0705 a practical guide to clinical medicine

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A Practical Guide to Clinical Medicine

http://medicine.ucsd.edu/clinicalmed/introduction.htm

A Practical Guide to Clinical MedicineA comprehensive physical examination and clinical education site formedical students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, !SDSchool of "edicine# !ontent and Photographs by !harlie $oldberg,"%D%, !SD School of "edicine and &A "edical !enter, San Diego,!alifornia '()'*+)--%

Introduction Exam of the Abdomen Write Ups istor! of Present IllnessMale Genital/"ectal Exam #he $ral Presentation #he "est of the istor! #he Upper Extremities $utpatient Clinics

%ital &i'ns #he (o)er Extremities Inpatient Medicine #he E!e Exam Musculo*&+eletal Exam Clinical ,ecision Ma+in'

ead and -ec+ Exam #he Mental &tatus Exam Commonl! Used Abbreiations #he (un' Exam #he -eurolo'ical Exam A e) #hou'hts

Exam of the eart Puttin' It All #o'ether "eferences Medical (in+s &end Comments to: Charlie Goldber'0 M.,.

#he 1da%inci Anatom! Icon1 denotes a lin+ to related 'ross anatom!

pictures.

Introduction

#his 'uide has been assembled )ith an e!e to)ards clinical releance. It represents a

departure from the usual ph!sical exam teachin' tools )hich0 in their attempts to be allinclusie0 tend to de*emphasi2e the practical nature of patient care. As a result0 students

fre3uentl! hae difficult! identif!in' )hat information is trul! releant0 )h! it4s

important and ho) it applies to the actual patient. 5! approachin' clinical medicine in a pra'matic and dem!stified fashion0 the si'nificance of the material should be readil!

apparent and the underl!in' principles more clearl! understood. In particular:

6. Each section is constructed to ans)er the 3uestion: 1What do I reall! need to

+no) about this area of medical care71 #he material coered is presented in aconcise0 ordered fashion that should be readil! applicable to the common clinical

scenarios that !ou )ill actuall! see in da! to da! practice. Esoterica has been

purposel! excluded.



http://medicine.ucsd.edu/clinicalmed/abdomen.htm

http://medicine.ucsd.edu/clinicalmed/write.htm

http://medicine.ucsd.edu/clinicalmed/history.htm

http://medicine.ucsd.edu/clinicalmed/genital.htm

http://medicine.ucsd.edu/clinicalmed/oral.htm

http://medicine.ucsd.edu/clinicalmed/rest.htm

http://medicine.ucsd.edu/clinicalmed/upper.htm

http://medicine.ucsd.edu/clinicalmed/clinic.htm

http://medicine.ucsd.edu/clinicalmed/vital.htm

http://medicine.ucsd.edu/clinicalmed/extremities.htm

http://medicine.ucsd.edu/clinicalmed/inpatient.htm

http://medicine.ucsd.edu/clinicalmed/eyes.htm

http://medicine.ucsd.edu/clinicalmed/Joints.html

http://medicine.ucsd.edu/clinicalmed/thinking.htm

http://medicine.ucsd.edu/clinicalmed/head.htm

http://medicine.ucsd.edu/clinicalmed/mental.htm


http://medicine.ucsd.edu/clinicalmed/abbreviation.htm


http://medicine.ucsd.edu/clinicalmed/lung.htm


http://medicine.ucsd.edu/clinicalmed/neuro2.htm

http://medicine.ucsd.edu/clinicalmed/thoughts.htm


http://medicine.ucsd.edu/clinicalmed/heart.htm

http://medicine.ucsd.edu/clinicalmed/together.htm

http://medicine.ucsd.edu/clinicalmed/refs.htm

http://medicine.ucsd.edu/clinicalmed/links.html

mailto:[email protected]




http://medicine.ucsd.edu/clinicalmed/abdomen.htm

http://medicine.ucsd.edu/clinicalmed/write.htm

http://medicine.ucsd.edu/clinicalmed/history.htm

http://medicine.ucsd.edu/clinicalmed/genital.htm

http://medicine.ucsd.edu/clinicalmed/oral.htm

http://medicine.ucsd.edu/clinicalmed/rest.htm

http://medicine.ucsd.edu/clinicalmed/upper.htm

http://medicine.ucsd.edu/clinicalmed/clinic.htm

http://medicine.ucsd.edu/clinicalmed/vital.htm

http://medicine.ucsd.edu/clinicalmed/extremities.htm

http://medicine.ucsd.edu/clinicalmed/inpatient.htm


http://medicine.ucsd.edu/clinicalmed/Joints.html

http://medicine.ucsd.edu/clinicalmed/thinking.htm

http://medicine.ucsd.edu/clinicalmed/head.htm




http://medicine.ucsd.edu/clinicalmed/neuro2.htm


http://medicine.ucsd.edu/clinicalmed/heart.htm

http://medicine.ucsd.edu/clinicalmed/together.htm

http://medicine.ucsd.edu/clinicalmed/refs.htm

http://medicine.ucsd.edu/clinicalmed/links.html




8. #he Web*5ased format allo)s for eas! access to information and proides

inte'ration of text0 pictures0 and sound.

9. Exam techni3ues are described in step*b!*step detail. &pecial maneuers that arefre3uentl! utili2ed are also described.

. #he rationale for each aspect of the examination is addressed and0 )here

appropriate0 releant pathoph!siolo'! discussed.;. ,etailed descriptions of ho) to function in clinical settin's are included. In

'eneral0 students identif! their role in patient care either b! trial and error or

throu'h the beneficence of more adanced students0 residents or staff. #his is not particularl! efficient and diminishes the potential for learnin' and fun. #he

follo)in' sections are included to specificall! address this issue:

a. $ral presentations

b. Patient )rite*upsc. Wor+in' in outpatient clinics

d. unctionin' on an inpatient serice

e. Clinical decision ma+in'

<. Pictures clearl! identif!in' appropriate techni3ues accompan! each section.Examples of common patholo'ic findin's are included as )ell.

=. Ima'es of 'ross anatomic correlates >denoted b! the 1da%inci Icon1 sho)n aboe?are incorporated )ithin a number of the se'ments.

@. %ideo clips of selected examination maneuers and findin's.

. Carefull! selected lin+s to other useful )ebsites are aailable.

I hope that this site helps to ma+e the educational process both fun and re)ardin'. As thes+ills re3uired of a ph!sician cannot be learned from an! sin'le source0 I encoura'e !ou

to ma+e use of as man! other references as possible. #his should reinforce basic

principles and alert !ou to the fact that there are often man! )a!s of achiein' the same

end >i.e. there is fre3uentl! no sin'le ri'ht )a! of doin' somethin'?. What follo)s0 then0seres merel! as an introduction. I hae tried to capture those core behaiors that define

clinical excellence and )ill hae prolon'ed applicabilit!0 een in a technolo'! drien

)orld. #he learnin' process continues >I hope? until the da! !ou stop practicin' medicine.#here are al)a!s ne) techni3ues to learn and unusual findin's to incorporate into !our

personal libraries of medical experience. o)eer0 unless !ou ta+e the time to build a

solid foundation0 !ou )ill neer hae confidence in the accurac! and alue of )hat !oucan uncoer )ith a sharp mind0 a'ile fin'ers and a fe) simple toolsB

Please Note: Medical and non medical practitioners are )elcome to use this site for

learnin' purposes. o)eer0 it is not meant as a substitute for appropriate ealuation of

medical conditions or pursuit of an adanced education throu'h traditional mechanisms.While the authors )elcome feedbac+ and comments0 please do not solicit medical adice.

