和贤学海南医学院HAINAN MEDICAL UNIVERSITYTeaching Syllabus ofDiagnostics(For M.B.B.S)Department of Diagnostics, Hainan medical University
HAINAN MEDICAL UNIVERSITY Teaching Syllabus of Diagnostics (For M.B.B.S) Department of Diagnostics, Hainan medical University
Physical diagnosticsIntroductionRequirementTo explain that Physical diagnostics is a significant connecting coursefrom the basis to the clinic in medical education, and is an importantelement for clinical special subject. It is akey course for cultivatingmedical students in basic skill and clinical practical competence.Toemphasizethe importance of mastering correctway of inquisition andsystematic physical check-up,it is not allowed to ignore under anycircumstances.In addition, objective diagnostic thinking approachshould be established in order to achieve the goal of proper understandingdiseases.Teaching contentsl. To learn the significance of clinical diagnosis2. The position and role of diagnostics in clinical medicine3.Thefundamental contents of physical diagnostics:common symptoms,inquisition, medical check-up, electrocardiography, ultrasonicexamination,casefilerecordinganddiagnosticthinkingmethods,thesummary of advanceddiagnostic method.4. The method and requirement for diagnostics learning[Teaching contentsl:one teaching hour[Teaching method]: lectureChapter 1 common symptoms and interrelated inquisition[Objective and requirement]In the teaching of these subjects stress shall be laid on basic principlesof the subjects with more emphasis on their applied aspects.By means of clinical common symptoms, teacher should narrate theassociationbetweenclinicalsymptomaticmanifestationandpathophysiology or anatomopathology.Students should understand thefeatures of common symptoms and inferthe rest from what is alreadyknown
Physical diagnostics Introduction Requirement To explain that Physical diagnostics is a significant connecting course from the basis to the clinic in medical education, and is an important element for clinical special subject. It is a key course for cultivating medical students in basic skill and clinical practical competence. To emphasize the importance of mastering correct way of inquisition and systematic physical check-up, it is not allowed to ignore under any circumstances. In addition, objective diagnostic thinking approach should be established in order to achieve the goal of proper understanding diseases. Teaching contents 1. To learn the significance of clinical diagnosis 2. The position and role of diagnostics in clinical medicine 3. The fundamental contents of physical diagnostics: common symptoms, inquisition, medical check-up, electrocardiography, ultrasonic examination, case file recording and diagnostic thinking methods, the summary of advanced diagnostic method. 4. The method and requirement for diagnostics learning [Teaching contents]: one teaching hour [Teaching method]: lecture Chapter 1 common symptoms and interrelated inquisition [Objective and requirement] In the teaching of these subjects stress shall be laid on basic principles of the subjects with more emphasis on their applied aspects. By means of clinical common symptoms, teacher should narrate the association between clinical symptomatic manifestation and pathophysiology or anatomopathology. Students should understand the features of common symptoms and infer the rest from what is already known
and then should know the causes and mechanism. The importance of symptomanalysis on diagnosis should be stressed thoroughly for students:students should be taught how to inquire patients about related symptoms.Teaching contents: fever, dyspnea, cough, expectoration and hemoptysis,edema, jaundice, disturbance of consciousness.一,Fever()overview of fever（二)pathogeny and sortl. infective fever2. noninfective fever（三）occurrencemechanism（四）clinical occurrence: grade of fever, clinical features of fever(五)pattern of fever:continuousfever,remittentfever,intermittentundulantfever,relapsingfever,episodic fever,fever,pel-epstein fever二、 edemapathophysiology, clinical occurrence, idiopathic edema, tropical edema,angioedema.三、dyspneaIn the teaching of dyspnea stress should be laid on the pathophysiologyand clinical occurrence of dyspnea, in addition the differentiatediagnosis on dyspnea of heart origin (left ventricle failure and rightventricle failure:dyspnea of respiratory origin (exhale, inhale andmixed.四、cough,expectoration,hemoptysisCauses and clinical features五、jaundiceThe pathogenesisof jaundice should be stressed, so students could havea clear understanding of unconjugated hyperbilirubinemia, conjugatedhyperbilirubinemia and mixed hyperbilirubinemia.Clinical occurrence: pruritus, urine color, acholic feces
