, chemosis, and blepharedema.
Thyroid exam: Palpating the neck to    feel the thyroid gland can help diagnose thyroid disease. A nodule can indicate thyroid cancer. Without thorough training, people often feel too high on the neck or place their fingers at an angle that precludes feeling a nodule. Ultrasound can directly visualize the various lobes of the thyroid and detect much smaller tumors than fingers could ever palpate.  We can differentiate something solid and potentially more concerning than something benign like a cyst.
Neck veins: Because the jugular veins in the neck go directly to the heart, they can indicate cardiovascular problems. Seeing the neck veins and discerning pulses takes a practiced eye, good patient positioning, good light and patience. Once it’s seen, the pulse level can be measured and abnormalities identified that can diagnose cardiac conditions such as tricuspid incompetence and complete heart block. One can directly measure the central venous pressure by measuring the point at which the internal jugular vein tapers off down to the manubrium of the sternum.  In obese patients or patients with short necks, attempting to visualize the neck veins is simply not possible without ultrasound.  With pulsed wave Doppler, we can much more accurately visualize the waveforms consistent with tricuspid incompetence and heart block.  This is all without good patient position, good light, or much patience.
Lung: Percussing (tapping) on the chest and sounding out the lung’s boundaries are useful for detecting fluid or pneumonia, particularly in areas without access to radiology equipment and blood testing. Ultrasound can accurately diagnose a host of lung pathology such as pneumothorax, alveolar interstitial syndrome (pulmonary edema), pneumonia, pleural effusion, and confirmation of endotracheal tube placement immediately after intubation by visualizing both diaphragms sliding.
Point of maximal impulse (PMI) and parasternal heave: The PMI is a dime-sized area of the chest, just left of the breastbone, where the beating of the heart can be felt. Heart and lung problems, such as hypertension or cardiomyopathy, create unique point of maximal impulse.  The parasternal heave is an impulse originating in the heart or large vessels that can be felt with the heel of the hand resting on the left sternum. Though these are crude and simple maneuvers, they reveal much about the heart and can help physicians ask better questions of echocardiograms they order. Indeed, the PMI is a tiny spot somewhere below the left nipple.  We localize this with ultrasound when we view the Apical 4-chamber window.  With Chronic Obstructive Pulmonary Disease, the PMI is no longer present on ultrasound thereby confirming the diagnosis. This is quite the opposite of patients with cardiomyopathy, where we view the heart easily in any window and can measure the walls with a quick drop of the calipers to accurately differentiate the subtype. We perform the echocardiogram at the bedside contemporaneously with the physical exam.
Liver: This session covers percussion to approximate liver size as well as techniques to feel the liver edge and to feel its surface for nodules and masses. It includes feeling for tenderness in the gallbladder region and signs of gallbladder inflammation. Bedside ultrasound can trace the edges of the liver from its location along the underside of the diaphragm over to its left lobe just as it passes over the pancreas. The liver can be visualized and screened for masses, nodularity, and inflammation by having a ground glass appearance, failure by identifying the presence of ascites, or a blockage by visualizing dilated intrahepatic ducts. The gallbladder is clearly evident and its walls can be measured for inflammation.  Lean in on the probe while it is over a gallstone and determine if the patient has acute cholecystitis. Also seen in this location is the inferior vena cava and its variation with respiration to estimate central venous pressure in a noninvasive way.
Palpation, percussion of spleen: The spleen is notoriously difficult to feel, yet it is embarrassing to miss an enlarged spleen. When enlarged it is almost always abnormal: It can be a sign of infection, tumor or liver disease. Positioning both the patient and the examiner properly is critical for success. The spleen is difficult to palpate when normal, but very easy to see on ultrasound in all individuals. Drop the calipers and measure its size. If the spleen has been lacerated, the blood collects between the spleen and the kidney and is jet black in appearance.
Common gait abnormalities:  A person’s walk can indicate the nervous system and musculoskeletal problems. The long hospital corridors provide a great opportunity to observe gait abnormalities common in patients with a stroke or with Parkinson’s disease, or peripheral neuropathy (damage to nerves outside the brain and spinal cord) and multiple other conditions. Musculoskeletal ultrasound has far-reaching possibilities being able to visualize the joints, tendons, and muscles. In the limping child it is possible to differentiate a fluid collection in the hip from a proximal femur fracture.  If a fluid collection is present, ultrasound can be used to guide the needle safely to the joint space for aspiration
Ankle jerk: This is a natural reflex, a brisk forward movement of the foot, which occurs when a hammer strikes the Achilles tendon above the heel. An absent reflex might suggest nerve damage, but often a reflex is labeled absent only because of incorrect technique (in a bedridden patient in particular). The ankle reflex is almost a metaphor for the Stanford 25. Being able to elicit this reflex generally means the examiner can elicit the other reflexes, which are easier to bring out With ultrasound, we can diagnose Achilles tendon partial and complete tears
Stigmata of liver disease: The paradox of liver dysfunction is that its signs are found outside the abdomen. These so-called stigmata include spider angiomas (dilated capillaries) on the cheeks, parotid gland enlargement, diminished armpit hair, breast enlargement in a male, islands of redness on the palms and myriad other findings The stigmata of liver disease are detected long before it becomes obvious on the physical exam.  For example, the liver itself can start to show signs of inflammation before fulminant failure ensues. Also, very small amounts of ascites, as little as 50 cc, can be detected way in advance of the “fluid shift” seen on physical exam with massive ascites.
