(A Practical Guide to Clinical Medicine)

Saturday, April 14, 2007

12:21 AM

Getting Started:
Always introduce yourself to the patient. Then try to make the
environment as private and free of distractions as possible. If
possible, sit down next to the patient while conducting the
interview. Remove any physical barriers that stand between
yourself and the interviewee (e.g. put down the side rail so that
your view of one another is unimpeded... though make sure to put
it back up at the conclusion of the interview). These simple
maneuvers help to put you and the patient on equal footing.
Furthermore, they enhance the notion that you are completely
focused on them. If the interview is being conducted in an
outpatient setting, it is probably better to allow the patient to
wear their own clothing while you chat with them. At the
conclusion of your discussion, provide them with a gown and
leave the room while they undress in preparation for the physical
exam.

Initial Question(s):
These include: "What brings your here? How can I help you?
What seems to be the problem?" Push them to be as descriptive
as possible.
Follow-up Questions:
There is no single best way to question a patient. Successful
interviewing requires that you avoid medical terminology and
make use of a descriptive language that is familiar to them. There
are several broad questions which are applicable to any
complaint. These include:

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1. Duration: How long has this condition lasted? Is it similar to a
past problem? If so, what was done at that time?
2. Severity/Character: How bothersome is this problem? Does it
interfere with your daily activities? Does it keep you up at
night? Try to have them objectively rate the problem. If they
are describing pain, ask them to rate it from 1 to 10 with 10
being the worse pain of their life, though first find out what
that was so you know what they are using for comparison (e.g.
childbirth, a broken limb, etc.). Furthermore, ask them to
describe the symptom in terms with which they are already
familiar. When describing pain, ask if it's like anything else that
they've felt in the past. Knife-like? A sensation of pressure? A
toothache? If it affects their activity level, determine to what
degree this occurs. For example, if they complain of shortness
of breath with walking, how many blocks can they walk? How
does this compare with 6 months ago?
3. Location/Radiation: Is the symptom (e.g. pain) located in a
specific place? Has this changed over time? If the symptom is
not focal, does it radiate to a specific area of the body?
4. Have they tried any therapeutic maneuvers?: If so, what's
made it better (or worse)?
5. Pace of illness: Is the problem getting better, worse, or staying
the same? If it is changing, what has been the rate of change?
6. Are there any associated symptoms? Often times the patient
notices other things that have popped up around the same
time as the dominant problem. These tend to be related.
7. What do they think the problem is and/or what are they
worried it might be?
8. Why today?: This is particularly relevant when a patient
chooses to make mention of symptoms/complaints that appear
to be long standing. Is there something new/different today as
opposed to every other day when this problem has been
present? Does this relate to a gradual worsening of the
symptom itself? Has the patient developed a new perception of
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 symptom itself? Has the patient developed a new perception of
its relative importance (e.g. a friend told them they should get
it checked out)? The content of subsequent questions will
depend both on what you uncover and your knowledge
base/understanding of patients and their illnesses. If, for
example, the patient's initial complaint was chest pain you
might have uncovered the following by using the above
questions:
The pain began 1 month ago and only occurs with activity. It
rapidly goes away with rest. When it does occur, it is a steady
pressure focused on the center of the chest that is roughly a 5
(on a scale of 1 to 10). Over the last week, it has happened 6
times while in the first week it happened only once. The patient
has never experienced anything like this previously and has not
mentioned this problem to anyone else prior to meeting with
you. As yet, they have employed no specific therapy.

This is quite a lot of information. However, if you were not aware

that coronary-based ischemia causes a symptom complex identical
to what the patient is describing, you would have no idea what
further questions to ask. That's OK. With additional experience,
exposure, and knowledge you will learn the appropriate settings
for particular lines of questioning. When clinicians obtain a
history, they are continually generating differential diagnoses in
their minds, allowing the patient's answers to direct the logical
use of additional questions. With each step, the list of probable
diagnoses is pared down until a few likely choices are left from
what was once a long list of possibilities. Perhaps an easy way to
understand this would be to think of the patient problem as a
Windows-Based computer program. The patient tells you a
symptom. You click on this symptom and a list of general
questions appears. The patient then responds to these questions.
You click on these responses and... blank screen. No problem. As
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You click on these responses and... blank screen. No problem. As
yet, you do not have the clinical knowledge base to know what
questions to ask next. With time and experience you will be able
to click on the patient's response and generate a list of additional
appropriate questions. In the previous patient with chest pain, you
will learn that this patient's story is very consistent with
significant, symptomatic coronary artery disease. As such, you
would ask follow-up questions that help to define a cardiac basis
for this complaint (e.g. history of past myocardial infarctions, risk
factors for coronary disease, etc.). You'd also be aware that other
disease states (e.g. emphysema) might cause similar symptoms
and would therefore ask questions that could lend support to
these possible diagnoses (e.g. history of smoking or wheezing). At
the completion of the HPI, you should have a pretty good idea as
to the likely cause of a patient's problem. You may then focus your
exam on the search for physical signs that would lend support to
your working diagnosis and help direct you in the rational use of
adjuvant testing.
Recognizing symptoms/responses that demand an urgent
assessment (e.g. crushing chest pain) vs. those that can be
handled in a more leisurely fashion (e.g. fatigue) will come with
time and experience. All patient complaints merit careful
consideration. Some, however, require time to play out, allowing
them to either become "a something" (a recognizable clinical
entity) or "a nothing," and simply fade away. Clinicians are
constantly on the look-out for markers of underlying illness,
historical points which might increase their suspicion for the
existence of an underlying disease process. For example, a patient
who does not usually seek medical attention yet presents with a
new, specific complaint merits a particularly careful evaluation.
More often, however, the challenge lies in having the discipline to
continually re-consider the diagnostic possibilities in a patient with
multiple, chronic complaints who presents with a variation of
his/her "usual" symptom complex.
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his/her "usual" symptom complex.
You will undoubtedly forget to ask certain questions, requiring a
return visit to the patient's bedside to ask, "Just one more thing."
Don't worry, this happens to everyone! You'll get more efficient
with practice.

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The Rest Of The History
Saturday, April 14, 2007
1:18 AM

The remainder of the history is obtained after completing the HPI. As such,
the previously discussed techniques for facilitating the exchange of
information still apply.
Past Medical History: Start by asking the patient if they have any medical
problems. If you receive little/no response, the following questions can
help uncover important past events: Have they ever received medical
care? If so, what problems/issues were addressed? Was the care
continuous (i.e. provided on a regular basis by a single person) or episodic?
Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or
other special testing? Ever been hospitalized? If so, for what? It's quite
amazing how many patients forget what would seem to be important
medical events.
Past Surgical History: Were they ever operated on, even as a child? What
year did this occur? Were there any complications? If they don't know the
name of the operation, try to at least determine why it was performed.
Encourage them to be as specific as possible.