#his site is0 and )ill al)a!s remain0 a )or+ in pro'ress. I loo+ for)ard to receiin' an!

and all comments/su''estions/feedbac+ >use the lin+ to m! e*mail0 located at the top of

each pa'e?.



Charlie Goldber'0 M.,.

Uniersit! of California0 &an ,ie'o &chool of Medicine

&an ,ie'o %A Medical Center

an #hompson

Uniersit! of California0 &an ,ie'o &chool of Medicine

&an ,ie'o0 CA

&eptember0 8DD

History of Present Illness (HPI)

$btainin' an accurate histor! is the critical first step in determinin' the etiolo'! of a patient4s problem. A lar'e percenta'e of the time0 !ou )ill actuall! be able ma+e a

dia'nosis based on the histor! alone. #he alue of the histor!0 of course0 )ill depend on

!our abilit! to elicit releant information. our sense of )hat constitutes important data)ill 'ro) exponentiall! in the comin' !ears as !ou 'ain a 'reater understandin' of the

pathoph!siolo'! of disease throu'h increased exposure to patients and illness. o)eer0

!ou are alread! in possession of the tools that )ill enable !ou to obtain a 'ood histor!.#hat is0 an abilit! to listen and as+ common*sense 3uestions that help define the nature of

a particular problem. It does not ta+e a ast0 sophisticated fund of +no)led'e tosuccessfull! interie) a patient. In fact seasoned ph!sicians often lose site of this

important point0 placin' too much emphasis on the use of testin' )hile failin' to ta+e thetime to listen to their patients. &uccessful interie)in' is for the most part dependent

upon !our alread! )ell deeloped communication s+ills.

What follo)s is a frame)or+ for approachin' patient complaints in a problem orientedfashion. #he patient initiates this process b! describin' a s!mptom. It falls to !ou to ta+e

that information and use it as a sprin'board for additional 3uestionin' that )ill help to

identif! the root cause of the problem. -ote that this is different from tr!in' to identif!

disease states )hich mi'ht exist !et do not 'enerate oert s!mptoms. #o uncoer these

issues re3uires an extensie 1"eie) $f &!stems1 >a.+.a. "$&?. Generall!0 this consistsof a list of 3uestions 'rouped accordin' to or'an s!stem and desi'ned to identif! disease

)ithin that area. or example0 a reie) of s!stems for respirator! illnesses )ouldinclude: ,o !ou hae a cou'h7 If so0 is it productie of sputum7 ,o !ou feel short of

breath )hen !ou )al+7 etc. In a practical sense0 it is not necessar! to memori2e an

extensie "$& 3uestion list. "ather0 !ou )ill hae an opportunit! to learn the releant3uestions that uncoer or'an d!sfunction )hen !ou reie) the ph!sical exam for each



s!stem indiiduall!. In this )a!0 the "$& )ill be 'ien some context0 increasin' the

li+elihood that !ou )ill actuall! remember the releant 3uestions.

#he patient4s reason for presentin' to the clinician is usuall! referred to as the 1ChiefComplaint.1 Perhaps a less peForatie/more accurate nomenclature )ould be to identif!

this as their area of 1Chief Concern.1

Getting Started:

Al)a!s introduce !ourself to the patient. #hen tr! to ma+e the enironment as priate andfree of distractions as possible. #his ma! be difficult dependin' on )here the interie) is

ta+in' place. #he emer'enc! room or a non*priate patient room are notoriousl! difficult

spots. ,o the best that !ou can and feel free to be creatie. If the room is cro)ded0 it4s$ to tr! and find alternate sites for the interie). It4s also acceptable to politel! as+

isitors to leae so that !ou can hae some priac!.

If possible0 sit do)n next to the patient )hile conductin' the interie). "emoe an!

ph!sical barriers that stand bet)een !ourself and the interie)ee >e.'. put do)n the siderail so that !our ie) of one another is unimpeded... thou'h ma+e sure to put it bac+ up at

the conclusion of the interie)?. #hese simple maneuers help to put !ou and the patient

on e3ual footin'. urthermore0 the! enhance the notion that !ou are completel! focused

on them. ou can either disarm or build )alls throu'h the speech0 posture and bod!lan'uar'e that !ou adopt. "eco'ni2e the po)er of these cues and the impact that the! can

hae on the interie). While there is no )a! of creatin' instant intimac! and rapport0

pa!in' attention to )hat ma! seem li+e rather small details as )ell as al)a!s sho)in'+indness and respect can 'o a lon' )a! to)ards creatin' an enironment that )ill

facilitate the exchan'e of useful information.

If the interie) is bein' conducted in an outpatient settin'0 it is probabl! better to allo)the patient to )ear their o)n clothin' )hile !ou chat )ith them. At the conclusion of!our discussion0 proide them )ith a 'o)n and leae the room )hile the! undress in

preparation for the ph!sical exam.

Initial Question(s):

Ideall!0 !ou )ould li+e to hear the patient describe the problem in their o)n )ords. $penended 3uestions are a 'ood )a! to 'et the ball rollin'. #hese include: 1What brin's !our

here7 o) can I help !ou7 What seems to be the problem71 Push them to be as

descriptie as possible. While it4s simplest to focus on a sin'le0 dominant problem0 patients occasionall! identif! more then one issue that the! )ish to address. When this

occurs0 explore each one indiiduall! usin' the strate'! described belo).

Follow-up Questions:

#here is no sin'le best )a! to 3uestion a patient. &uccessful interie)in' re3uires that!ou aoid medical terminolo'! and ma+e use of a descriptie lan'ua'e that is familiar to

them. #here are seeral broad 3uestions )hich are applicable to an! complaint. #hese

include:



exposure0 and +no)led'e !ou )ill learn the appropriate settin's for particular lines of

3uestionin'. When clinicians obtain a histor!0 the! are continuall! 'eneratin' differential

dia'noses in their minds0 allo)in' the patient4s ans)ers to direct the lo'ical use ofadditional 3uestions. With each step0 the list of probable dia'noses is pared do)n until a

fe) li+el! choices are left from )hat )as once a lon' list of possibilities. Perhaps an eas!

)a! to understand this )ould be to thin+ of the patient problem as a Windo)s*5asedcomputer pro'ram. #he patient tells !ou a s!mptom. ou clic+ on this s!mptom and a list

of 'eneral 3uestions appears. #he patient then responds to these 3uestions. ou clic+ on

these responses and... blan+ screen. -o problem. As !et0 !ou do not hae the clinical+no)led'e base to +no) )hat 3uestions to as+ next. With time and experience !ou )ill

be able to clic+ on the patient4s response and 'enerate a list of additional appropriate

3uestions. In the preious patient )ith chest pain0 !ou )ill learn that this patient4s stor! is

er! consistent )ith si'nificant0 s!mptomatic coronar! arter! disease. As such0 !ou)ould as+ follo)*up 3uestions that help to define a cardiac basis for this complaint >e.'.

histor! of past m!ocardial infarctions0 ris+ factors for coronar! disease0 etc.?. ou4d also

be a)are that other disease states >e.'. emph!sema? mi'ht cause similar s!mptoms and

)ould therefore as+ 3uestions that could lend support to these possible dia'noses >e.'.histor! of smo+in' or )hee2in'?. At the completion of the PI0 !ou should hae a prett!