and then should know the causes and mechanism. The importance of symptom analysis on diagnosis should be stressed thoroughly for students; students should be taught how to inquire patients about related symptoms. Teaching contents: fever, dyspnea, cough, expectoration and hemoptysis, edema, jaundice, disturbance of consciousness. 一、Fever ﹙一﹚overview of fever ﹙二﹚pathogeny and sort 1. infective fever 2. noninfective fever ﹙三﹚occurrence mechanism ﹙四﹚clinical occurrence：grade of fever, clinical features of fever ﹙五﹚pattern of fever: continuous fever, remittent fever, intermittent fever, undulant fever, relapsing fever, episodic fever, pel-epstein fever 二、edema pathophysiology, clinical occurrence, idiopathic edema, tropical edema, angioedema. 三、dyspnea In the teaching of dyspnea stress should be laid on the pathophysiology and clinical occurrence of dyspnea, in addition the differentiate diagnosis on dyspnea of heart origin (left ventricle failure and right ventricle failure; dyspnea of respiratory origin (exhale, inhale and mixed. 四、cough, expectoration, hemoptysis Causes and clinical features 五、jaundice The pathogenesisof jaundice should be stressed, so students could have a clear understanding of unconjugated hyperbilirubinemia, conjugated hyperbilirubinemia and mixed hyperbilirubinemia. Clinical occurrence: pruritus, urine color, acholic feces
六，disturbance of consciousness(-)pathophysiology(二) clinical occurrence: metabolic encephalopathy, transtentorialherniation and brainstem injury（三）syncope[Teaching hours] 10 hours[Teaching method]According to the clinical situation, 5~6 common symptoms can beselected to teach in class, other symptoms can be taught in clinicaldemonstration or clinical practice.Demonstration and audiovisuals canbe used forteaching othercommon symptoms, students should learn to observe, discuss and analysisthese symptoms.Chapter 2 Physical examinationphysical examination, vital signs and anthropomorphic data[Objective and requirement]Students should understand and know how to use the basic method:inspection,palpation,percussion, auscultation.Understanding the examination contents of general state and thesignificance of normal and abnormal.Understanding the point ofsystematicphysical三、correctexamination.[Teaching content]The methods of inspection, palpation, percussion, auscultation.Gender, age and the relation to diseasesBody temperature (method of measuring, normal body temperature,diurnal variation and simultaneous temperature in various regions),respirations, the pulse, blood pressure and pulse pressure. The clinicalimportance of the four vital signs should be stressed and analyzed.四、Anthropomorphic data and the judgment of growth and nutritionalstate, height and weight.五、The common abnormalities of psychiatricand social disorders.Causes of gait disorders.六、Recognitionofskincoloration,moisture,skineruption,intradermal hemorrhage and scar and their clinical meanings
六、disturbance of consciousness （一） pathophysiology （二） clinical occurrence: metabolic encephalopathy, transtentorial herniation and brainstem injury （三） syncope [Teaching hours] 10 hours [Teaching method] 一、 According to the clinical situation, 5~6 common symptoms can be selected to teach in class, other symptoms can be taught in clinical demonstration or clinical practice. 二、 Demonstration and audiovisuals can be used for teaching other common symptoms, students should learn to observe, discuss and analysis these symptoms. Chapter 2 Physical examination physical examination, vital signs and anthropomorphic data [Objective and requirement] 一、 Students should understand and know how to use the basic method: inspection, palpation, percussion, auscultation. 二、 Understanding the examination contents of general state and the significance of normal and abnormal. 三、 Understanding the point of correct systematic physical examination. [Teaching content] 一、 The methods of inspection, palpation, percussion, auscultation. 二、 Gender, age and the relation to diseases 三、 Body temperature (method of measuring, normal body temperature, diurnal variation and simultaneous temperature in various regions), respirations, the pulse, blood pressure and pulse pressure. The clinical importance of the four vital signs should be stressed and analyzed. 四、 Anthropomorphic data and the judgment of growth and nutritional state, height and weight. 五、 The common abnormalities of psychiatric and social disorders. Causes of gait disorders. 六、 Recognition of skin coloration, moisture, skin eruption, intradermal hemorrhage and scar and their clinical meanings