Medications: Do they take any prescription medicines? If so, what is the

dose and frequency? Do they know why they are being treated?*
Medication non-compliance/confusion is a major clinical problem,
particularly when regimens are complex, patients older, cognitively
impaired or simply disinterested. It's important to ascertain if they are
actually taking the medication as prescribed. This can provide critical
information as frequently what appears to be a failure to respond to a
particular therapy is actually non-compliance with a prescribed regimen.
Identifying these situations requires some tact, as you'd like to encourage
honesty without sounding accusatory. It helps to clearly explain that
without this information your ability to assess treatment efficacy and
make therapeutic adjustments becomes difficult/potentially dangerous. If
patients are, in fact, missing doses or not taking medications altogether,
ask them why this is happening. Perhaps there is an important side effect
that they are experiencing, a reasonable fear that can be addressed, or a
more acceptable substitute regimen which might be implemented. Don't
forget to ask about over the counter or "non-traditional" medications.
How much are they taking and what are they treating? Has it been
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How much are they taking and what are they treating? Has it been
effective? Are these medicines being prescribed by a practitioner? Self
administered?
* You'll be surprised to learn how many patients don't know the answers
to these questions. Encourage them to keep an up to date medication list
and/or write one out for them. When all else fails, ask the patient to bring
their meds with them when they return or, if they are in-patients, see if a
family member/friend can do so for them.

Allergies/Reactions: Have they experienced any adverse reactions to

medications? The exact nature of the reaction should be clearly identified
as it can have important clinical implications. Anaphylaxis extreme sensitivity to a particular
substance such as a specific protein or drug, for example, is a

life threatening reaction and an absolute contraindication to re-exposure

to the drug. A rash, however, does not raise the same level of concern,
particularly if the agent in question is clearly the treatment of choice.

Smoking History: Have they ever smoked cigarettes? If so, how many
packs per day and for how many years? If they quit, when did this occur?
The packs per day multiplied by the number of years gives the pack-years,
a widely accepted method for smoking quantification. Pipe, cigar and
chewing tobacco use should also be noted.

Alcohol: Do they drink alcohol? If so, how much per day and what type of
drink? Encourage them to be as specific as possible. One drink may mean a
beer or a 12 oz glass of whiskey, each with different implications. If they
don't drink on a daily basis, how much do they consume over a week or
month?

Other Drug Use: Any drug use, past or present, should be noted. Get in the
habit of asking all your patients these questions as it can be surprisingly
difficult to accurately determine who is at risk strictly on the basis of
appearance. Remind them that these questions are not meant to judge
but rather to assist you in identifying risk factors for particular illnesses
(e.g. HIV, hepatitis). In some cases, however, a patient will clearly indicate
that they do not wish to discuss these issues. Respect their right to privacy

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and move on. Perhaps they will be more forthcoming at a later date.

Obstetric (where appropriate): Have they ever been pregnant? If so, how
many times? What was the outcome of each pregnancy (e.g. full term
delivery; spontaneous abortion; therapeutic abortion).

Sexual Activity: This is an uncomfortable line of questioning for many

practitioners. However, it can provide important information and should
be pursued. As with questions about substance abuse, your ability to
determine on sight who is sexually active (and in what type of activity) is
rather limited. By asking all of your patients these questions, the process
will become less awkward. Do they participate in intercourse? With
persons of the same or opposite sex? Are they involved in a stable
relationship? Do they use condoms or other means of birth control?
Married? Health of spouse? Divorced? Past sexually transmitted diseases?
Do they have children? If so, are they healthy? Do they live with the
patient?

Family History: In particular, you are searching for heritable illnesses

among first or second degree relatives. Most common, at least in America,
are coronary artery disease, diabetes and certain malignancies. Patients
should be as specific as possible. "Heart disease," for example, includes
valvular disorders, coronary artery disease and congenital abnormalities,
of which only coronary disease has genetic implications. Find out the age
of onset of the illnesses, as this has prognostic importance for the patient.
For example, a father who had an MI at age 70 is not a marker of genetic
predisposition while one who had a similar event at age 40 certainly would
be. Also ask about any unusual illnesses among relatives, perhaps
revealing evidence for rare genetic conditions.

Work/Hobbies/Other: What sort of work does the patient do? Have they
always done the same thing? Do they enjoy it? If retired, what do they do
to stay busy? Any hobbies? Participation in sports or other physical
activity? Where are they from originally? These questions do not
necessarily reveal information directly related to the patient's health.
However, it is nice to know something non-medical about them. This may
help improve the patient-physician bond and relay the sense that you care

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about them as a person. It also gives you something to refer back to during
later visits, letting the patient know that you paid attention and really
remember them.

In recounting their history, patient's frequently drop clues that suggest

issues meriting further exploration. If, for example, they are taking anti-
hypertensive or anti-anginal medications yet made no mention of cardiac
disease, additional history taking would be in order. Furthermore, if at any
time you uncover information relevant to the chief complaint don't be
afraid to revisit the HPI.

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 Vital signs
Saturday, April 14, 2007
5:35 PM