'ood idea as to the li+el! cause of a patient4s problem. ou ma! then focus !our exam onthe search for ph!sical si'ns that )ould lend support to !our )or+in' dia'nosis and help

direct !ou in the rational use of adFuant testin'.

"eco'ni2in' s!mptoms/responses that demand an ur'ent assessment >e.'. crushin' chest

pain? s. those that can be handled in a more leisurel! fashion >e.'. fati'ue? )ill come)ith time and experience. All patient complaints merit careful consideration. &ome0

ho)eer0 re3uire time to pla! out0 allo)in' them to either become 1a somethin'1 >a

reco'ni2able clinical entit!? or 1a nothin'01 and simpl! fade a)a!. Clinicians are

constantl! on the loo+*out for mar+ers of underl!in' illness0 historical points )hichmi'ht increase their suspicion for the existence of an underl!in' disease process. or

example0 a patient )ho does not usuall! see+ medical attention !et presents )ith a ne)0

specific complaint merits a particularl! careful ealuation. More often0 ho)eer0 thechallen'e lies in hain' the discipline to continuall! re*consider the dia'nostic

possibilities in a patient )ith multiple0 chronic complaints )ho presents )ith a ariation

of his/her 1usual1 s!mptom complex.

ou )ill undoubtedl! for'et to as+ certain 3uestions0 re3uirin' a return isit to the

patient4s bedside to as+0 1ust one more thin'.1 ,on4t )orr!0 this happens to eer!oneB

ou4ll 'et more efficient )ith practice.

Dealing it# ,our wn Disco&fort:

Man! of !ou )ill feel uncomfortable )ith the patient interie). #his process is0 b! its

er! nature0 hi'hl! intrusie. #he patient has been stripped0 both literall! and fi'uratiel!0

of the la!ers that protect them from the ph!sical and ps!cholo'ical probes of the outside

)orld. urthermore0 in order to be successful0 !ou must as+ in*depth0 intimate 3uestionsof a person )ith )hom !ou essentiall! hae no relationship. #his is completel! at odds

)ith !our normal da! to da! interactions. #here is no )a! to proceed )ithout as+in'



3uestions0 peerin' into the life of an other)ise complete stran'er. #his can0 ho)eer0 be

done in a )a! that maintains respect for the patient4s di'nit! and priac!. In fact0 at this

sta'e of !our careers0 !ou perhaps hae an adanta'e oer more experienced proiders as!ou are h!per*a)are that this is not a natural enironment. Man! ph!sicians become

immune to the sense that the! are iolatin' a patient4s personal space and can

thou'htlessl! oer step boundaries. Aoidin' this is not an eas! tas+. (isten and respondappropriatel! to the internal )arnin's that help to sculpt !our normal interactions.

.#e %est f .#e History

#he remainder of the histor! is obtained after completin' the PI. As such0 the

preiousl! discussed techni3ues for facilitatin' the exchan'e of information still appl!.

Past /edical History: &tart b! as+in' the patient if the! hae an! medical problems. If!ou receie little/no response0 the follo)in' 3uestions can help uncoer important past

eents: ae the! eer receied medical care7 If so0 )hat problems/issues )ere

addressed7 Was the care continuous >i.e. proided on a re'ular basis b! a sin'le person?

or episodic7 ae the! eer under'one an! procedures0 H*"a!s0 CA# scans0 M"Is orother special testin'7 Eer been hospitali2ed7 If so0 for )hat7 It4s 3uite ama2in' ho)

man! patients for'et )hat )ould seem to be important medical eents. ou )ill all

encounter the patient )ho reports little past histor! durin' !our interie) !et reeals acomplex series of illnesses to !our resident or attendin'B #hese patients are 'enerall! not

purposefull! concealin' information. #he! simpl! need to be prompted b! the ri'ht

3uestionsB

Past Surgical History: Were the! eer operated on0 een as a child7 What !ear did thisoccur7 Were there an! complications7 If the! don4t +no) the name of the operation0 tr! to

at least determine )h! it )as performed. Encoura'e them to be as specific as possible.

/edications: ,o the! ta+e an! prescription medicines7 If so0 )hat is the dose and

fre3uenc!7 ,o the! +no) )h! the! are bein' treated7 Medication non*compliance/confusion is a maFor clinical problem0 particularl! )hen re'imens are

complex0 patients older0 co'nitiel! impaired or simpl! disinterested. It4s important to

ascertain if the! are actuall! ta+in' the medication as prescribed. #his can proide critical

information as fre3uentl! )hat appears to be a failure to respond to a particular therap! isactuall! non*compliance )ith a prescribed re'imen. Identif!in' these situations re3uires

some tact0 as !ou4d li+e to encoura'e honest! )ithout soundin' accusator!. It helps toclearl! explain that )ithout this information !our abilit! to assess treatment efficac! and

ma+e therapeutic adFustments becomes difficult/potentiall! dan'erous. If patients are0 in

fact0 missin' doses or not ta+in' medications alto'ether0 as+ them )h! this is happenin'.Perhaps there is an important side effect that the! are experiencin'0 a reasonable fear that

can be addressed0 or a more acceptable substitute re'imen )hich mi'ht be implemented.



!ou to practice obtainin' ital si'ns but proides an opportunit! to erif! their accurac!.

As noted belo)0 there is si'nificant potential for measurement error0 so repeat

determinations can proide critical information.

Getting Started: #he examination room should be 3uiet0 )arm and )ell lit. After !ou

hae finished interie)in' the patient0 proide them )ith a 'o)n >a.+.a. 1ohnn!1? andleae the room >or dra) a separatin' curtain? )hile the! chan'e. Instruct them to remoe

all of their clothin' >except for briefs? and put on the 'o)n so that the openin' is in therear. $ccasionall!0 patient4s )ill end up usin' them as ponchos0 capes or in other creatie

)a!s. While this ma! ma+e for a more attractie ensemble it )ill also0 unfortunatel!0

interfere )ith !our abilit! to perform an examinationB Prior to measurin' ital si'ns0 the patient should hae had the opportunit! to sit for approximatel! fie minutes so that the

alues are not affected b! the exertion re3uired to )al+ to the exam room. All

measurements are made )hile the patient is seated.

+seration: 5efore diin' in0 ta+e a minute or so to loo+ at the patient in their entiret!0

ma+in' !our obserations0 if possible0 from an out*of*the )a! perch. ,oes the patientseem anxious0 in pain0 upset7 What about their dress and h!'iene7 "emember0 the exam

be'ins as soon as !ou la! e!es on the patient.

.e&perature: #his is 'enerall! obtained usin' an oral thermometer that proides adi'ital readin' )hen the sensor is placed under the patient4s ton'ue. As most exam rooms

do not hae thermometers0 it is not necessar! to repeat this measurement unless0 of

course0 the recorded alue seems discordant )ith the patient4s clinical condition >e.'. the!feel hot but reportedl! hae no feer or ice ersa?. ,ependin' on the bias of a particular

institution0 temperature is measured in either Celcius or arenheit0 )ith a feer defined as

'reater then 9@*9@.; C or 6D6*6D6.; . "ectal temperatures0 )hich most closel! reflect

internal or core alues0 are approximatel! 6 de'ree hi'her then those obtained orall!.