七、The examining method of lymph nodes, the clinical meanings of lymphnode distribution and changing.[Teaching hour] lecture 3 hours,clinical practice 8 hours[Contents] The examine methods and clinical meanings should be stressedin lecture, clinical demonstration and audiovisuals can be used forlearning and practice.Head and neck examination[Objective and requirement]Students should understand the examine sequence and methods for head andneck, and understand the clinical meanings of normal state and abnormalchanging.[Contents]The general examination of external headThe examination of eyes, ears and noseThe examination of mouth and parotid gland, the clinical meanings三、of the examination of lips, buccal mucosa, teeth and gums, tongue,oropharynx and tonsils,larynx and parotidgland.四、The examination of neck:shape and movement,blood vesselsexamination and its clinical meanings,theposition of thyroid gland andtrachea.[Teaching hour] lecture 3 hours, clinical practice 8 hours[Teaching method]Demonstrationbymeans of teachingaid,then studentscan examineeach other and practice more times the examine sequence and methods, andrecognize normal state.Students should learn these examinations and recognize abnormalsigns by demonstration and audiovisuals or in clinical practice, andunderstand the clinical meanings.Chest[Objective and requirement]Students should understand and know how to use the four basicexamine methods (inspection, palpation, percussion, auscultation) in the
七、 The examining method of lymph nodes, the clinical meanings of lymph node distribution and changing. [Teaching hour] lecture 3 hours, clinical practice 8 hours [Contents] The examine methods and clinical meanings should be stressed in lecture, clinical demonstration and audiovisuals can be used for learning and practice. Head and neck examination [Objective and requirement] Students should understand the examine sequence and methods for head and neck, and understand the clinical meanings of normal state and abnormal changing. [Contents] 一、 The general examination of external head 二、 The examination of eyes, ears and nose 三、 The examination of mouth and parotid gland, the clinical meanings of the examination of lips, buccal mucosa, teeth and gums, tongue, oropharynx and tonsils, larynx and parotid gland. 四、 The examination of neck: shape and movement, blood vessels examination and its clinical meanings, the position of thyroid gland and trachea. [Teaching hour] lecture 3 hours, clinical practice 8 hours [Teaching method] 一、 Demonstration by means of teaching aid, then students can examine each other and practice more times the examine sequence and methods, and recognize normal state. 二、 Students should learn these examinations and recognize abnormal signs by demonstration and audiovisuals or in clinical practice, and understand the clinical meanings. Chest [Objective and requirement] 一、 Students should understand and know how to use the four basic examine methods (inspection, palpation, percussion, auscultation) in the
examination of chest,lung and heart. They can have fairly accurateexamine results by practice on each other.Students should understand the abnormal signs of lungs and heart,and know how to analyze their clinical meanings.[Contents]The anatomic landmarks and imaginary lines of chest wall, thetopography of lungs and pleuraChest wall and rib cage: subcutaneous emphysema, tendernessinspiratory retraction of interspaces,thoracic deformity and thoracicspine deformity.三、Breast and nipple examination, breast signs.四、Lungs and pleura(-) Inspection:The clinical meanings of increased and decreasedrespiratory rate and changes of rhythm and depth should be taught entirelyto students.(二) Palpation:Testing excursion of thorax, methods of vibratorypalpation and procedure for vibratory palpation.Students should know thecharacteristics of normal vibratory palpation.(三) Percussion:techniques of percussion, definitive percussion ofthe chest,abnormal percussion notes.The sort of percussion: resonant note, hyperresonant note, tympaniticresonance,dullness and flatness.The percussion methods of upper boundand lower bound of lungs and their clinical meanings should be taught inclass.(四)Auscultationl. The sort, features and distribution of normal breath sound (vesicularbreath sound, bronchial breath sound, bronchovesicularbreath sound)2. The clinical meanings of abnormal breath sounds should be taughtclearly to students.3. The mechanism of rales and classification,features and clinicalmeanings.Auscultation of adventitious sounds: crackles, wheezes, rhonchus,special sounds in hydropneumothorax. Auscultation of voice sounds andabnormal voice sounds, Pleural friction rub.4. The mechanism of pleural rale,features and clinical meanings