Vital Signs
Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and, where
appropriate, blood oxygen saturation. These numbers provide critical information (hence the name
"vital") about a patient's state of health. In particular, they:
1. Can identify the existence of an acute medical problem.
2. Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping
with the resultant physiologic stress. The more deranged the vitals, the sicker the patient.
3. Are a marker of chronic disease states (e.g. hypertension is defined as chronically elevated blood
pressure).
Most patients will have had their vital signs measured by an RN or health care assistant before you have
a chance to see them. However, these values are of such great importance that you should get in the
habit of repeating them yourself, particularly if you are going to use these values as the basis for
management decisions. This not only allows you to practice obtaining vital signs but provides an
opportunity to verify their accuracy. As noted below, there is significant potential for measurement
error, so repeat determinations can provide critical information.
Getting Started: The examination room should be quiet, warm and well lit. After you have finished
interviewing the patient, provide them with a gown (a.k.a. "Johnny") and leave the room (or draw a
separating curtain) while they change. Instruct them to remove all of their clothing (except for briefs)
and put on the gown so that the opening is in the rear. Occasionally, patient's will end up using them as
ponchos, capes or in other creative ways. While this may make for a more attractive ensemble it will
also, unfortunately, interfere with your ability to perform an examination! Prior to measuring vital signs,
the patient should have had the opportunity to sit for approximately five minutes so that the values are
not affected by the exertion required to walk to the exam room. All measurements are made while the
patient is seated.
Observation: Before diving in, take a minute or so to look at the patient in their entirety, making your
observations, if possible, from an out-of-the way perch. Does the patient seem anxious, in pain, upset?
What about their dress and hygiene? Remember, the exam begins as soon as you lay eyes on the
patient.
Temperature: This is generally obtained using an oral thermometer that provides a digital reading when
the sensor is placed under the patient's tongue. As most exam rooms do not have thermometers, it is
not necessary to repeat this measurement unless, of course, the recorded value seems discordant with
the patient's clinical condition (e.g. they feel hot but reportedly have no fever or vice versa). Depending
on the bias of a particular institution, temperature is measured in either Celcius or Farenheit, with a
fever defined as greater than 38-38.5 C or 101-101.5 F. Rectal temperatures, which most closely reflect
internal or core values, are approximately 1 degree F higher than those obtained orally.
Respiratory Rate: Respirations are recorded as breaths per minute. They should be counted for at least
30 seconds as the total number of breaths in a 15 second period is rather small and any miscounting can
result in rather large errors when multiplied by 4. Try to do this as surreptitiously as possible so that the
patient does not consciously alter their rate of breathing. This can be done by observing the rise and fall
of the patient's hospital gown while you appear to be taking their pulse. Normal is between 12 and 20.
In general, this measurement offers no relevant information for the routine examination. However,
particularly in the setting of cardio-pulmonary illness, it can be a very reliable marker of disease activity.
Pulse: This can be measured at any place where there is a large artery (e.g. carotid, femoral, or simply by
listening over the heart), though for the sake of convenience it is generally done by palpating the radial
impulse. You may find it helpful to feel both radial arteries simultaneously, doubling the sensory input
and helping to insure the accuracy of your measurements. Place the tips of your index and middle
fingers just proximal to the patients wrist on the thumb side, orienting them so that they are both over
the length of the vessel.
Vascular Anatomy

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Technique for Measuring the Radial Pulse
The pictures below demonstrate the location of the radial artery (surface anatomy on the left, gross
anatomy on the right).

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Frequently, you can see transmitted pulsations on careful visual inspection of this region, which may
help in locating this artery. Upper extremity peripheral vascular disease is relatively uncommon, so the
radial artery should be readily palpable in most patients. Push lightly at first, adding pressure if there is a
lot of subcutaneous fat or you are unable to detect a pulse. If you push too hard, you might occlude the
vessel and mistake your own pulse for that of the patient. During palpation, note the following:
1. Quantity: Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and
multiply by 2 (or 15 seconds x 4). If the rate is particularly slow or fast, it is probably best to
measure for a full 60 seconds in order to minimize the impact of any error in recording over
shorter periods of time. Normal is between 60 and 100.
2. Regularity: Is the time between beats constant? In the normal setting, the heart rate should
appear metronomic. Irregular rhythms, however, are quite common. If the pattern is entirely
chaotic with no discernable pattern, it is referred to as irregularly irregular and likely represents
atrial fibrillation. Extra beats can also be added into the normal pattern, in which case the rhythm
is described as regularly irregular. This may occur, for example, when impulses originating from
the ventricle are interposed at regular junctures on the normal rhythm. If the pulse is irregular, it's
a good idea to verify the rate by listening over the heart (see cardiac exam section). This is
because certain rhythm disturbances do not allow adequate ventricular filling with each beat. The
resultant systole may generate a rather small stroke volume whose impulse is not palpable in the
periphery.
3. Volume: Does the pulse volume (i.e. the subjective sense of fullness) feel normal? This reflects
changes in stroke volume. In the setting of hypovolemia, for example, the pulse volume is
relatively low (aka weak or thready). There may even be beat to beat variation in the volume,
occurring occasionally with systolic heart failure.
Blood Pressure: Blood pressure (BP) is measured using mercury based manometers, with readings
reported in millimeters of mercury (mm Hg). The size of the BP cuff will affect the accuracy of these
readings. The inflatable bladder, which can be felt through the vinyl covering of the cuff, should reach
roughly 80% around the circumference of the arm while its width should cover roughly 40%. If it is too
small, the readings will be artificially elevated. The opposite occurs if the cuff is too large. Clinics should
have at least 2 cuff sizes available, normal and large. Try to use the one that is most appropriate,
recognizing that there will rarely be a perfect fit.

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recognizing that there will rarely be a perfect fit.
Blood Pressure Cuffs

In order to measure the BP, proceed as follows:

1. Wrap the cuff around the patient's upper arm so that the line marked "artery" is roughly over the
brachial artery, located towards the medial aspect of the antecubital fossa (i.e. the crook on the
inside of their elbow). The placement does not have to be exact nor do you actually need to
identify this artery by palpation.
Antecubital Fossa
The pictures below demonstrate the antecubital fossa anatomy (surface anatomy on the left,
gross anatomy on the right).

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2. Put on your stethescope so that the ear pieces are angled away from your head. Twist the head
piece so that the diaphragm is engaged. This can be verified by gently tapping on the end, which
should produce a sound. With your left hand, place the diaphragm over the area of the brachial
artery. While most practitioners use the diaphragm of the stethescope, the bell may actually be
superior for picking up the low pitched sounds used for measuring BP. Experiment with both and
see if this makes a difference. It's worth mentioning that a number of different models of
stethescops are available on the market, each with its own variation on the structure of the
diaphragm and bell. Read the instruction manual accompanying your stethoscope in order to
determine how your device works.
3. Grasp the patient's right elbow with your right hand and raise their arm so that the brachial artery
is roughly at the same height as the heart. The arm should remain somewhat bent and completely
relaxed. You can provide additional support by gently trapping their hand and forearm between
your body and right elbow. If the arm is held too high, the reading will be artifactually lowered,
and vice versa.
4. Turn the valve on the pumping bulb clockwise (may be counter clockwise in some cuffs) until it no
longer moves. This is the position which allows air to enter and remain in the bladder.
5. Hold the diaphragm in place with your left hand. Use your right hand to pump the bulb until you
have generated 150 mmHg on the manometer. This is a bit above the top end of normal for
systolic blood pressure (SBP). Then listen. If you immediately hear sound, you have
underestimated the SBP. Pump up an additional 20 mmHg and repeat. Now slowly deflate the
blood pressure cuff (i.e. a few mm Hg per second) by turning the valve in a counter -clockwise
direction while listening over the brachial artery and watching the pressure gauge. The first sound
that you hear reflects the flow of blood through the no longer completely occluded brachial
artery. The value on the manometer at this moment is the SBP. Note that although the needle
may oscillate prior to this time, it is the sound of blood flow that indicates the SBP.
6. Continue listening while you slowly deflate the cuff. The diastolic blood pressure (DBP) is
measured when the sound completely disappears. This is the point when the pressure within the
vessel is greater then that supplied by the cuff, allowing the free flow of blood without turbulence
and thus no audible sound. These are known as the Sounds of Koratkoff.
Technique for Measuring Blood Pressure
7. Repeat the measurement on the patient's other arm, reversing the position of your hands. The
two readings should be within 10-15 mm Hg of each other. Differences greater then this imply
that there is differential blood flow to each arm, which most frequently occurs in the setting of
subclavian artery atherosclerosis.
8. Occasionally you will be unsure as to the point where systole or diastole occurred and wish to
repeat the measurement. Ideally, you should allow the cuff to completely deflate, permit any
venous congestion in the arm to resolve (which otherwise may lead to inaccurate measurements),
and then repeat a minute or so later. Furthermore, while no one has ever lost a limb secondary to
BP cuff induced ischemia, repeated measurement can be uncomfortable for the patient, another
good reason for giving the arm a break.
9. Avoid moving your hands or the head of the stethescope while you are taking readings as this may