%espiratory %ate: "espirations are recorded as breaths per minute. #he! should be

counted for at least 9D seconds as the total number of breaths in a 6; second period is

rather small and an! miscountin' can result in rather lar'e errors )hen multiplied b! .#r! to do this as surreptitiousl! as possible so that the patient does not consciousl! alter

their rate of breathin'. #his can be done b! obserin' the rise and fall of the patient4s

hospital 'o)n )hile !ou appear to be ta+in' their pulse. -ormal is bet)een 68 and 8D. In'eneral0 this measurement offers no releant information for the routine examination.

o)eer0 particularl! in the settin' of cardio*pulmonar! illness0 it can be a er! reliable

mar+er of disease actiit!.

Pulse: #his can be measured at an! place )here there is a lar'e arter! >e.'. carotid0femoral0 or simpl! b! listenin' oer the heart?0 thou'h for the sa+e of conenience it is

'enerall! done b! palpatin' the radial impulse. ou ma! find it helpful to feel both radial

arteries simultaneousl!0 doublin' the sensor! input and helpin' to insure the accurac! of!our measurements. Place the tips of !our index and middle fin'ers Fust proximal to the

patients )rist on the thumb side0 orientin' them so that the! are both oer the len'th of

the essel.



2ascular nato&y

.ec#ni3ue for /easuring t#e %adial Pulse

#he pictures belo) demonstrate the location of the radial arter! >surface anatom! on theleft0 'ross anatom! on the ri'ht?.



re3uentl!0 !ou can see transmitted pulsations on careful isual inspection of this re'ion0)hich ma! help in locatin' this arter!. Upper extremit! peripheral ascular disease is

relatiel! uncommon0 so the radial arter! should be readil! palpable in most patients.

Push li'htl! at first0 addin' pressure if there is a lot of subcutaneous fat or !ou are unableto detect a pulse. If !ou push too hard0 !ou mi'ht occlude the essel and mista+e !our

o)n pulse for that of the patient. ,urin' palpation0 note the follo)in':

6. Kuantit!: Measure the rate of the pulse >recorded in beats per minute?. Count for

9D seconds and multipl! b! 8 >or 6; seconds x ?. If the rate is particularl! slo)or fast0 it is probabl! best to measure for a full <D seconds in order to minimi2e

the impact of an! error in recordin' oer shorter periods of time. -ormal is

bet)een <D and 6DD.8. "e'ularit!: Is the time bet)een beats constant7 In the normal settin'0 the heart

rate should appear metronomic. Irre'ular rh!thms0 ho)eer0 are 3uite common. If

the pattern is entirel! chaotic )ith no discernable pattern0 it is referred to asirre'ularl! irre'ular and li+el! represents atrial fibrillation. Extra beats can also be



added into the normal pattern0 in )hich case the rh!thm is described as re'ularl!

irre'ular. #his ma! occur0 for example0 )hen impulses ori'inatin' from the

entricle are interposed at re'ular Functures on the normal rh!thm. If the pulse isirre'ular0 it4s a 'ood idea to erif! the rate b! listenin' oer the heart >see cardiac

exam section?. #his is because certain rh!thm disturbances do not allo) ade3uate

entricular fillin' )ith each beat. #he resultant s!stole ma! 'enerate a rathersmall stro+e olume )hose impulse is not palpable in the peripher!.

9. %olume: ,oes the pulse olume >i.e. the subFectie sense of fullness? feel normal7

#his reflects chan'es in stro+e olume. In the settin' of h!poolemia0 forexample0 the pulse olume is relatiel! lo) >a+a )ea+ or thread!?. #here ma!

een be beat to beat ariation in the olume0 occurrin' occasionall! )ith s!stolic

heart failure.

4lood Pressure: 5lood pressure >5P? is measured usin' mercur! based manometers0)ith readin's reported in millimeters of mercur! >mm '?. #he si2e of the 5P cuff )ill

affect the accurac! of these readin's. #he inflatable bladder0 )hich can be felt throu'h

the in!l coerin' of the cuff0 should reach rou'hl! @DL around the circumference of thearm )hile its )idth should coer rou'hl! DL. If it is too small0 the readin's )ill be

artificiall! eleated. #he opposite occurs if the cuff is too lar'e. Clinics should hae at

least 8 cuff si2es aailable0 normal and lar'e. #r! to use the one that is most appropriate0

reco'ni2in' that there )ill rarel! be a perfect fit.

4lood Pressure "uffs



In order to measure the 5P0 proceed as follo)s:

6. Wrap the cuff around the patient4s upper arm so that the line mar+ed 1arter!1 is

rou'hl! oer the brachial arter!0 located to)ards the medial aspect of theantecubital fossa >i.e. the croo+ on the inside of their elbo)?. #he placement does

not hae to be exact nor do !ou actuall! need to identif! this arter! b! palpation.

ntecu+ital Fossa

#he pictures belo) demonstrate the antecubital fossa anatom! >surface anatom!

on the left0 'ross anatom! on the ri'ht?.



8. Put on !our stethescope so that the ear pieces are an'led a)a! from !our head.

#)ist the head piece so that the diaphra'm is en'a'ed. #his can be erified b!

'entl! tappin' on the end0 )hich should produce a sound. With !our left hand0

place the diaphra'm oer the area of the brachial arter!. While most practitionersuse the diaphra'm of the stethescope0 the bell ma! actuall! be superior for pic+in'

up the lo) pitched sounds used for measurin' 5P. Experiment )ith both and see

if this ma+es a difference. It4s )orth mentionin' that a number of different modelsof stethescops are aailable on the mar+et0 each )ith its o)n ariation on the

structure of the diaphra'm and bell. "ead the instruction manual accompan!in'!our stethoscope in order to determine ho) !our deice )or+s.



9. Grasp the patient4s ri'ht elbo) )ith !our ri'ht hand and raise their arm so that the

brachial arter! is rou'hl! at the same hei'ht as the heart. #he arm should remain

some)hat bent and completel! relaxed. ou can proide additional support b!'entl! trappin' their hand and forearm bet)een !our bod! and ri'ht elbo). If the

arm is held too hi'h0 the readin' )ill be artifactuall! lo)ered0 and ice ersa.

. #urn the ale on the pumpin' bulb cloc+)ise >ma! be counter cloc+)ise in somecuffs? until it no lon'er moes. #his is the position )hich allo)s air to enter and

remain in the bladder.

