I've finished vital signs, now moving on to an assessment of head and hair.
We're going to look at Steve's hair, make sure there's no thinness or loss or abnormalities of the hair and the scalp.
I'm palpating or checking for any lumps, or if the patient had tenderness of the scalp to find the area of the tenderness there, too. I see no abnormalities, so I'll move into eyes.
The next part of the exam is the eye exam. And with all exams, of course, you're going to start with inspection. With inspection of the eye, you'll look first, top to bottom. Start with the eyebrows, eye lids, look where the lacrimal [tear] glands are. Look at the sclera and conjunctiva and the pupils. And always, of course, comparing one eye to the other.
Now the next part of this is, I want you to look up towards the ceiling, and I'm going to just pull down the lids here, and looking at the lower part of the lids. All right, good. And again, comparing sides there.
The next part is visual acuity, when I'm going to assess Frank's vision. Now in your clinical practice, you'll often see your preceptors checking with an eye chart that's 20 feet away. I'm checking near vision, and that'll be about 14 inches [35.56 cm] away.And for anybody who needs reading glasses, they should put those reading glasses on. So, Frank, you can put your reading glasses on because, with near vision, you'll not be able to see if he needs reading glasses. Now Frank, can you hold this about 14 inches away? Now cover up your left eye cause I'm going to be checking one eye at a time, and with, Frank, with your right eye exposed, look at the lowest line of numbers that you can read there along the left side of the chart.
[Frank, patient] 937826.
[physician continues] All right, so when I look at that, that is 20/25 vision with the right eye.
Now if you can cover your right eye, I'll do the same thing with the left eye, and check your vision again on the left eye.
[Frank, patient] 937826.
[physician continues] All right, so it's the same thing, 20/25 vision on both sides.
Now what I'll do is assess visual fields. You think of the visual fields as in four separate quadrants. There's an upper quadrant, temporal quadrant; lower temporal quadrant; upper nasal quadrant; and lower nasal quadrant. That's for each eye.
So I'm going to check each of those quadrants. I'm going to use fingers. I'm going to ask Frank if he's seeing one, two, or five fingers. I'm using those numbers of fingers because it's easy to distinguish one and two and five from other digits.
So, Frank, if you can cover your left eye with your left hand, and what I'm going to do while he's doing that, is I'm covering my right eye, so that I can check my field of vision against his, as a standard. Now look at my nose, and then tell me how many fingers you see me holding up. [Patient: One?]. And just watch my nose if you can. Okay, now tell me how many fingers? [Patient: Two.] All right, and how many fingers here? [Patient:Five.] And you see that I am holding it in a way that he is going to be able to see how many fingers, I'm not going to turn my hand in different directions where numbers of fingers can be confused.
Now we'll check the same thing with the other-- keep your hand there-- and how many fingers do you see here? [Patient: Two.] and how many fingers here? [Patient: Two.]
All right, now you see that he didn't see the right number of fingers in the upper outer quadrant, so I'm going to check that again. Now tell me again, how many fingers you're seeing here. [Patient: Two.] All right, so I've checked all four quadrants of the right eye.
Now you can replace your hand and now cover up your right eye. Now we'll check the left eye. We'll do the same thing, starting first with the upper and lower outer quadrants, and then switching to the inner higher and lower quadrants.
All right, so again tell me how many fingers. [Patient: Five.] And how many fingers? [Patient: One.] All right, and here? [Patient: Two] And here? [Patient: One.] Good. So he's checked all those quadrants on both sides.
Now the next part of the check here is to check for the near response. I want to see that as Frank looks in the distance, and then brings his eyes in and looking towards me, his eyes converge a little, come in a little closer together, and there's a little bit of pupillary restriction, but I may not be able to see that.
Now Frank, if you can look at the wall over there, and now look at my finger here, and what I see is that his eyes converge and come together, you see a little bit of pupillary restriction.
Now I'll move right into checking extra-ocular motions, just watch my finger here, and I'm going to move this in an H pattern, out this way, and up this way. I'm watching both eyes, making sure that they are both moving in conjunction with each other.
