The Stanford 25

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Written by stanford25admin

August 27, 2010 at 12:39 pm

17 Responses

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  1. Hello,
    I was at the Stanford 25 presentation as part of the WGEA conference recently, and wanted to offer a contribution regarding the cremasteric reflex’s use in diagnosing testicular torsion. In a retrospective study of pediatric cases of testicular torsion, all patients with a confirmed torsion had an absent cremasteric reflex, and absence of the cremasteric reflex was stated to be the most sensitive physical finding.

    Reference and abstract below.

    Pediatrics. 1998 Jul;102(1 Pt 1):73-6.
    A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages.
    Kadish HA, Bolte RG.

    Department of Pediatrics, University of Utah School of Medicine, Emergency Department, Primary Children’s Medical Center, Salt Lake City, Utah, USA.

    To compare historical features, physical examination findings, and testicular color Doppler ultrasound in pediatric patients with epididymitis, testicular torsion, and torsion of appendix testis.

    A retrospective review of patients with the diagnosis of epididymitis, testicular torsion, or torsion of appendix testis.

    Ninety patients were included in the study (64 with epididymitis, 13 with testicular torsion, and 13 with torsion of appendix testis). Historical features did not differ among groups except for duration of symptoms. Of 13 patients with testicular torsion all had a tender testicle and an absent cremasteric reflex. When compared with the testicular torsion group, fewer patients with epididymitis had a tender testicle (69%) or an absent cremasteric reflex (14%). 62 (97%) patients with epididymitis had a tender epididymis and 43 (67%) had scrotal erythema/edema. By comparison, 3 (23%) and 5 (38%) patients with testicular torsion had a tender epididymis or scrotal erythema/edema, respectively. Doppler ultrasound showed decreased or absent blood flow in 8 patients, 7 of whom were diagnosed with testicular torsion. Ten out of 13 patients with testicular torsion had a salvageable testicle at the time of surgery.

    The physical examination is helpful in distinguishing among epididymitis, testicular torsion, and torsion of appendix testis. Patients presenting with a tender testicle and an absent cremasteric reflex were more likely to have a testicular torsion rather than epididymitis or torsion of appendix testis. An absent cremasteric reflex was the most sensitive physical finding for diagnosing testicular torsion. Color Doppler ultrasound is a useful adjunct in the evaluation of the acute scrotum when physical findings are equivocal.

    Braden Meason

    May 4, 2011 at 4:46 pm

  2. This is excellent, but I wish some of the “forthcoming” videos would soon be ready. Do you have any idea when they will be done?

    Thanks again for the wonderful “Twenty Five”.

    I am an Adjunct Professor of Medicine at Stanford.

    Jeffrey D. Urman, M.D.

    May 13, 2011 at 3:49 pm

  3. Hi,

    I am in the process of putting together a seamless physical exam that incorporates many of the values that the Stanford 25 achieves. In my attempt to ensure that I have done the proper research in validating the effectiveness of a thorough physical exam (both in better patient care, and decreasing long-term costs), I would appreciate any guidance you may have (other than the links provided).

    I am in San Francisco, and am available for communication through email, phone, skype or could make a trip down to PA if it would be easier.

    This is an extremely important project for me, and I could really use some expert advice as well as an ear from those for whom I have a great deal of respect.

    Thank you, and I look forward to hearing from your team.


    Dr. Sean O’Grady

    Dr. Sean O'Grady

    September 2, 2011 at 2:24 pm

    • Dr. O’Grady,

      What is the best reference for the general physical exam? If you or one of your students were to buy one text book on physical examination, which one would it be? Thank you.

      David Durand

      David Durand

      April 13, 2012 at 10:32 am

      • Hi David,

        The textbook I learned from was Bates’ Guide to Physical Examination and History Taking but that only provided the basic framework for conducting the exam. It is thorough, and will suffice for learning the components and technical procedures.

        There is much more to be learned that can’t quite come across in a book, however. Bedside manor (or an empathetic approach), non-verbal cues, proper palpation, etc. are all skills that help to make a patient comfortable enough to be truthful and honest in an exam. I believe these are equally important skills and that’s why I like the approach Dr. Verghese employs in teaching the Stanford 25.

        My advice to a student is to buy Bates, but to learn its content in the appropriate context, with an experienced mentor to help connect the dots and make it real. Hope that helps!


        Dr. Sean O'Grady

        April 23, 2012 at 12:51 pm

  4. I’ve been hearing about the Stanford 25 for over a year. This is my first visit to the site. I am totally in agreement with the spirit and direction of this initiative. I have been practicing family med and geriatrics in a rural community health center for 33 years. HISTORY and pe is 95% of everything. 30% of our patients still have no health insurance so many studies simply aren’t possible for them.
    I started my journey through the 25 with the fundiscopic exam. I watched your video and one other. I noted that there is no mention of venous pulsations at the optic disc. Since this is a snNout for increased intracranial pressure (Oxford CEBM) I’m surprised you don’t mention it. Many med students, residents, and physicians have never seen it. I get them to see it once and teach the concept of snNout. Then they can keep learning on their own.
    Dan Doyle M.D.
    Oak Hill, WV

    Dan Doyle

    October 28, 2011 at 1:03 pm

    • Thank you for your comment and I apologize for the late reply. You make a good point about the venous pulsations. Since venous pulsations of the optic disc of normally absent in 20-30% of patients and we are normally looking in undilated eyes, I try to get my students to simply focus on finding the optic disc and surrounding region at the beginning. However, as you note, it is good form to be about to identify venous pulsations and know if they are there, then increased cranial pressure is indeed essentially ruled out.

      Thank you.


      April 17, 2012 at 10:50 pm

  5. thank u

    ann minix

    November 20, 2011 at 9:23 pm

  6. This is wonderful. Does your group know of anyone working on something similar for pediatrics? Would include things like ear exam, HEADDS exam, infant neuro exam, tricks for examining fussy child, Tanner staging, etc. I teach Stanford med students and peds residents. Something like this would be so useful!
    -Heidi Roman pediatrician

    My Two Hats

    February 10, 2012 at 11:51 am

    • Your website is nice as well! Sorry for the late reply, we do not use this website much anymore and are going to take it down soon. Our new live website is To my knowledge I do not know if there is a pediatrician but I’m sure there is one that we just haven’t met….yet.


      April 17, 2012 at 10:41 pm

  7. The video clip on the precordial movements page is no longer valid. YouTube says it has been removed by the user.

    Paul K.

    March 5, 2012 at 11:47 pm

  8. I am unable to visualize any of the videos from the Stanford 25 site. Is this something that can be resolved?

    Thank you


    March 6, 2012 at 12:34 pm

    • We have a new website that is about to be announced but has been live for some time. We will be closing this website soon as the new one is a much improved version. The website’s address is All videos are now open to everyone.


      April 17, 2012 at 10:36 pm

  9. I was recently reading The Rational Clinical Examination (JAMA) paper – “Does This Patient Have a Pleural Effusion?” and came across the description of the Auscultatory Percussion technique originally described
    by Laennec in 1821 and modified by Guarino in 1974. I am just curious if this technique is commonly used during pulmonary exam. I have not previously encountered it and have been unable to find a video of someone performing it. I plan to look at the original papers referenced in the article but am curious if in your experience this technique has been beneficial in refining your diagnosis or guiding your investigations. Thank you for putting together this excellent resource on physical exam techniques.

    Paul B. Jones, PGY1 Family Medicine
    McMaster University, Canada

    Paul Jones

    March 13, 2012 at 10:25 am

    • Thank you for the message! Please note this website is being rerouted to


      April 23, 2012 at 12:56 am

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