;. old the diaphra'm in place )ith !our left hand. Use !our ri'ht hand to pump the bulb until !ou hae 'enerated 6;D mm' on the manometer. #his is a bit aboe

the top end of normal for s!stolic blood pressure >&5P?. #hen listen. If !ou

immediatel! hear sound0 !ou hae underestimated the &5P. Pump up an

additional 8D mm' and repeat. -o) slo)l! deflate the blood pressure cuff >i.e. afe) mm ' per second? b! turnin' the ale in a counter*cloc+)ise direction

)hile listenin' oer the brachial arter! and )atchin' the pressure 'au'e. #he first

sound that !ou hear reflects the flo) of blood throu'h the no lon'er completel!

occluded brachial arter!. #he alue on the manometer at this moment is the &5P. -ote that althou'h the needle ma! oscillate prior to this time0 it is the sound of

blood flo) that indicates the &5P.<. Continue listenin' )hile !ou slo)l! deflate the cuff. #he diastolic blood pressure

>,5P? is measured )hen the sound completel! disappears. #his is the point )hen

the pressure )ithin the essel is 'reater then that supplied b! the cuff0 allo)in'the free flo) of blood )ithout turbulence and thus no audible sound. #hese are

+no)n as the &ounds of orat+off.

.ec#ni3ue for /easuring 4lood Pressure

=. "epeat the measurement on the patient4s other arm0 reersin' the position of !our

hands. #he t)o readin's should be )ithin 6D*6; mm ' of each other.,ifferences 'reater then this impl! that there is differential blood flo) to each



arm0 )hich most fre3uentl! occurs in the settin' of subclaian arter!

atherosclerosis.

@. $ccasionall! !ou )ill be unsure as to the point )here s!stole or diastole occurredand )ish to repeat the measurement. Ideall!0 !ou should allo) the cuff to

completel! deflate0 permit an! enous con'estion in the arm to resole >)hich

other)ise ma! lead to inaccurate measurements?0 and then repeat a minute or solater. urthermore0 )hile no one has eer lost a limb secondar! to 5P cuff induced

ischemia0 repeated measurement can be uncomfortable for the patient0 another

'ood reason for 'iin' the arm a brea+.. Aoid moin' !our hands or the head of the stethescope )hile !ou are ta+in'

readin's as this ma! produce noise that can obscure the &ounds of orat+off.

6D. ou can erif! the &5P b! palpation. #o do this0 position the patient4s ri'ht arm as

described aboe. Place the index and middle fin'ers of !our ri'ht hand oer theradial arter!. Inflate the cuff until !ou can no lon'er feel the pulse0 or simpl! to a

alue 6D points aboe the &5P as determined b! auscultation. &lo)l! deflate the

cuff until !ou can a'ain detect a radial pulse and note the readin' on the

manometer. #his is the &5P and should be the same as the alue determined )iththe use of !our stethescope.

-ormal is bet)een 6DD/<D and 6D/D. !pertension is thus defined as either &5P 'reater

then 6D or ,5P 'reater than D. It is important to reco'ni2e that blood pressure is rarel!eleated to a leel that causes acute s!mptoms. #hat is0 )hile h!pertension in 'eneral is

common0 emer'encies resultin' from extremel! hi'h alues and subse3uent acute end

or'an d!sfunction are 3uite rare. "ather0 it is the chronicall! eleated alues )hich leadto tar'et or'an dama'e0 thou'h in a slo) and relatiel! silent fashion. At the other end of

the spectrum0 the minimal &5P re3uired to maintain perfusion aries )ith the indiidual.

#herefore0 interpretation of lo) alues must ta+e into account the clinical situation.

#hose )ith poorl! functionin' hearts0 for example0 can adFust to a chronicall! lo) &5P>e.'. @D*D? and lie )ithout s!mptoms of h!poperfusion. o)eer others0 used to hi'her

baseline alues0 mi'ht become 3uite ill if their &5Ps )ere suddenl! decreased to these

same leels.

Man! thin's can alter the accurac! of !our readin's. In order to limit their impact0

remember the follo)in':

6. ,o not place the blood pressure cuff oer a patients clothin' or roll a ti'ht fittin'

sleee aboe their biceps )hen determinin' blood pressure as either can causeeleated readin's.

8. Ma+e sure the patient has had an opportunit! to rest before measurin' their 5P.

#r! the follo)in' experiment to assess the impact that this can hae. #a+e a patient4s 5P after the!4e rested. #hen repeat after the!4e )al+ed bris+l! in place

for seeral minutes. Patients )ho are not too ph!sicall! actie >i.e. relatiel!

deconditioned? )ill deelop an eleation in both their &5P and ,5P. Also0 see

)hat effect raisin' or lo)erin' the arm0 and thus the position of the brachial arter!relatie to the heart0 has on 5P. If !ou hae a chance0 obtain measurements on the

same patient )ith both a lar'e and small cuff. #hese exercises should 'ie !ou an



appreciation for the ma'nitude of error that can be introduced )hen improper

techni3ue is utili2ed.

9. If the readin' is surprisin'l! hi'h or lo)0 repeat the measurement to)ards the endof !our exam.

. Instruct !our patients to aoid coffee0 smo+in' or an! other unprescribed dru'

)ith s!mpathomimetic actiit! on the da! of the measurement.;. $rthostatic >a.+.a. postural? measurements of pulse and blood pressure are part of

the assessment for h!poolemia. #his re3uires first measurin' these alues )hen

the patient is supine and then repeatin' them after the! hae stood for 8 minutes0)hich allo)s for e3uilibration. -ormall!0 &5P does not ar! b! more then 8D

points )hen a patient moes from l!in' to standin'. In the settin' of si'nificant

olume depletion0 a 'reater then 8D point drop ma! be seen. Chan'es of lesser

ma'nitude occur )hen moin' from l!in' to sittin' or sittin' to standin'. #his isfre3uentl! associated )ith s!mptoms of cerebral h!poperfusion >e.'.. li'ht

headedness?. eart rate should increase b! more then 8D points in a normal

ph!siolo'ic attempt to au'ment cardiac output b! proidin' chronotropic

compensation. In the settin' of GI bleedin'0 for example0 a drop in blood pressureand/or rise in heart rate after this maneuer is a mar+er of si'nificant blood loss

and has important pro'nostic implications. $rthostatic measurements ma! also beused to determine if postural di22iness0 a common complaint )ith multiple

possible explanations0 is the result of a fall in blood pressure. or example0

patients )ho suffer from diabetes fre3uentl! hae autonomic nerous s!stemd!sfunction and cannot 'enerate appropriate arteriolar aosconstriction )hen

chan'in' positions. #his results in postural ital si'n chan'es and s!mptoms. #he

8D point alue is a rou'h 'uideline. In 'eneral0 the 'reater the chan'e0 the more

li+el! it is to cause s!mptoms and be of clinical releance.<. If possible0 measure the blood pressure of a patient )ho has an ind)ellin' arterial

catheter >these patients can be found in the ICU )ith the help of a preceptor?.

Arterial transducers are an extremel! accurate tool for assessin' blood pressureand therefore proide a method for chec+in' !our non*inasie techni3ue.

1ygen Saturation: $er the past decade0 this non*inasie measurement of 'as

exchan'e and red blood cell ox!'en carr!in' capacit! has become aailable in all

hospitals and man! clinics. While imperfect0 it can proide important information aboutcardio*pulmonar! d!sfunction and is considered b! man! to be a fifth ital si'n. In

particular0 for those sufferin' from either acute or chronic cardio*pulmonar! disorders0 it

can help 3uantif! the de'ree of impairment.