And out this way, up the H pattern up to the top, and then down to the bottom. Okay. And then back to the center.So that checks all the extra ocular motions of many of the different eye muscles.
And the next part I'm going to check is watch for pupils, to see that they react to light. Now typically, for checking pupils, you want to turn off the light. I'm going to leave the light on so you can see what it is I'm doing. But as you're examining patients eyes, especially the pupils, and looking at the retina, you would turn the light off.
[minute 5:33]
Now I'm going to bring over the opthalmoscope, and I'm going to show you a few aspects of this opthalmoscope. So you can see what are the characteristics here. First, this is the back of the opthalmoscope. This top part you would rest right on your forehead, and this is what you would look through, this aperture here. And right down on the bottom are a set of numbers. And that number you should always set at zero (0).
This dial on the side is how you would turn that number away from zero, but you're going to keep it always on zero, here.
Now I'll turn the opthalmoscope around the other way, this is the patient's side to show you some of what you see here. There's one dial here that will control the light characteristics, and then there's another dial here that controls how bright the light is. So I'll show you how that works. I'll use Frank's gown here.
First, the brightness. This is this dial here. As you watch that light, you see that it's getting brighter and dimmer as I'm moving this around. And when you're examining someone's eye, when you're looking at the back of their eye, you want to leave that light source about in the middle: not super bright, not too dim.
[6:44] And then that other dial I showed you, for the source of the light, you can move that back and forth, first to see a small amount of light, medium amount of light, large amount of light, and then you go to some other aspects that we don't use in PDS.
One is a target, a slit light, and then a blue light. But what you want to use for the light source is about the medium size. So medium size light source, about medium intensity of light here.
[7:14] Now what I'm going to check first is Frank's pupillary response. And as I said, I would typically dim the lights here, but I'll keep them bright, so if you can look against the opposite wall, here. What I'm doing is I'm shining the light in one eye here, to see that the pupil is constricting. And while this pupil, the right pupil, is constricting, the other one should also be constricting.
[7:48} And then I'll go over and check the left pupil. And see that the left pupil is constricting, at the same time that the right pupil is constricting, that's normal, for both pupils to constrict, even though light is shining just in one pupil.
Now the other part of this is the swinging flashlight test, or checking to make sure that pupils stay constricted. So I shine on this eye, then I move over here just for a few seconds,
I've finished vital signs, now moving on to an assessment of head and hair.
We're going to look at Steve's hair, make sure there's no thinness or loss or abnormalities of the hair and the scalp.
I'm palpating or checking for any lumps, or if the patient had tenderness of the scalp to find the area of the tenderness there, too. I see no abnormalities, so I'll move into eyes.
The next part of the exam is the eye exam. And with all exams, of course, you're going to start with inspection. With inspection of the eye, you'll look first, top to bottom. Start with the eyebrows, eye lids, look where the lacrimal [tear] glands are. Look at the sclera and conjunctiva and the pupils. And always, of course, comparing one eye to the other.
Now the next part of this is, I want you to look up towards the ceiling, and I'm going to just pull down the lids here, and looking at the lower part of the lids. All right, good. And again, comparing sides there.
The next part is visual acuity, when I'm going to assess Frank's vision. Now in your clinical practice, you'll often see your preceptors checking with an eye chart that's 20 feet away. I'm checking near vision, and that'll be about 14 inches [35.56 cm] away.And for anybody who needs reading glasses, they should put those reading glasses on. So, Frank, you can put your reading glasses on because, with near vision, you'll not be able to see if he needs reading glasses. Now Frank, can you hold this about 14 inches away? Now cover up your left eye cause I'm going to be checking one eye at a time, and with, Frank, with your right eye exposed, look at the lowest line of numbers that you can read there along the left side of the chart.
[Frank, patient] 937826.
[physician continues] All right, so when I look at that, that is 20/25 vision with the right eye.
Now if you can cover your right eye, I'll do the same thing with the left eye, and check your vision again on the left eye.
[Frank, patient] 937826.
[physician continues] All right, so it's the same thing, 20/25 vision on both sides.
Now what I'll do is assess visual fields. You think of the visual fields as in four separate quadrants. There's an upper quadrant, temporal quadrant; lower temporal quadrant; upper nasal quadrant; and lower nasal quadrant. That's for each eye.