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 9. Avoid moving your hands or the head of the stethescope while you are taking readings as this may
produce noise that can obscure the Sounds of Koratkoff.
10. You can verify the SBP by palpation. To do this, position the patient's right arm as described
above. Place the index and middle fingers of your right hand over the radial artery. Inflate the cuff
until you can no longer feel the pulse, or simply to a value 10 points above the SBP as determined
by auscultation. Slowly deflate the cuff until you can again detect a radial pulse and note the
reading on the manometer. This is the SBP and should be the same as the value determined with
the use of your stethescope.
Normal is between 100/60 and 140/90. Hypertension is thus defined as either SBP greater then 140 or
DBP greater than 90. It is important to recognize that blood pressure is rarely elevated to a level that
causes acute symptoms. That is, while hypertension in general is common, emergencies resulting from
extremely high values and subsequent acute end organ dysfunction are quite rare. Rather, it is the
chronically elevated values which lead to target organ damage, though in a slow and relatively silent
fashion. At the other end of the spectrum, the minimal SBP required to maintain perfusion varies with
the individual. Therefore, interpretation of low values must take into account the clinical situation.
Those with poorly functioning hearts, for example, can adjust to a chronically low SBP (e.g. 80-90) and
live without symptoms of hypoperfusion. However others, used to higher baseline values, might become
quite ill if their SBPs were suddenly decreased to these same levels.
Many things can alter the accuracy of your readings. In order to limit their impact, remember the
following:
1. Do not place the blood pressure cuff over a patients clothing or roll a tight fitting sleeve above
their biceps when determining blood pressure as either can cause elevated readings.
2. Make sure the patient has had an opportunity to rest before measuring their BP. Try the following
experiment to assess the impact that this can have. Take a patient's BP after they've rested. Then
repeat after they've walked briskly in place for several minutes. Patients who are not too
physically active (i.e. relatively deconditioned) will develop an elevation in both their SBP and DBP.
Also, see what effect raising or lowering the arm, and thus the position of the brachial artery
relative to the heart, has on BP. If you have a chance, obtain measurements on the same patient
with both a large and small cuff. These exercises should give you an appreciation for the
magnitude of error that can be introduced when improper technique is utilized.
3. If the reading is surprisingly high or low, repeat the measurement towards the end of your exam.
4. Instruct your patients to avoid coffee, smoking or any other unprescribed drug with
sympathomimetic activity on the day of the measurement.
5. Orthostatic (a.k.a. postural) measurements of pulse and blood pressure are part of the assessment
for hypovolemia. This requires first measuring these values when the patient is supine and then
repeating them after they have stood for 2 minutes, which allows for equilibration. Normally, SBP
does not vary by more then 20 points when a patient moves from lying to standing. In the setting
of significant volume depletion, a greater then 20 point drop may be seen. Changes of lesser
magnitude occur when moving from lying to sitting or sitting to standing. This is frequently
associated with symptoms of cerebral hypoperfusion (e.g.. light headedness). Heart rate should
increase by more then 20 points in a normal physiologic attempt to augment cardiac output by
providing chronotropic compensation. In the setting of GI bleeding, for example, a drop in blood
pressure and/or rise in heart rate after this maneuver is a marker of significant blood loss and has
important prognostic implications. Orthostatic measurements may also be used to determine if
postural dizziness, a common complaint with multiple possible explanations, is the result of a fall
in blood pressure. For example, patients who suffer from diabetes frequently have autonomic
nervous system dysfunction and cannot generate appropriate arteriolar vaosconstriction when
changing positions. This results in postural vital sign changes and symptoms. The 20 point value is
a rough guideline. In general, the greater the change, the more likely it is to cause symptoms and
be of clinical relevance.
6. If possible, measure the blood pressure of a patient who has an indwelling arterial catheter (these
patients can be found in the ICU with the help of a preceptor). Arterial transducers are an
extremely accurate tool for assessing blood pressure and therefore provide a method for checking
your non-invasive technique.
Oxygen Saturation: Over the past decade, this non-invasive measurement of gas exchange and red
blood cell oxygen carrying capacity has become available in all hospitals and many clinics. While
imperfect, it can provide important information about cardio-pulmonary dysfunction and is considered
by many to be a fifth vital sign. In particular, for those suffering from either acute or chronic cardio-
pulmonary disorders, it can help quantify the degree of impairment.
Pulse Oxymeter

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history Page 16
 EYE EXAM
Saturday, April 14, 2007
5:49 PM

The Eye Exam

Assessment of Visual Acuity: The first part of the eye exam is an assessment of acuity. This can be done
with either a standard Snellen hanging wall chart read with the patient standing at a distance of 20 feet
or a specially designed pocket card (held at 14 inches). Each eye is tested independently (i.e. one is
covered while the other is used to read). The patient should be allowed to wear their glasses and the
results are referred to as "Best corrected vision." You do not need to assess their ability to read every
line on the chart. If they have no complaints, rapidly skip down to the smaller characters. The numbers
at the end of the line provide an indication of the patient's acuity compared with normal subjects. The
larger the denominator, the worse the acuity. 20/200, for example, means that they can see at 20 feet
what a normal individual can at 200 feet (i.e. their vision is pretty lousy). If the patient is unable to read
any of the lines, indicative of a big problem if this was a new complaint, a gross estimate of what they
are capable of seeing should be determined (e.g. ability to detect light, motion or number of fingers
placed in front of them). In general, acuity is only tested when there is a new, specific, visual complaint.