Pulse 1y&eter



http://medicine.ucsd.edu/clinicalmed/e!es.htm

.#e 5ye 51a&

ssess&ent of 2isual cuity: #he first part of the e!e exam is an assessment of acuit!.#his can be done )ith either a standard &nellen han'in' )all chart read )ith the patient

standin' at a distance of 8D feet or a speciall! desi'ned poc+et card >held at 6 inches?.Each e!e is tested independentl! >i.e. one is coered )hile the other is used to read?. #he patient should be allo)ed to )ear their 'lasses and the results are referred to as 15est

corrected ision.1 ou do not need to assess their abilit! to read eer! line on the chart. If

the! hae no complaints0 rapidl! s+ip do)n to the smaller characters. #he numbers at the

end of the line proide an indication of the patient4s acuit! compared )ith normalsubFects. #he lar'er the denominator0 the )orse the acuit!. 8D/8DD0 for example0 means

that the! can see at 8D feet )hat a normal indiidual can at 8DD feet >i.e. their ision is

prett! lous!?. If the patient is unable to read an! of the lines0 indicatie of a bi' problemif this )as a ne) complaint0 a 'ross estimate of )hat the! are capable of seein' should be

determined >e.'. abilit! to detect li'ht0 motion or number of fin'ers placed in front of

them?. In 'eneral0 acuit! is onl! tested )hen there is a ne)0 specific0 isual complaint.Hand Held cuity "ard Snellen "#art





Pin#ole .esting: #he pinhole testin' deice can determine if a problem )ith acuit! is theresult of refractie error >and thus correctable )ith 'lasses? or due to another process. #he pinholes onl! allo) the passa'e of li'ht )hich is perpendicular to the lens0 and thus does

not need to be bent prior to bein' focused onto the retina. #he patient is instructed to

ie) the &nellen chart )ith the pinholes up >belo) left? and then a'ain )ith them in thedo)n position >belo) ri'ht?. If the deficit corrects )ith the pinholes in place0 the acuit!

issue is related to a refractie problem.

+seration of 51ternal Structures:

6. $ccular &!mmetr!: $ccasionall!0 one of the muscles that controls e!e moement

)ill be )ea+ or foreshortened0 causin' one e!e to appear deiated mediall! orlaterall! compared )ith the other.



8. E!e (id &!mmetr!: 5oth e!e lids should coer approximatel! the same amount of e!eball. ,ama'e to the neres controllin' these structures >Cranial -eres 9 and

=? can cause the upper or lo)er lids on one side to appear lo)er then the other.

Patient una+le to co&pletely close left upper eyelid due to perip#eral "N 6

dysfunction7

9. &clera: #he normal sclera is )hite and surrounds the iris and pupil. In the settin'

of lier or blood disorders that cause h!perbilirubinemia0 the sclera ma! appear

!ello)0 referred to as icterus. #his can be easil! confused )ith a mudd!*bro)ndiscoloration common amon' older African Americans that is a ariant of normal.

Icteric Sclera



Muddy Brown Sclera

. ConFunctia: #he sclera is coered b! a thin transparent membrane +no)n as theconFunctia0 )hich reflects bac+ onto the underside of the e!elids. -ormall!0 it4s

inisible except for the fine blood essels that run throu'h it. When infected or

other)ise inflamed0 this la!er can appear 3uite red0 a condition +no)n asconFunctiitis. Alternatiel!0 the conFunctia can appear pale if patient is er!

anemic. 5! 'entl! appl!in' pressure and pullin' do)n and a)a! on the s+in

belo) the lo)er lid0 !ou can examine the conFunctial reflection0 )hich is the best place to identif! this findin'.

Nor&al ppearing "on8unctial

%eflection9 $ower $id Pale "on8unctia9 due to seere ane&ia7



;.

7 "on8unctiitis

=. 5lood can also accumulate underneath the conFunctia )hen one of the small blood essels )ithin it ruptures. #his ma! be the result of relatiel! minor trauma

>cou'h0 snee2e0 or direct blo)?0 a bleedin' disorder or idiopathic. #he resultin'

collection of blood is called a subconFunctial hemorrha'e. While dramatic0 it is'enerall! self limited and does not affect ision.

;7 Su+con8unctial He&orr#age

.

6D. Pupil and Iris: -ormall!0 both of these structures are round and s!mmetric.



When performin' the rest of the exam0 ma+e sure that !ou are in a comfortable position.

#he critical maneuer is assurin' that the patient is seated at a hei'ht such that their e!es

are essentiall! on the same leel as !our o)n )hen !ou are standin' next to them.

.esting 51tra-ccular /oe&ents: Instruct the patient to follo) !our index fin'er )ith

their e!es onl! >i.e. their head remains in one position? as !ou first moe it to either theextreme ri'ht or left. #hen0 once !ou hae the patient loo+in' out laterall!0 hae them

follo) !our fin'er as !ou moe it first up0 then do)n. -o) moe !our fin'er across tothe other side and repeat. our path should trace out the letter . At the end0 brin' !our

fin'er directl! in to)ards the patient4s nose. #his )ill cause the patient to loo+ cross*e!ed

and the pupils should constrict0 a response referred to as accommodation.

#racin' out this path allo)s !ou to test each of the extra*occular muscles indiiduall! and

aoids moements that are dependent on more then one muscle0 as occurs if !ou hae the

patient loo+ up or do)n )hile the pupil is oriented strai'ht ahead. Assessments of both

extra*occular moements and isual acuit! are actuall! tests of cranial nere >C-?

function. C-s 90 0 and < control moement and C- 8 ision. As these neres are criticalto e!e function0 it ma+es sense to ealuate them at this sta'e rather then durin' the

neurolo'ical examination.

.esting 51tra ccular /oe&ents

"Ns and t#e /uscles .#at "ontrol 51tra ccular /oe&ents



%ig#t "N< $esion: -ote patient4s ri'ht e!e is deiated laterall! and there is ptosis of thelid >picture on left?0

and the ri'ht pupil >middle picture? is more dilated than the left pupil >picture on far

ri'ht?.

,isorders of e!e moement can also be due to problems )ith the extraocular musclesthemseles. or example0 pictured belo) is a patient )ho has suffered a traumatic left

orbital inFur!. #he inferior rectus muscle has become entrapped )ithin the resultin'

fracture0 preentin' the left e!e from bein' able to loo+ do)n)ard.

5ntrap&ent of $eft Inferior %ectus /uscle

&imulation of extra occular moement and pupillar! disorders. from UC ,ais.

2isual fields: #he normal isual field for each e!e extends out from the patient in all

directions0 )ith an area of oerlap directl! in front. ield cuts refer to specific re'ions)here the patient has lost their abilit! to see. #his occurs )hen the transmitted isual

impulse is interrupted at some point in its path from the retina to the isual cortex in the

bac+ of the brain. ou )ould0 in 'eneral0 onl! include a isual field assessment if the patient complained of loss of si'htJ in particular 1blind spots1 or 1holes1 in their

ision.%isual fields can be crudel! assessed as follo)s:

http://cim.ucdavis.edu/EyeRelease/Interface/eSim.htm





6. #he examiner should be nose to nose )ith the patient0 separated b!

approximatel! @ to 68 inches.

8. Each e!e is chec+ed separatel!. #he examiner closes one e!e and the patient closes the one opposite. #he open e!es should then be starin'

directl! at one another.

9. #he examiner should moe their hand out to)ards the peripher! of his/herisual field on the side )here the e!es are open. #he fin'er should be

e3uidistant from both persons.