So I'm going to check each of those quadrants. I'm going to use fingers. I'm going to ask Frank if he's seeing one, two, or five fingers. I'm using those numbers of fingers because it's easy to distinguish one and two and five from other digits.
So, Frank, if you can cover your left eye with your left hand, and what I'm going to do while he's doing that, is I'm covering my right eye, so that I can check my field of vision against his, as a standard. Now look at my nose, and then tell me how many fingers you see me holding up. [Patient: One?]. And just watch my nose if you can. Okay, now tell me how many fingers? [Patient: Two.] All right, and how many fingers here? [Patient:Five.] And you see that I am holding it in a way that he is going to be able to see how many fingers, I'm not going to turn my hand in different directions where numbers of fingers can be confused.
Now we'll check the same thing with the other-- keep your hand there-- and how many fingers do you see here? [Patient: Two.] and how many fingers here? [Patient: Two.]
All right, now you see that he didn't see the right number of fingers in the upper outer quadrant, so I'm going to check that again. Now tell me again, how many fingers you're seeing here. [Patient: Two.] All right, so I've checked all four quadrants of the right eye.
Now you can replace your hand and now cover up your right eye. Now we'll check the left eye. We'll do the same thing, starting first with the upper and lower outer quadrants, and then switching to the inner higher and lower quadrants.
All right, so again tell me how many fingers. [Patient: Five.] And how many fingers? [Patient: One.] All right, and here? [Patient: Two] And here? [Patient: One.] Good. So he's checked all those quadrants on both sides.
Now the next part of the check here is to check for the near response. I want to see that as Frank looks in the distance, and then brings his eyes in and looking towards me, his eyes converge a little, come in a little closer together, and there's a little bit of pupillary restriction, but I may not be able to see that.
Now Frank, if you can look at the wall over there, and now look at my finger here, and what I see is that his eyes converge and come together, you see a little bit of pupillary restriction.
Now I'll move right into checking extra-ocular motions, just watch my finger here, and I'm going to move this in an H pattern, out this way, and up this way. I'm watching both eyes, making sure that they are both moving in conjunction with each other.
And out this way, up the H pattern up to the top, and then down to the bottom. Okay. And then back to the center.So that checks all the extra ocular motions of many of the different eye muscles.
And the next part I'm going to check is watch for pupils, to see that they react to light. Now typically, for checking pupils, you want to turn off the light. I'm going to leave the light on so you can see what it is I'm doing. But as you're examining patients eyes, especially the pupils, and looking at the retina, you would turn the light off.
[minute 5:33]
Now I'm going to bring over the opthalmoscope, and I'm going to show you a few aspects of this opthalmoscope. So you can see what are the characteristics here. First, this is the back of the opthalmoscope. This top part you would rest right on your forehead, and this is what you would look through, this aperture here. And right down on the bottom are a set of numbers. And that number you should always set at zero (0).
This dial on the side is how you would turn that number away from zero, but you're going to keep it always on zero, here.
Now I'll turn the opthalmoscope around the other way, this is the patient's side to show you some of what you see here. There's one dial here that will control the light characteristics, and then there's another dial here that controls how bright the light is. So I'll show you how that works. I'll use Frank's gown here.
First, the brightness. This is this dial here. As you watch that light, you see that it's getting brighter and dimmer as I'm moving this around. And when you're examining someone's eye, when you're looking at the back of their eye, you want to leave that light source about in the middle: not super bright, not too dim.
[6:44] And then that other dial I showed you, for the source of the light, you can move that back and forth, first to see a small amount of light, medium amount of light, large amount of light, and then you go to some other aspects that we don't use in PDS.
One is a target, a slit light, and then a blue light. But what you want to use for the light source is about the medium size. So medium size light source, about medium intensity of light here.
[7:14] Now what I'm going to check first is Frank's pupillary response. And as I said, I would typically dim the lights here, but I'll keep them bright, so if you can look against the opposite wall, here. What I'm doing is I'm shining the light in one eye here, to see that the pupil is constricting. And while this pupil, the right pupil, is constricting, the other one should also be constricting.