Hand Held Acuity Card Snellen Chart

Pinhole Testing: The pinhole testing device can determine if a problem with acuity is the result of
refractive error (and thus correctable with glasses) or due to another process. The pinholes only allow
the passage of light which is perpendicular to the lens, and thus does not need to be bent prior to being
focused onto the retina. The patient is instructed to view the Snellen chart with the pinholes up (below
left) and then again with them in the down position (below right). If the deficit corrects with the
pinholes in place, the acuity issue is related to a refractive problem.

Observation of External Structures:

1. Occular Symmetry: Occasionally, one of the muscles that controls eye movement will be weak or
foreshortened, causing one eye to appear deviated medially or laterally compared with the other.
2. Eye Lid Symmetry: Both eye lids should cover approximately the same amount of eyeball. Damage
to the nerves controlling these structures (Cranial Nerves 3 and 7) can cause the upper or lower
lids on one side to appear lower then the other.
Patient unable to completely close left upper eyelid due to peripheral CN 7 dysfunction.
3. Sclera: The normal sclera is white and surrounds the iris and pupil. In the setting of liver or blood
disorders that cause hyperbilirubinemia, the sclera may appear yellow, referred to as icterus. This
can be easily confused with a muddy-brown discoloration common among older African
Americans that is a variant of normal.
Icteric Sclera
Muddy Brown Sclera
4. Conjunctiva: The sclera is covered by a thin transparent membrane known as the conjunctiva,
which reflects back onto the underside of the eyelids. Normally, it's invisible except for the fine
blood vessels that run through it. When infected or otherwise inflamed, this layer can appear
quite red, a condition known as conjunctivitis. Alternatively, the conjunctiva can appear pale if
patient is very anemic. By gently applying pressure and pulling down and away on the skin below
the lower lid, you can examine the conjunctival reflection, which is the best place to identify this
finding.

Normal Appearing Conjunctival Pale Conjunctiva, due to severe anemia.

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 Normal Appearing Conjunctival Pale Conjunctiva, due to severe anemia.
Reflection, Lower Lid

Conjunctivitis
Blood can also accumulate underneath the conjunctiva when one of the small blood vessels within
it ruptures. This may be the result of relatively minor trauma (cough, sneeze, or direct blow), a
bleeding disorder or idiopathic. The resulting collection of blood is called a subconjunctival
hemorrhage. While dramatic, it is generally self limited and does not affect vision.
Subconjunctival Hemorrhage

5. Pupil and Iris: Normally, both of these structures are round and symmetric.
When performing the rest of the exam, make sure that you are in a comfortable position. The critical
maneuver is assuring that the patient is seated at a height such that their eyes are essentially on the
same level as your own when you are standing next to them.
Testing Extra-Occular Movements: Instruct the patient to follow your index finger with their eyes only
(i.e. their head remains in one position) as you first move it to either the extreme right or left. Then,
once you have the patient looking out laterally, have them follow your finger as you move it first up,
then down. Now move your finger across to the other side and repeat. Your path should trace out the
letter H. At the end, bring your finger directly in towards the patient's nose. This will cause the patient to
look cross-eyed and the pupils should constrict, a response referred to as accommodation.
Tracing out this path allows you to test each of the extra-occular muscles individually and avoids
movements that are dependent on more then one muscle, as occurs if you have the patient look up or
down while the pupil is oriented straight ahead. Assessments of both extra-occular movements and
visual acuity are actually tests of cranial nerve (CN) function. CNs 3, 4, and 6 control movement and CN 2
vision. As these nerves are critical to eye function, it makes sense to evaluate them at this stage rather
then during the neurological examination.
Testing Extra Occular Movements

CNs and the Muscles That Control Extra Occular Movements

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 CNs and the Muscles That Control Extra Occular Movements

The cranial nerves and the muscles that they innervate can be remembered using the following
mnemonic: SO '4', LR '6', all the rest '3.' Each CN permits the following movements:
• CN 4: Innervates the superior oblique muscle. Allows you to move either eyeball down and
inward.
• CN 6: Innervates the lateral rectus muscle. Allows you to move either eyeball laterally.

•
Patient with non-functional
left 6th cranial
nerve. He cannot move left
eye all the
way to the left.

• CN 3: Innervates the remaining extra occular muscles as well as the upper eye lid. Therefore allows
eyeball movement in all remaining directions as well as lifting of the upper lid. The dilation is due to
disruption of the parasympathetic fibers which run along the outside of CN3.

Right CN3 Lesion: Note patient's right eye is deviated laterally and there is ptosis of the lid (picture on
left),
and the right pupil (middle picture) is more dilated than the left pupil (picture on far right).
Disorders of eye movement can also be due to problems with the extraocular muscles themselves. For
example, pictured below is a patient who has suffered a traumatic left orbital injury. The inferior rectus
muscle has become entrapped within the resulting fracture, preventing the left eye from being able to
look downward.

Entrapment of Left Inferior Rectus Muscle

Simulation of extra occular movement and pupillary disorders. from UC Davis.
Visual fields: The normal visual field for each eye extends out from the patient in all directions, with an
area of overlap directly in front. Field cuts refer to specific regions where the patient has lost their ability
to see. This occurs when the transmitted visual impulse is interrupted at some point in its path from the
retina to the visual cortex in the back of the brain. You would, in general, only include a visual field
assessment if the patient complained of loss of sight; in particular "blind spots" or "holes" in their
vision.Visual fields can be crudely assessed as follows:
1. The examiner should be nose to nose with the patient, separated by approximately 8 to 12
inches.
2. Each eye is checked separately. The examiner closes one eye and the patient closes the one
opposite. The open eyes should then be staring directly at one another.
3. The examiner should move their hand out towards the periphery of his/her visual field on