examination of chest, lung and heart. They can have fairly accurate examine results by practice on each other. 二、 Students should understand the abnormal signs of lungs and heart, and know how to analyze their clinical meanings. [Contents] 一、 The anatomic landmarks and imaginary lines of chest wall, the topography of lungs and pleura 二、 Chest wall and rib cage: subcutaneous emphysema, tenderness, inspiratory retraction of interspaces, thoracic deformity and thoracic spine deformity. 三、 Breast and nipple examination, breast signs. 四、 Lungs and pleura （一） Inspection: The clinical meanings of increased and decreased respiratory rate and changes of rhythm and depth should be taught entirely to students. （二） Palpation: Testing excursion of thorax, methods of vibratory palpation and procedure for vibratory palpation. Students should know the characteristics of normal vibratory palpation. （三） Percussion: techniques of percussion, definitive percussion of the chest, abnormal percussion notes. The sort of percussion: resonant note, hyperresonant note, tympanitic resonance, dullness and flatness. The percussion methods of upper bound and lower bound of lungs and their clinical meanings should be taught in class. (四) Auscultation 1. The sort, features and distribution of normal breath sound （vesicular breath sound, bronchial breath sound, bronchovesicular breath sound） 2. The clinical meanings of abnormal breath sounds should be taught clearly to students. 3. The mechanism of rales and classification,features and clinical meanings. Auscultation of adventitious sounds: crackles, wheezes, rhonchus, special sounds in hydropneumothorax. Auscultation of voice sounds and abnormal voice sounds, Pleural friction rub. 4. The mechanism of pleural rale,features and clinical meanings
5.The examinational methods of vocal resonance,andits clinical meanings(五).main symptoms and signs of common pulmonary diseases;consolidationof lung,pulmonaryemphysema,atelectasis, pleural effusion,pneumothorax.[Teaching hour] lecture 8 hours, practice 18 hous[Teaching method]() Teacher should teach students to check up each other,and inspectthem to master the sequences and methods and understand normal lungssigns.(二) Students should understand and know various abnormal signs of lungsby demonstrating teaching aid and typical signs.(三) Students should write down the record of inquisition and respiratoryexaminationbymeansof clinicalpractice.(四) The body surface symbol of chest, chest wall, thorax and breast canbe taught by demonstration in practice.The body surface symbol of lungs,lobes of lung and pleural can be taught the same way.Heart and blood vessels[Objective and requirement]-,Students should understand the meanings of various heart vibrationand could percuss accurately the boundary of heart.二、 Students should understand the mechanism of first heart sound andsecond heart sound, recognize thedifferences andunderstand the clinicalmeanings of sound increasing and decreasing.三、Students should understand the clinical meanings of heart murmurmechanism, master the correct point of auscultation and distinguishsystolic murmur and diastolic murmur.四、Students should understand the features of common heart rhythmdisorder(sychnosphygmia,bradycardia,prematurebeat,atrialfibrillation)五、Students should knowhowto measure blood pressureand understand themeanings of changing
5. The examinational methods of vocal resonance, and its clinical meanings (五). main symptoms and signs of common pulmonary diseases；consolidation of lung, pulmonary emphysema, atelectasis, pleural effusion, pneumothorax. [Teaching hour] lecture 8 hours, practice 18 hous [Teaching method] （一） Teacher should teach students to check up each other, and inspect them to master the sequences and methods and understand normal lungs signs. （二） Students should understand and know various abnormal signs of lungs by demonstrating teaching aid and typical signs. (三) Students should write down the record of inquisition and respiratory examination by means of clinical practice. (四) The body surface symbol of chest, chest wall, thorax and breast can be taught by demonstration in practice. The body surface symbol of lungs, lobes of lung and pleural can be taught the same way. Heart and blood vessels [Objective and requirement] 一、Students should understand the meanings of various heart vibration and could percuss accurately the boundary of heart. 二、Students should understand the mechanism of first heart sound and second heart sound, recognize the differences and understand the clinical meanings of sound increasing and decreasing. 三、Students should understand the clinical meanings of heart murmur mechanism, master the correct point of auscultation and distinguish systolic murmur and diastolic murmur. 四、 Students should understand the features of common heart rhythm disorder (sychnosphygmia, bradycardia, premature beat, atrial fibrillation) 五、Students should know how to measure blood pressure and understand the meanings of changing