[7:48} And then I'll go over and check the left pupil. And see that the left pupil is constricting, at the same time that the right pupil is constricting, that's normal, for both pupils to constrict, even though light is shining just in one pupil.
Now the other part of this is the swinging flashlight test, or checking to make sure that pupils stay constricted. So I shine on this eye, then I move over here just for a few seconds,
I've finished vital signs, now moving on to an assessment of head and hair.
We're going to look at Steve's hair, make sure there's no thinness or loss or abnormalities of the hair and the scalp.
I'm palpating or checking for any lumps, or if the patient had tenderness of the scalp to find the area of the tenderness there, too. I see no abnormalities, so I'll move into eyes.
The next part of the exam is the eye exam. And with all exams, of course, you're going to start with inspection. With inspection of the eye, you'll look first, top to bottom. Start with the eyebrows, eye lids, look where the lacrimal [tear] glands are. Look at the sclera and conjunctiva and the pupils. And always, of course, comparing one eye to the other.
Now the next part of this is, I want you to look up towards the ceiling, and I'm going to just pull down the lids here, and looking at the lower part of the lids. All right, good. And again, comparing sides there.
The next part is visual acuity, when I'm going to assess Frank's vision. Now in your clinical practice, you'll often see your preceptors checking with an eye chart that's 20 feet away. I'm checking near vision, and that'll be about 14 inches [35.56 cm] away.And for anybody who needs reading glasses, they should put those reading glasses on. So, Frank, you can put your reading glasses on because, with near vision, you'll not be able to see if he needs reading glasses. Now Frank, can you hold this about 14 inches away? Now cover up your left eye cause I'm going to be checking one eye at a time, and with, Frank, with your right eye exposed, look at the lowest line of numbers that you can read there along the left side of the chart.
[Frank, patient] 937826.
[physician continues] All right, so when I look at that, that is 20/25 vision with the right eye.
Now if you can cover your right eye, I'll do the same thing with the left eye, and check your vision again on the left eye.
[Frank, patient] 937826.
[physician continues] All right, so it's the same thing, 20/25 vision on both sides.
Now what I'll do is assess visual fields. You think of the visual fields as in four separate quadrants. There's an upper quadrant, temporal quadrant; lower temporal quadrant; upper nasal quadrant; and lower nasal quadrant. That's for each eye.
So I'm going to check each of those quadrants. I'm going to use fingers. I'm going to ask Frank if he's seeing one, two, or five fingers. I'm using those numbers of fingers because it's easy to distinguish one and two and five from other digits.
So, Frank, if you can cover your left eye with your left hand, and what I'm going to do while he's doing that, is I'm covering my right eye, so that I can check my field of vision against his, as a standard. Now look at my nose, and then tell me how many fingers you see me holding up. [Patient: One?]. And just watch my nose if you can. Okay, now tell me how many fingers? [Patient: Two.] All right, and how many fingers here? [Patient:Five.] And you see that I am holding it in a way that he is going to be able to see how many fingers, I'm not going to turn my hand in different directions where numbers of fingers can be confused.
Now we'll check the same thing with the other-- keep your hand there-- and how many fingers do you see here? [Patient: Two.] and how many fingers here? [Patient: Two.]
All right, now you see that he didn't see the right number of fingers in the upper outer quadrant, so I'm going to check that again. Now tell me again, how many fingers you're seeing here. [Patient: Two.] All right, so I've checked all four quadrants of the right eye.
Now you can replace your hand and now cover up your right eye. Now we'll check the left eye. We'll do the same thing, starting first with the upper and lower outer quadrants, and then switching to the inner higher and lower quadrants.
All right, so again tell me how many fingers. [Patient: Five.] And how many fingers? [Patient: One.] All right, and here? [Patient: Two] And here? [Patient: One.] Good. So he's checked all those quadrants on both sides.
Now the next part of the check here is to check for the near response. I want to see that as Frank looks in the distance, and then brings his eyes in and looking towards me, his eyes converge a little, come in a little closer together, and there's a little bit of pupillary restriction, but I may not be able to see that.