. #he examiner should then moe the )i''lin' fin'er in to)ards them0alon' an ima'inar! line dra)n bet)een the t)o persons.#he patient and

examiner should detect the fin'er at more or less the same time.

;. #he fin'er is then moed out to the dia'onal corners of the field and

moed in)ards from each of these directions. #estin' is then done startin'at a point in front of the closed e!es. #he )i''lin' fin'er is moed

to)ards the open e!es.

<. #he other e!e is then tested.

Meanin'ful interpretation is predicated upon the examiner hain' normal fields0 as the!

are usin' themseles for comparison.

If the examiner cannot seem to moe their fin'er to a point that is outside the patients

field dont )orr!0 as it simpl! means that their fields are normal.

Interpretation: #his test is rather crude0 and it is 3uite possible to hae small isual fielddefects that )ould not be apparent on this t!pe of testin'. Prior to interpretin' abnormal

findin's0 the examiner must understand the normal path)a!s b! )hich isual impulses

trael from the e!e to the brain.

or more information about isual field testin'0 see the follo)in' lin+s:

Washin'ton Uniersit!0 reie) of isual field of testin' and patholo'!

Uniersit! of Ar+ansas0 'ross anatom! of isual path)a!

0sing t#e pt#al&oscope

#his aspect of the exam is0 at least initiall!0 3uite a)+)ard. ,on4t )orr!0 it )ill 'et easier

)ith practiceB #a+e some time to pla! )ith !our scope0 pa!in' attention to its assembl!0

on/off mechanism as )ell as the arious lens and li'ht settin's )hich can be utili2ed.#here are a number of different brands on the mar+et and each is a bit different. or the

purposes of the 'eneral exam0 )e4ll focus on the simplest settin's and most basic

techni3ues.

Side of Scope Facing 51a&iner Side of Scope Facing Patient

http://thalamus.wustl.edu/course/basvis.html

http://anatomy.uams.edu/anatomyhtml/atlas_html/eye_38.html

http://thalamus.wustl.edu/course/basvis.html

http://anatomy.uams.edu/anatomyhtml/atlas_html/eye_38.html



ssessing Pupillary %esponse to $ig#t:

#he normal pupil constricts )hen either exposed directl! to bri'ht li'ht or )hen that

same li'ht is presented to the other e!e0 referred to as the consensual response. #his is

due to the fact that stimulation of the afferent >i.e. sensor!0 carried )ith C- 8? neres inone e!e )ill tri''er efferent >i.e. motor0 carried )ith C- 9? actiation and subse3uent

constriction of the pupils of both e!es. ,isease affectin' either the efferent or afferent

limbs )ill alter these responses accordin'l!. Also0 processes )hich raise intracranial pressure >e.'. brain tumors0 collections of blood? can cause C- 9 d!sfunction0 resultin' in

dilatation of the pupils and uresponsieness to direct stimulation b! li'ht. #o assess

pupillar! reactions0 proceed as follo)s:

6. Instruct the patient to loo+ to)ards a distant area in the room >e.'. the corner)here the )all and ceilin' meet? )hile +eepin' both of their e!es open. ou ma!

need to 'entl! remind them throu'hout the exam to continue loo+in' in that

direction as it is er! difficult to examine a roin' e!eball. ,o not as+ them tofocus on a specific obFect as this )ill lead to pupillar! constriction.

8. #urn on !our opthalmoscope and adFust the li'ht intensit! to mid*ran'e po)er.

#he cone of li'ht produced should be a )hite0 medium si2ed circle. Circle si2esaailable include small0 medium and lar'e. If possible0 turn off most of the li'hts

in the room. #his allo)s the pupil to dilate and cuts do)n on reflections from the

surface of the e!e.

9. Ma+e note of the si2e and shape of each pupil. #hen assess )hether each pupilconstricts appropriatel! in response to direct and indirect stimulation. If !ou4re

hain' trouble detectin' an! chan'e0 hae the patient close their e!e for seeral

seconds and place !our hand oer their e!ebro)s to proide additional shade.#his helps to ma+e it as dar+ as possible0 encoura'in' 'reater pupillar! dilation

and therefore accentuatin' an! chan'e )hich ma! occur after li'ht is introduced.

It ma! be hard to detect the consensual response if the li'htin' in !our room issub*optimal >i.e. if it4s too dar+0 !ou )on4t be able to see the other e!e?. -ote that



!ou do not need to loo+ throu'h the ie)in' )indo) of the scope to perform this

part of the exam as !ou are essentiall! usin' it as a flashli'ht.

"loser 51a& of t#e uter Structures of t#e 5ye: 6. Eer! opthalmoscope has a mechanism for chan'in' the ie)in' lens. #hese

lenses ar! in their abilit! to bend li'ht and are numbered and color coded. #hespecific lens that allo)s !ou to see somethin' in focus )ill ar! )ith !our

distance from that structure as )ell as the refractie error of both !our e!es andthe patients. #o better examine the sclera0 conFunctia0 pupil0 cornea or iris0 start

)ith the lens identified b! a 'reen or <.

8. -o) 'rasp the handle )ith !our ri'ht hand >the follo)in' instructions are forexaminin' the patient4s ri'ht e!e? such that !our middle fin'er is restin' on the

lo)er0 front aspect of the head of the opthalmoscope.

9. 5rin' !our ri'ht e!e up to the ie)in' )indo). While !ou can either )ear orremoe !our o)n 'lasses0 the patient4s should be ta+en off. It4s $ to leae

contacts in place.

. #a+e !our left hand and place it on the patient4s forehead and 'entl! appl! up)ardtraction on the top lid )ith !our thumb. #his )ill 1remind1 them not to blin+ and

let !ou +no) their precise location. $biousl!0 tr! not to po+e them in the e!e

)ith this fin'erB Alternatiel!0 !ou can place !our left hand on the patient4s

shoulder as a means of +eepin' trac+ of their location. #r! to +eep both of !oure!es open )hen performin' the exam as !ou mi'ht find it 3uite tirin' to

continuall! s3uint )ith the non*examinin' e!e.

;. &tart approximatel! 6; cm from the patient and approach from about 6; or 8Dde'rees to the left of center. When !ou loo+ throu'h the ie)in' )indo)0 the

outer structures of the e!e should come into sharp focus. If not0 slo)l! moe

closer or further from the patient until these structures become clear. It ta+es a bit

of experimentation to find the lens that is ri'ht for an! 'ien distance0 so ma+elens chan'es slo)l! b! rotatin' the adFustment )heel. #here is no ma'ic )a! of

'uessin' )hich lens )ill allo) the sharpest ie).

Most clinicians don4t perform a detailed examination of the outer structures of the e!e ifthe patient has neither obious abnormalities nor complaints referable to this re'ion.

2iewing t#e Fundus (t#e retina and associated structures):

6. "epeat steps 6 thru ; as aboe. AdFust the

lens selection )heel so that D appears in

the displa! )indo).



%ed %efle1

8. (oo+ throu'h the ie)in' )indo) at the

patient4s pupil0 usin' !our ri'ht e!e to

examine their ri'ht e!e. ou should see aspar+l!0 oran'e*red color +no)n as the red

reflex. #his is caused b! li'ht reflectin'

off of the retina and is the same phenomenon that produces red e!es in

flash photo'raphs. $ccasionall!0 the

translucent structures )hich allo) li'ht to pass unimpeded from outside the e!e to

the retina become opacified and the red

reflex is lost. In adults0 this is most

commonl! associated )ith cataracts0 a process caused b! cloudin' of the lens.