六,Students shouldknowthe examinemethods of pulse and vascular signs.[Contents] Heart(-) Inspection:Precordium contour; apical beat and its position,intensity, range and clinical meanings; the clinical meanings of enlargedheart beating.(二)palpation:Apical impulse, right ventricular impulse, thrills,palpable friction rubs.(三) percussion:methods of percussing cardiac dullness, normal cardiacdullness, the causes and features and clinical meanings of cardiacdullness changing.（四）Auscultation:1. The location of 5 cardiac sounds.2.cardiac rate and rhythm, heart sounds and their physiology orpathophysiology (normal heart sounds, abnormal heart sounds).3. extracardiac sounds and cardiac murmurs (systolic murmurs anddiastolic murmurs).4. Clinical meanings and causes of varied intensity and quality of normalcardiac sounds, clinical meanings and causes of increased or decreasedor splitting second heart sounds in aortic valve area and in pulmonic valvearea.5. The mechanism of cardiacmurmur,location, quality,timing, (systolicor diastolic period or successivemurmur), intensity (grades of systolicmurmur),pattern or configuration,pitch,postureandexercise conductingdirection.6. Systolic and diastolic rubs: The pathophysiology of pericardialfriction rubs.二、Bloodvessels()Arterial circulation in the extremities;Examination of large armand leg arteries
六、Students should know the examine methods of pulse and vascular signs. [Contents] 一 Heart ( 一 ) Inspection: Precordium contour; apical beat and its position, intensity,range and clinical meanings; the clinical meanings of enlarged heart beating. （二）palpation： Apical impulse, right ventricular impulse, thrills, palpable friction rubs. （三）percussion: methods of percussing cardiac dullness, normal cardiac dullness, the causes and features and clinical meanings of cardiac dullness changing. （四）Auscultation： 1. The location of 5 cardiac sounds. 2.cardiac rate and rhythm, heart sounds and their physiology or pathophysiology （normal heart sounds, abnormal heart sounds）. 3. extracardiac sounds and cardiac murmurs (systolic murmurs and diastolic murmurs). 4. Clinical meanings and causes of varied intensity and quality of normal cardiac sounds, clinical meanings and causes of increased or decreased or splitting second heart sounds in aortic valve area and in pulmonic valve area. 5. The mechanism of cardiac murmur, location, quality, timing, (systolic or diastolic period or successive murmur), intensity (grades of systolic murmur), pattern or configuration, pitch, posture and exercise conducting direction. 6. Systolic and diastolic rubs: The pathophysiology of pericardial friction rubs. 二、 Blood vessels （一）Arterial circulation in the extremities；Examination of large arm and leg arteries
(二)vascular signs of cardiac activity:Arterial signs of cardiac actionpulse contour; pulse volume changes; disordered changes in pulse volumeor rhythm; arterial sound; capillary pulsation.三、main symptoms and signs of common cardiovascular diseases(-) valvular heart disease:mitral stenosis, mitral regurgitation,aortic stenosis, aortic regurgitation(二) Heart enlargement (dilatation and hypertrophy)(三） arrhythmia: pathophysiology and clinical occurrence in sinustachycardia, sinus bradycardia, sinus rhythm with second-degree block,third-degree (complete)Av block, premature beats, atrial fibrillation,atrial flutter, paroxysmal atrial (supraventricular) tachycardia (SvT,PSvT), ventricular tachycardia, ventricular fibrillation (vF)(四)dysarteriotony (hypertension and hypotension):pathophysiology andclinical occurrence of hypertension and hypotension.(五) heart failure: pathophysiology, symptoms and signs and clinicaloccurrence（六）pericardial effusion:pathophysiology, symptoms and signs andelectrocardiogram[Teaching hour] lecture 10 hours,clinical practice 18 hours[Teaching method]After lecture,students shouldrepeatedlypracticeexamination ofheart and blood vessels on each other.Students should practice listening to heart sounds and murmursunder teacher guidance through clinical practice.Students should understand and master the signs and clinicalmeanings of heart and vessels by means of clinical practice and teachingaids (cardiac sound imitator and records of heart murmurs.四、Students should write down the examination records of heart andblood vessels (history and signs included)Abdomen[Objective and requirement]