Now Frank, if you can look at the wall over there, and now look at my finger here, and what I see is that his eyes converge and come together, you see a little bit of pupillary restriction.
Now I'll move right into checking extra-ocular motions, just watch my finger here, and I'm going to move this in an H pattern, out this way, and up this way. I'm watching both eyes, making sure that they are both moving in conjunction with each other.
And out this way, up the H pattern up to the top, and then down to the bottom. Okay. And then back to the center.So that checks all the extra ocular motions of many of the different eye muscles.
And the next part I'm going to check is watch for pupils, to see that they react to light. Now typically, for checking pupils, you want to turn off the light. I'm going to leave the light on so you can see what it is I'm doing. But as you're examining patients eyes, especially the pupils, and looking at the retina, you would turn the light off.
[minute 5:33]
Now I'm going to bring over the opthalmoscope, and I'm going to show you a few aspects of this opthalmoscope. So you can see what are the characteristics here. First, this is the back of the opthalmoscope. This top part you would rest right on your forehead, and this is what you would look through, this aperture here. And right down on the bottom are a set of numbers. And that number you should always set at zero (0).
This dial on the side is how you would turn that number away from zero, but you're going to keep it always on zero, here.
Now I'll turn the opthalmoscope around the other way, this is the patient's side to show you some of what you see here. There's one dial here that will control the light characteristics, and then there's another dial here that controls how bright the light is. So I'll show you how that works. I'll use Frank's gown here.
First, the brightness. This is this dial here. As you watch that light, you see that it's getting brighter and dimmer as I'm moving this around. And when you're examining someone's eye, when you're looking at the back of their eye, you want to leave that light source about in the middle: not super bright, not too dim.
[6:44] And then that other dial I showed you, for the source of the light, you can move that back and forth, first to see a small amount of light, medium amount of light, large amount of light, and then you go to some other aspects that we don't use in PDS.
One is a target, a slit light, and then a blue light. But what you want to use for the light source is about the medium size. So medium size light source, about medium intensity of light here.
[7:14] Now what I'm going to check first is Frank's pupillary response. And as I said, I would typically dim the lights here, but I'll keep them bright, so if you can look against the opposite wall, here. What I'm doing is I'm shining the light in one eye here, to see that the pupil is constricting. And while this pupil, the right pupil, is constricting, the other one should also be constricting.
[7:48} And then I'll go over and check the left pupil. And see that the left pupil is constricting, at the same time that the right pupil is constricting, that's normal, for both pupils to constrict, even though light is shining just in one pupil.
Now the other part of this is the swinging flashlight test, or checking to make sure that pupils stay constricted. So I shine on this eye, then I move over here just for a few seconds,
I've finished vital signs, now moving on to an assessment of head and hair.
We're going to look at Steve's hair, make sure there's no thinness or loss or abnormalities of the hair and the scalp.
I'm palpating or checking for any lumps, or if the patient had tenderness of the scalp to find the area of the tenderness there, too. I see no abnormalities, so I'll move into eyes.
The next part of the exam is the eye exam. And with all exams, of course, you're going to start with inspection. With inspection of the eye, you'll look first, top to bottom. Start with the eyebrows, eye lids, look where the lacrimal [tear] glands are. Look at the sclera and conjunctiva and the pupils. And always, of course, comparing one eye to the other.
Now the next part of this is, I want you to look up towards the ceiling, and I'm going to just pull down the lids here, and looking at the lower part of the lids. All right, good. And again, comparing sides there.
The next part is visual acuity, when I'm going to assess Frank's vision. Now in your clinical practice, you'll often see your preceptors checking with an eye chart that's 20 feet away. I'm checking near vision, and that'll be about 14 inches [35.56 cm] away.And for anybody who needs reading glasses, they should put those reading glasses on. So, Frank, you can put your reading glasses on because, with near vision, you'll not be able to see if he needs reading glasses. Now Frank, can you hold this about 14 inches away? Now cover up your left eye cause I'm going to be checking one eye at a time, and with, Frank, with your right eye exposed, look at the lowest line of numbers that you can read there along the left side of the chart.
[Frank, patient] 937826.
[physician continues] All right, so when I look at that, that is 20/25 vision with the right eye.