Internal capsule stroke: An area deep in the brain called the internal capsule is one of the most common sites of stroke. The condition produces a plethora of neurological signs that can be demonstrated, involving cranial nerves, muscles, sensation, reflexes and gait.  In this session, the student runs through a series of maneuvers from head to foot that help identify the location of the stroke. Neurosonology is the ability visualize vascular flow to the brain by placing the transducer through one of the four windows in which the boney structures of the skull are absent or thin such as the temple. Using Doppler, the anterior, middle, and posterior circulation is visualized and assessed for stenosis, occlusion, and for monitoring the effects of clot busting drugs like TPA.
Cardiac second sounds/ splitting: The healthy adult has two normal heart sounds (the familiar lub dub), produced when heart valves close. The second sound is actually composed of two separate sounds produced by closure of the aortic valve and the pulmonary valve. Though they close together they become asynchronous after a deep breath. Many variations on this theme — exaggerated splitting or paradoxical splitting or fixed splitting — can speak to specific conditions such as bundle branch blocks or atrial septal defect to name two. Echocardiography is the gold standard to assess the heart valves.  The only limitation is the delay and cost involved in obtaining the study. Color-flow Doppler can be used to assess patients for aortic and mitral valve regurgitation. Furthermore screening for hypertrophic cardiomyopathy in young athletes can reduce the amount of sudden deaths in this population
Hand: Many diseases show signs in the hand, from Down’s syndrome (evidenced by an extra crease in the palm) to certain cancers.  The nail is affected by disorders ranging from cystic fibrosis to lung cancer. In this session, students learn to read the hand for everything from nerve disorders to specific finger deformities that in turn predict systemic disease. Submerge the hand in a bucket of water and the ultrasound images are quite spectacular involving the joints, bones, tendons, cysts, neuromas, dislocations and fractures.  Foreign bodies as small as a bee stinger can be extracted under this water path technique.
Shoulder: Like the knee, the shoulder joint is commonly affected by injury and aging.  A series of observations and maneuvers can lead the clinician to strongly suspect a specific diagnosis, such as rotator cuff syndrome or even joint dislocation Ultrasound examination of the shoulder will enable easy identification of dislocations, separations, effusions, and the location for injections.
Cervical lymph node assessment: Enlarged lymph nodes in the neck are easily overlooked. Their size and presence can indicate cancer as well as responses to therapy. All neck masses are initially located and biopsied using ultrasound. Careproviders will become very adept at picking out lymph nodes throughout the body using ultrasound not just in patients who have a mass in the back of the throat.  By inserting the endocavitary transducer in the mouth, users are able to determine a surgically drainable abscess from a medically treatable enlarged lymph node. If an abscess is indeed diagnosed, then ultrasound can be used for surgical guidance so as to keep the needle away from the carotid artery.
Ascites: Ascites is the buildup of free fluid in the abdomen, around the organs. Ascites is often associated with liver disease, such as cirrhosis, but also develops in heart failure and ovarian cancers. A technique involving percussion detects fluid. One must always check with ultrasound before performing paracentesis or one risks causing inadvertent enterotomies. Obese patients are often misdiagnosed with ascites after a false-positive “fluid shift” is seen on physical exam.
Rectal exam: Many cancers of the colon are in the rectum, and a good many of these are within reach of the examining finger.  In addition, the rectal exam is a useful way to feel the prostate and other pelvic pathology. The endorectal transducer is a safe and comfortable way to have the prostate size measured as well as a screening test for any tumors.
The evaluation of scrotal mass:  A mass, or lump, in the testicle is a possible symptom of infectious disease, tumor or hernia.  Ultrasound can distinguish infectious etiologies from tumors and from hernias quite easily in the scrotum.
Bedside ultrasound: Use of portable ultrasound at the bedside can identify fluid in the lung, free blood in the belly and determine if the patient is dehydrated or fluid-overloaded by studying a central vein. The technology in this area is rapidly evolving and an ultrasound might one day be among the contents of the white coat pocket. Many additional applications:  Pelvic Ultrasound: In pregnant patients in the first trimester, pelvic endovaginal ultrasound can identify the location of the pregnancy and provide prognostic information about viability down to 5 weeks of gestational age.  In nonpregnant patients it was shown that OB/GYN attendings are not able to reliably palpate adnexal masses until they are greater than 4cm. Using endovaginal ultrasound students will identify masses less than 1 cm, as well as presence of free fluid, and the endometrial stripe thickness.

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