（二）vascular signs of cardiac activity: Arterial signs of cardiac action; pulse contour; pulse volume changes; disordered changes in pulse volume or rhythm; arterial sound; capillary pulsation. 三、main symptoms and signs of common cardiovascular diseases （一）valvular heart disease: mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation (二) Heart enlargement (dilatation and hypertrophy) ( 三 ) arrhythmia: pathophysiology and clinical occurrence in sinus tachycardia, sinus bradycardia, sinus rhythm with second-degree block, third-degree (complete) AV block, premature beats, atrial fibrillation, atrial flutter, paroxysmal atrial (supraventricular) tachycardia (SVT, PSVT), ventricular tachycardia, ventricular fibrillation (VF) （四）dysarteriotony (hypertension and hypotension): pathophysiology and clinical occurrence of hypertension and hypotension. （五）heart failure: pathophysiology, symptoms and signs and clinical occurrence （六）pericardial effusion: pathophysiology, symptoms and signs and electrocardiogram [Teaching hour] lecture 10 hours, clinical practice 18 hours [Teaching method] 一、 After lecture, students should repeatedly practice examination of heart and blood vessels on each other. 二、 Students should practice listening to heart sounds and murmurs under teacher guidance through clinical practice. 三、 Students should understand and master the signs and clinical meanings of heart and vessels by means of clinical practice and teaching aids (cardiac sound imitator and records of heart murmurs. 四、 Students should write down the examination records of heart and blood vessels (history and signs included) Abdomen [Objective and requirement]
Students should handle themethods of abdomen examination (stresson palpation of liver and spleen) ,and know the superficial anatomy andsubregion of the abdomen.Students should know common signs and clinical meanings ofabdomen.[Contents]Superficial anatomy and subregion of the abdomen1Abdomen examination()inspection:l.Abdominal wall;2.Distendedveinin abdominal wall;3.Visible peristalsis: 4.Visible pulsations(二) Auscultation: 1.Peristaltic sounds; 2. Abdominal bruits; 3.Peritoneal frictionrub(三)Percussion:l.Percussion of abdomen; 2.liver percussion;3.Spleenpercussion;4.Shifting dullness:5.Percussionfor costovertebralangle tenderness（四）Palpation:1. Methods;2.Contents: (1) tensity of abdominal wall; (2)direct tenderness andrebound tenderness: (3) palpation of viscera:liver, spleen, gallbladder,mass in the abdomen,fluidwave,succession splash三、 Main symptoms and signs of common abdominal diseasesAscites, abdominal masses,hepatomegaly,splenomegaly[Teaching hour] lecture 8 hours, practice 16 hours[Teaching methods]Afterclass,students shouldpracticeon eachother andmakemoredrills.Students should learn to observe abnormal signs and check up thepatients by themselves if condition possible in clinical practice. Or theycan exercise examinemethods of liver and spleenbymeans of teaching aidmodel.三、Students could discuss symptoms and signs of typical cases ingroups.四、Students should write down abdominal history and record ofabdominal examination after demonstration and practice
一、 Students should handle the methods of abdomen examination (stress on palpation of liver and spleen) ,and know the superficial anatomy and subregion of the abdomen. 二、 Students should know common signs and clinical meanings of abdomen. [Contents] 一、 Superficial anatomy and subregion of the abdomen 二、 Abdomen examination （一） inspection：1. Abdominal wall; 2.Distended vein in abdominal wall; 3.Visible peristalsis; 4.Visible pulsations （二） Auscultation：1. Peristaltic sounds; 2. Abdominal bruits; 3. Peritoneal friction rub （三） Percussion: 1. Percussion of abdomen; 2. liver percussion; 3. Spleen percussion; 4. Shifting dullness; 5. Percussion for costovertebral angle tenderness （四） Palpation: 1. Methods; 2. Contents: ⑴ tensity of abdominal wall; ⑵direct tenderness and rebound tenderness; ⑶ palpation of viscera: liver, spleen, gallbladder, mass in the abdomen, fluid wave, succession splash 三、Main symptoms and signs of common abdominal diseases Ascites, abdominal masses, hepatomegaly, splenomegaly [Teaching hour] lecture 8 hours, practice 16 hours [Teaching methods] 一、 After class, students should practice on each other and make more drills. 二、 Students should learn to observe abnormal signs and check up the patients by themselves if condition possible in clinical practice. Or they can exercise examine methods of liver and spleen by means of teaching aid model. 三、 Students could discuss symptoms and signs of typical cases in groups. 四、 Students should write down abdominal history and record of abdominal examination after demonstration and practice