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 opposite. The open eyes should then be staring directly at one another.
3. The examiner should move their hand out towards the periphery of his/her visual field on
the side where the eyes are open. The finger should be equidistant from both persons.
4. The examiner should then move the wiggling finger in towards them, along an imaginary
line drawn between the two persons.The patient and examiner should detect the finger at
more or less the same time.
5. The finger is then moved out to the diagonal corners of the field and moved inwards from
each of these directions. Testing is then done starting at a point in front of the closed eyes.
The wiggling finger is moved towards the open eyes.
6. The other eye is then tested.
Meaningful interpretation is predicated upon the examiner having normal fields, as they are using
themselves for comparison.
If the examiner cannot seem to move their finger to a point that is outside the patient’s field don’t
worry, as it simply means that their fields are normal.
Interpretation: This test is rather crude, and it is quite possible to have small visual field defects
that would not be apparent on this type of testing. Prior to interpreting abnormal findings, the
examiner must understand the normal pathways by which visual impulses travel from the eye to
the brain.
For more information about visual field testing, see the following links:
Washington University, review of visual field of testing and pathology
University of Arkansas, gross anatomy of visual pathway
Using the Opthalmoscope
This aspect of the exam is, at least initially, quite awkward. Don't worry, it will get easier with practice!
Take some time to play with your scope, paying attention to its assembly, on/off mechanism as well as
the various lens and light settings which can be utilized. There are a number of different brands on the
market and each is a bit different. For the purposes of the general exam, we'll focus on the simplest
settings and most basic techniques.

Side of Scope Facing Examiner Side of Scope Facing Patient

Assessing Pupillary Response to Light:

The normal pupil constricts when either exposed directly to bright light or when that same light is
presented to the other eye, referred to as the consensual response. This is due to the fact that
stimulation of the afferent (i.e. sensory, carried with CN 2) nerves in one eye will trigger efferent (i.e.
motor, carried with CN 3) activation and subsequent constriction of the pupils of both eyes. Disease
affecting either the efferent or afferent limbs will alter these responses accordingly. Also, processes
which raise intracranial pressure (e.g. brain tumors, collections of blood) can cause CN 3 dysfunction,
resulting in dilatation of the pupils and uresponsiveness to direct stimulation by light. To assess pupillary
reactions, proceed as follows:
1. Instruct the patient to look towards a distant area in the room (e.g. the corner where the wall and
ceiling meet) while keeping both of their eyes open. You may need to gently remind them
throughout the exam to continue looking in that direction as it is very difficult to examine a roving
eyeball. Do not ask them to focus on a specific object as this will lead to pupillary constriction.
2. Turn on your opthalmoscope and adjust the light intensity to mid-range power. The cone of light
produced should be a white, medium sized circle. Circle sizes available include small, medium and
large. If possible, turn off most of the lights in the room. This allows the pupil to dilate and cuts
down on reflections from the surface of the eye.
3. Make note of the size and shape of each pupil. Then assess whether each pupil constricts
appropriately in response to direct and indirect stimulation. If you're having trouble detecting any
change, have the patient close their eye for several seconds and place your hand over their
eyebrows to provide additional shade. This helps to make it as dark as possible, encouraging
greater pupillary dilation and therefore accentuating any change which may occur after light is
introduced. It may be hard to detect the consensual response if the lighting in your room is sub-
optimal (i.e. if it's too dark, you won't be able to see the other eye). Note that you do not need to
look through the viewing window of the scope to perform this part of the exam as you are
essentially using it as a flashlight.
Closer Exam of the Outer Structures of the Eye:
1. Every opthalmoscope has a mechanism for changing the viewing lens. These lenses vary in their
ability to bend light and are numbered and color coded. The specific lens that allows you to see
something in focus will vary with your distance from that structure as well as the refractive error
of both your eyes and the patients. To better examine the sclera, conjunctiva, pupil, cornea or iris,
start with the lens identified by a green 4 or 6.
2. Now grasp the handle with your right hand (the following instructions are for examining the
patient's right eye) such that your middle finger is resting on the lower, front aspect of the head of
the opthalmoscope.
3. Bring your right eye up to the viewing window. While you can either wear or remove your own
glasses, the patient's should be taken off. It's OK to leave contacts in place.

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 4. Take your left hand and place it on the patient's forehead and gently apply upward traction on the
top lid with your thumb. This will "remind" them not to blink and let you know their precise
location. Obviously, try not to poke them in the eye with this finger! Alternatively, you can place
your left hand on the patient's shoulder as a means of keeping track of their location. Try to keep
both of your eyes open when performing the exam as you might find it quite tiring to continually
squint with the non-examining eye.
5. Start approximately 15 cm from the patient and approach from about 15 or 20 degrees to the left
of center. When you look through the viewing window, the outer structures of the eye should
come into sharp focus. If not, slowly move closer or further from the patient until these structures
become clear. It takes a bit of experimentation to find the lens that is right for any given distance,
so make lens changes slowly by rotating the adjustment wheel. There is no magic way of guessing
which lens will allow the sharpest view.
*Most clinicians don't perform a detailed examination of the outer structures of the eye if the
patient has neither obvious abnormalities nor complaints referable to this region.
Viewing the Fundus (the retina and associated structures):

1. Repeat steps 1 thru 5 as above. Adjust the lens

selection wheel so that 0 appears in the display
window.

2. Look through the viewing window at the patient's

pupil, using your right eye to examine their right
eye. You should see a sparkly, orange-red color
known as the red reflex. This is caused by light
reflecting off of the retina and is the same
phenomenon that produces red eyes in flash
photographs. Occasionally, the translucent
structures which allow light to pass unimpeded
from outside the eye to the retina become
opacified and the red reflex is lost. In adults, this is
most commonly associated with cataracts, a
process caused by clouding of the lens.
Red Reflex
Eye Cross Section
(Picture Courtesy of Ray Kelly)

3. In order to see the fundus in greater detail, you will need to move very close to the patient,
analogous to looking through a key hole (i.e. the closer you are, the more you'll see). Your middle
finger, the one resting on the low front of the head piece, should be on or near the patient's
cheek. Starting with the 0 lens in place, rotate the adjustment wheel counter clockwise. If you
change lenses too quickly, you'll probably whizz right by the one that gives the sharpest picture, so
be patient. In the event that this does not bring anything into focus, trying rotating the adjustment
wheel in the opposite direction. It doesn't really matter what number lens is required to achieve
the clearest view. Again, this will vary with the refractive error of both you and the patient. The
numbers are simply provided for reference. Thus, while you may be able to see the fundus of
some patients with the green numbers still visible, you will need red 8 or 10 to visualize the same
region in a different person. Once you're close in and have the retina in clear view, you should
only need to change the lens one or two clicks in order to keep all structures in focus as you scan
across.
4. You will only be able to see a relatively small segment of the retina at any one time. Your initial
view will probably be of blood vessels on a random patch of retina (see below).
The retina has a refractile, orange-red appearance, varying a bit with the skin color and age of the
patient. Fundoscopy provides important information as it not only enables you to detect diseases of the
eyes but is also the only area of the body where small blood vessels can be studied with relative ease.