5ye "ross Section

(Picture "ourtesy of %ay =elly)

9. In order to see the fundus in 'reater detail0 !ou )ill need to moe er! close to the

patient0 analo'ous to loo+in' throu'h a +e! hole >i.e. the closer !ou are0 the more!ou4ll see?. our middle fin'er0 the one restin' on the lo) front of the head piece0

should be on or near the patient4s chee+. &tartin' )ith the D lens in place0 rotate

the adFustment )heel counter cloc+)ise. If !ou chan'e lenses too 3uic+l!0 !ou4ll probabl! )hi22 ri'ht b! the one that 'ies the sharpest picture0 so be patient. In

the eent that this does not brin' an!thin' into focus0 tr!in' rotatin' the

adFustment )heel in the opposite direction. It doesn4t reall! matter )hat numberlens is re3uired to achiee the clearest ie). A'ain0 this )ill ar! )ith the



refractie error of both !ou and the patient. #he numbers are simpl! proided for

reference. #hus0 )hile !ou ma! be able to see the fundus of some patients )ith

the 'reen numbers still isible0 !ou )ill need red @ or 6D to isuali2e the samere'ion in a different person. $nce !ou4re close in and hae the retina in clear ie)0

!ou should onl! need to chan'e the lens one or t)o clic+s in order to +eep all

structures in focus as !ou scan across.. ou )ill onl! be able to see a relatiel! small se'ment of the retina at an! one

time. our initial ie) )ill probabl! be of blood essels on a random patch of

retina >see belo)?.

#he retina has a refractile0 oran'e*red appearance0 ar!in' a bit )ith the s+in color anda'e of the patient. undoscop! proides important information as it not onl! enables !ou

to detect diseases of the e!es but is also the onl! area of the bod! )here small blood

essels can be studied )ith relatie ease. #here are a number of chronic s!stemic diseases>most commonl! h!pertension0 diabetes and atherosclerosis? that affect essels of this

si2e in a relatiel! slo) and silent fashion. It is0 ho)eer0 fre3uentl! impossible to

directl! assess the extent of this dama'e durin' ph!sical examination as the affectedor'ans0 e.'. +idne!s0 are )ell hidden. Ealuation of the retina proides an opportunit! to

directl! isuali2e these processes. 5ased on this information0 clinicians can ma+e

educated 'uesses as to )hat is occurrin' else)here in the bod!. ain' said this0 do not

be discoura'ed if it ta+es a )hile before !ou4re able to identif! structures )ith an! de'reeof confidence. Practice on eer! patient that !ou examine. It )ill come )ith time. A fe)

thin's to pa! attention to:

6. When !ou first isuali2e the retina0 !ou )ill note branchin' blood essels. #he bi''er0 dar+er ones are the eins and the smaller0 bri'hter red structures the

arteries. Chan'es in the appearance of the arteries >copper )irin'? as )ell as

alterations in the arterial*enous crossin' pattern >a* nic+in'? occur )ith

atherosclerosis and h!pertension respectiel! >see an! text for pictures?. #heseessels are more obious in the superior and inferior aspects of the retina0 )ith

relatie sparin' of the temporal and medial re'ions.

8. Ima'ine that the blood essels are the branches of a tree. ollo) them in adirection that leads to less branchin' >i.e. to)ards the trun+?. #his )ill direct !ou

to)ards the optic disc0 the point at )hich the essels enter the retina alon' )ith

the head of the optic nere. #he ed'es of this round disc are sharp and )elldefined in the normal state. It should be a bit more !ello)/oran'e )hen compared

to the rest of the retina. At the center of the disc is the optic cup0 a distinct circular

area from )hich the blood essels actuall! emer'e. #he disc is not located in theexact center of the retina but rather to)ards its medial/nasal aspect. Measurements

in the e!e are made usin' disc si2e as a measurin' deice >e.'. a findin' ma! be

described as bein' at 8 $4cloc+0 8 disc diameters from the center of the disc?. If!ou are unable to locate the disc after follo)in' the essels in one direction0

simpl! head the other )a!.

9. #he macula is a re'ion located lateral to the optic disc. It loo+s some)hat dar+er

then the rest of the retina and0 as opposed to the disc0 has no distinct borders. #hemacula proides the sharpest ision. It can be best isuali2ed b! as+in' the patient



to stare directl! at the li'ht of the opthalmoscope )hile !ou remain focused on a

fixed area of the retina.

. ou )ill not be able to isuali2e the entire retina at an! one time >approximatel!one disc diameter should be isible?. #o ie) different areas0 !ou4ll hae to shift

the an'le )ith )hich !ou peer throu'h the pupil. #his re3uires er! small

moements. #r! to examine the entire structure s!stematicall!0 loo+in' up0 do)n0left and ri'ht. ou )ill undoubtedl! hae to remind the patient to continue

loo+in' strai'ht ahead0 else the fundus )ill be in continual motion and !ou )ill

hae no chance of findin' an!thin'. It4s also a 'ood idea to periodicall! 'ie the patient a brea+ >particularl! if the exam is ta+in' a )hile?0 allo)in' them to blin+

in the dar+ before resumin'.

%etina--%ig#t 5ye

(Picture "ourtesy of %ay =elly)



In order to ie) the patient4s left e!e0 'rasp the scope in !our left hand and use !our left

e!eJ then repeat the process described aboe.

If possible0 tr! to aoid eatin' 'arlic0 onions or other stron' smellin' food. If !ou are1dependent1 on these substances0 inest in a box of tic*tacs for use durin' the examB

It is much easier to examine the retina after the pupil has been pharmacolo'icall! dilated.

In actual practice0 ho)eer0 most proiders0 )ith the exception of optometrists andophthalmolo'ists0 do not routinel! perform dilated e!e exams. #his is because dilation

ta+es time and is a bit uncomfortable for the patient as it causes increased li'ht sensitiit!

that lasts for seeral hours. Additionall!0 a non*dilated ie) of the retina is ade3uate for a

'eneral exam in )hich the patient has no specific ophthalmolo'ic complaints. #a+eadanta'e of an! opportunit! to perform an examination throu'h a dilated pupil as this is

a 'reat )a! of learnin'. Ma+e use of additional reference texts0 pa!in' particular

attention to color photos depictin' ariants of normal as )ell as the findin's associated)ith common disease states.

#he follo)in' lin+s proide excellent ima'es of assorted ophthalmolo'ic patholo'!.

Atlas of $phthalmolo'ic Ima'es

,i'ital Atlas of $phthalmolo'!0 - E!e and Ear Infirmar!

E!e Atlas >5est )hen ie)ed )ith Internet Explorer?0 ohns op+ins Uniersit!

http://www.eyeatlas.com/contents.htm

http://www.nyee.edu/page_deliv.html?page_no=50

http://www.redatlas.org/

http://www.eyeatlas.com/contents.htm

http://www.nyee.edu/page_deliv.html?page_no=50

http://www.redatlas.org/

0705 a practical guide to clinical medicine

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