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eyes but is also the only area of the body where small blood vessels can be studied with relative ease.
There are a number of chronic systemic diseases (most commonly hypertension, diabetes and
atherosclerosis) that affect vessels of this size in a relatively slow and silent fashion. It is, however,
frequently impossible to directly assess the extent of this damage during physical examination as the
affected organs, e.g. kidneys, are well hidden. Evaluation of the retina provides an opportunity to
directly visualize these processes. Based on this information, clinicians can make educated guesses as to
what is occurring elsewhere in the body. Having said this, do not be discouraged if it takes a while
before you're able to identify structures with any degree of confidence. Practice on every patient that
you examine. It will come with time. A few things to pay attention to:
1. When you first visualize the retina, you will note branching blood vessels. The bigger, darker ones
are the veins and the smaller, brighter red structures the arteries. Changes in the appearance of
the arteries (copper wiring) as well as alterations in the arterial-venous crossing pattern (a-v
nicking) occur with atherosclerosis and hypertension respectively (see any text for pictures). These
vessels are more obvious in the superior and inferior aspects of the retina, with relative sparing of
the temporal and medial regions.
2. Imagine that the blood vessels are the branches of a tree. Follow them in a direction that leads to
less branching (i.e. towards the trunk). This will direct you towards the optic disc, the point at
which the vessels enter the retina along with the head of the optic nerve. The edges of this round
disc are sharp and well defined in the normal state. It should be a bit more yellow/orange when
compared to the rest of the retina. At the center of the disc is the optic cup, a distinct circular area
from which the blood vessels actually emerge. The disc is not located in the exact center of the
retina but rather towards its medial/nasal aspect. Measurements in the eye are made using disc
size as a measuring device (e.g. a finding may be described as being at 2 O'clock, 2 disc diameters
from the center of the disc). If you are unable to locate the disc after following the vessels in one
direction, simply head the other way.
3. The macula is a region located lateral to the optic disc. It looks somewhat darker then the rest of
the retina and, as opposed to the disc, has no distinct borders. The macula provides the sharpest
vision. It can be best visualized by asking the patient to stare directly at the light of the
opthalmoscope while you remain focused on a fixed area of the retina.
4. You will not be able to visualize the entire retina at any one time (approximately one disc
diameter should be visible). To view different areas, you'll have to shift the angle with which you
peer through the pupil. This requires very small movements. Try to examine the entire structure
systematically, looking up, down, left and right. You will undoubtedly have to remind the patient
to continue looking straight ahead, else the fundus will be in continual motion and you will have
no chance of finding anything. It's also a good idea to periodically give the patient a break
(particularly if the exam is taking a while), allowing them to blink in the dark before resuming.

• Retina--Right Eye
(Picture Courtesy of Ray Kelly)
In order to view the patient's left eye, grasp the scope in your left hand and use your left eye; then
repeat the process described above.
If possible, try to avoid eating garlic, onions or other strong smelling food. If you are "dependent" on
these substances, invest in a box of tic-tacs for use during the exam!
It is much easier to examine the retina after the pupil has been pharmacologically dilated. In actual
practice, however, most providers, with the exception of optometrists and ophthalmologists, do not
routinely perform dilated eye exams. This is because dilation takes time and is a bit uncomfortable for
the patient as it causes increased light sensitivity that lasts for several hours. Additionally, a non-dilated
view of the retina is adequate for a general exam in which the patient has no specific ophthalmologic
complaints. Take advantage of any opportunity to perform an examination through a dilated pupil as
this is a great way of learning. Make use of additional reference texts, paying particular attention to
color photos depicting variants of normal as well as the findings associated with common disease states.

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Head and Neck Exam
Sunday, April 15, 2007
4:14 PM

Lymph Nodes: The major lymph node groups are located along the anterior and posterior aspects of the
neck and on the underside of the jaw. If the nodes are quite big, you may be able to see them bulging
under the skin, particularly if the enlargement is asymmetric (i.e. it will be more obvious if one side is
larger then the other). To palpate, use the pads of all four fingertips as these are the most sensitive parts
of your hands. Examine both sides of the head simultaneously, walking your fingers down the area in
question while applying steady, gentle pressure. The major groups of lymph nodes as well as the
structures that they drain, are listed below. The description of drainage pathways are rough
approximations as there is frequently a fair amount of variability and overlap. Nodes are generally
examined in the following order:

Palpating Anterior Cervical Lymph Nodes 1. Anterior Cervical (both superficial and deep):
Nodes that lie both on top of and beneath the
sternocleidomastoid muscles (SCM) on either side
of the neck, from the angle of the jaw to the top
of the clavicle. This muscle allows the head to turn
to the right and left. The right SCM turns the head
to the left and vice versa. They can be easily
identified by asking the patient to turn their head
into your hand while you provide resistance.
Drainage: The internal structures of the throat as
well as part of the posterior pharynx, tonsils, and
thyroid gland.
2. Posterior Cervical: Extend in a line posterior to the SCMs but in front of the trapezius, from the
level of the mastoid bone to the clavicle. Drainage: The skin on the back of the head. Also
frequently enlarged during upper respiratory infections (e.g. mononucleosis).
3. Tonsillar: Located just below the angle of the mandible. Drainage: The tonsilar and posterior
pharyngeal regions.
4. Sub-Mandibular: Along the underside of the jaw on either side. Drainage: The structures in the
floor of the mouth.
5. Sub-Mental: Just below the chin. Drainage: The teeth and intra-oral cavity.
6. Supra-clavicular: In the hollow above the clavicle, just lateral to where it joins the sternum.
Drainage: Part of the throacic cavity, abdomen.
Lymph nodes of the head and neck

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A number of other lymph node groups exist. However, palpation of these areas is limited to those
situations when a problem is identified in that specific region (e.g. the pre -auricular nodes, located in
front of the ears, may become inflamed during infections of the external canal of the ear).
What are you feeling for? Lymph nodes are part of the immune system. As such, they are most readily
palpable when fighting infections. Infections can either originate from the organs that they drain or
primarily within the lymph node itself, referred to as lymphadenitis. Infected lymph nodes tend to be:
• Firm, tender, enlarged and warm. Inflammation can spread to the overlying skin, causing it to
appear reddened.
If an infection remains untreated, the center of the node may become necrotic, resulting in the
accumulation of fluid and debris within the structure. This is known as an abscess and feels a bit like a
tensely filled balloon or grape (a.k.a. fluctuance). Knowledge of which nodes drain specific areas will
help you search efficiently. Following infection, lymph nodes occasionally remain permanently enlarged,
though they should be non-tender, small (less the 1 cm), have a rubbery consistency and none of the
characteristics described above or below. It is common, for example, to find small, palpable nodes in the
submandibular/tonsilar region of otherwise healthy individuals. This likely represents sequelae of past
pharyngitis or dental infections.
Malignancies may also involve the lymph nodes, either primarily (e.g. lymphoma) or as a site of
metastasis. In either case, these nodes are generally:
• Firm, non-tender, matted (i.e. stuck to each other), fixed (i.e. not freely mobile but rather stuck
down to underlying tissue), and increase in size over time.
The location of the lymph node may help to determine the site of malignancy. Diffuse, bilateral
involvement suggests a systemic malignancy (e.g. lymphoma) while those limited to a specific anatomic
region are more likely associated with a local problem. Enlargement of nodes located only on the right
side of the neck in the anterior cervical chain, for example, would be consistent with a squamous cell
carcinoma, frequently associated with an intra-oral primary cancer.

Cervical Adenopathy: Right

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 Cervical Adenopathy: Right
anterior cervical adenopathy
secondary to metastatic cancer.

Cervical Adenopathy: Massive right

side cervical adenopathy secondary
to metastatic squamous cell cancer
originating
from this patient's oropharynx.
Diffuse upper airway infections (e.g. mononucleosis), systemic
infections (e.g. tuberculosis) and inflammatory processes (e.g.
sarcoidosis) can also cause lymphadenopathy (i.e. lymph node
enlargement). This can be either symmetric or asymmetric. Historical
information as well findings elsewhere in the body are critical to
making these diagnoses. Furthermore, it may take serial examinations
over the course of weeks to determine whether a node is truly
enlarging, suggestive of malignancy, or responding to therapy/the
passage of time and regressing in size, as might occur with other
inflammatory processes.
The Ear
External structures: Briefly examine the outer structures, paying
particular attention to any skin changes suggestive of cancer (e.g
basal cell, melanoma, squamous cell), a common asymptomatic
abnormality affecting this sun exposed area. If the patient has pain,
try to identify its precise location. Infection within the external canal,
for example, may cause discharge from the ear as well as pain on
manipulation of any of the external structures.
Diffuse upper airway infections (e.g. mononucleosis), systemic
infections (e.g. tuberculosis) and inflammatory processes (e.g.
sarcoidosis) can also cause lymphadenopathy (i.e. lymph node
enlargement). This can be either symmetric or asymmetric. Historical
information as well findings elsewhere in the body are critical to
making these diagnoses. Furthermore, it may take serial examinations
over the course of weeks to determine whether a node is truly
enlarging, suggestive of malignancy, or responding to therapy/the
passage of time and regressing in size, as might occur with other
inflammatory processes.
The Ear
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The Ear
External structures: Briefly examine the outer structures, paying
particular attention to any skin changes suggestive of cancer (e.g
basal cell, melanoma, squamous cell), a common asymptomatic
abnormality affecting this sun exposed area. If the patient has pain,
try to identify its precise location. Infection within the external canal,
for example, may cause discharge from the ear as well as pain on
manipulation of any of the external structures.

Otoscope

Otoscopy: The otoscope allows you to examine the external canal, the
structure that connects the outside world with the middle ear, as well
as the ear drum and a few inner ear structures. Proceed as follows:
1. Put the otoscopic head on your oto-opthalmoscopic. It should
easily twist into position.
2. Turn on the light source.
3. Place one of the disposable specula on the end of the scope.
4. Grasp the scope so that the handle is either pointed directly
downward or angled up and towards the patient's forehead. Either
technique is acceptable. The scope should be in your right hand if
you are examining the right ear.
5. Place the tip of the specula in the opening of the external canal. Do
this under direct vision (i.e. not while looking through the scope).
6. Gently grasp the top of the left ear with your left hand and pull up
and backwards. This straightens out the canal, allowing easier
passage of the scope.
7. Look through the viewing window with either eye. Slowly advance
the scope, heading a bit towards the patient's nose but without any
up or down angle. Move in small increments. Try not to wiggle the

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up or down angle. Move in small increments. Try not to wiggle the
scope too much as the external canal is quite sensitive. I find it
helpful to extend the pinky and fourth fingers of my right hand and
place them on the side of the patient's head, which has a stabilizing
effect. As you advance, pay attention to the appearance of the
external canal. In the setting of infection, called otitis externa, the
walls becomes red, swollen and may not accommodate the
speculum. In the normal state there should be plenty of room. If
wax, which appears brownish, irregular and mushy, obscures your
view, stop and go to the other side. Do not try to extract it
until/unless you have had specific training in this area! There are
pharmacologic means of softening wax, which may then be easily
irrigated from the canal.

Otitis Externa: Swelling due to infection in the external canal of the

left ear (picture on right) limits the space around
the Q-Tip. Picture on left is of normal ear for comparison.

After moving ahead a few centimeters, you should see the

tympanic membrane (a.k.a. ear drum). Pay particular attention to:

Otoscopic Examination a. The color: When healthy, it

has a grayish, translucent
appearance.
b. The structures behind it: The
malleous, one of the bones of
the middle ear, touches the
drum. The drum is draped
over this bone, which is
visible through its top half,
angled down and backwards.
The part that is closest to the
top of the drum is called the
lateral process, and is
generally most prominent.
The tip at the bottom-most
aspect is the umbo.
c. The light reflex: Light
originating from your scope
will be reflected off the
surface of the drum, making a
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 surface of the drum, making a
triangle that is visible below
the malleous.
d. In the setting of infection within the middle ear (known as otitis
media, the most common pathologic process affecting this
area), the drum becomes diffusely red and the light reflex is
lost. The malleous also appears less prominent and you may be
able to see a line caused by fluid collecting behind the drum.
This is called a middle ear effusion and can cause the drum to
bulge outwards.
e. There is a valve on your scope that allows the attachment of a
small, compressible bulb. Place the bulb in the palm of the
hand which is not holding the scope. With this device, you can
squirt small puffs of air (known as pneumatic otoscopy) at the
tympanic membrane. The normal membrane moves, which can
be appreciated by the examiner. Effusions prevent this from
occurring. Ask an experienced examiner to demonstrate as this
is quite awkward at first and it's difficult to appreciate the
movement.
8. Move to the other side of the body and examine the left ear. Hand
position is reversed.
The University of Toronto's Medical Student Atlas, is an good
source for pictures of the tympanic membrane as well as other
assorted images related to the head and neck region.

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