Now if you can cover your right eye, I'll do the same thing with the left eye, and check your vision again on the left eye.
[Frank, patient] 937826.
[physician continues] All right, so it's the same thing, 20/25 vision on both sides.
Now what I'll do is assess visual fields. You think of the visual fields as in four separate quadrants. There's an upper quadrant, temporal quadrant; lower temporal quadrant; upper nasal quadrant; and lower nasal quadrant. That's for each eye.
So I'm going to check each of those quadrants. I'm going to use fingers. I'm going to ask Frank if he's seeing one, two, or five fingers. I'm using those numbers of fingers because it's easy to distinguish one and two and five from other digits.
So, Frank, if you can cover your left eye with your left hand, and what I'm going to do while he's doing that, is I'm covering my right eye, so that I can check my field of vision against his, as a standard. Now look at my nose, and then tell me how many fingers you see me holding up. [Patient: One?]. And just watch my nose if you can. Okay, now tell me how many fingers? [Patient: Two.] All right, and how many fingers here? [Patient:Five.] And you see that I am holding it in a way that he is going to be able to see how many fingers, I'm not going to turn my hand in different directions where numbers of fingers can be confused.
Now we'll check the same thing with the other-- keep your hand there-- and how many fingers do you see here? [Patient: Two.] and how many fingers here? [Patient: Two.]
All right, now you see that he didn't see the right number of fingers in the upper outer quadrant, so I'm going to check that again. Now tell me again, how many fingers you're seeing here. [Patient: Two.] All right, so I've checked all four quadrants of the right eye.
Now you can replace your hand and now cover up your right eye. Now we'll check the left eye. We'll do the same thing, starting first with the upper and lower outer quadrants, and then switching to the inner higher and lower quadrants.
All right, so again tell me how many fingers. [Patient: Five.] And how many fingers? [Patient: One.] All right, and here? [Patient: Two] And here? [Patient: One.] Good. So he's checked all those quadrants on both sides.
Now the next part of the check here is to check for the near response. I want to see that as Frank looks in the distance, and then brings his eyes in and looking towards me, his eyes converge a little, come in a little closer together, and there's a little bit of pupillary restriction, but I may not be able to see that.
Now Frank, if you can look at the wall over there, and now look at my finger here, and what I see is that his eyes converge and come together, you see a little bit of pupillary restriction.
Now I'll move right into checking extra-ocular motions, just watch my finger here, and I'm going to move this in an H pattern, out this way, and up this way. I'm watching both eyes, making sure that they are both moving in conjunction with each other.
And out this way, up the H pattern up to the top, and then down to the bottom. Okay. And then back to the center.So that checks all the extra ocular motions of many of the different eye muscles.
And the next part I'm going to check is watch for pupils, to see that they react to light. Now typically, for checking pupils, you want to turn off the light. I'm going to leave the light on so you can see what it is I'm doing. But as you're examining patients eyes, especially the pupils, and looking at the retina, you would turn the light off.
[minute 5:33]
Now I'm going to bring over the opthalmoscope, and I'm going to show you a few aspects of this opthalmoscope. So you can see what are the characteristics here. First, this is the back of the opthalmoscope. This top part you would rest right on your forehead, and this is what you would look through, this aperture here. And right down on the bottom are a set of numbers. And that number you should always set at zero (0).
This dial on the side is how you would turn that number away from zero, but you're going to keep it always on zero, here.
Now I'll turn the opthalmoscope around the other way, this is the patient's side to show you some of what you see here. There's one dial here that will control the light characteristics, and then there's another dial here that controls how bright the light is. So I'll show you how that works. I'll use Frank's gown here.
First, the brightness. This is this dial here. As you watch that light, you see that it's getting brighter and dimmer as I'm moving this around. And when you're examining someone's eye, when you're looking at the back of their eye, you want to leave that light source about in the middle: not super bright, not too dim.
[6:44] And then that other dial I showed you, for the source of the light, you can move that back and forth, first to see a small amount of light, medium amount of light, large amount of light, and then you go to some other aspects that we don't use in PDS.
One is a target, a slit light, and then a blue light. But what you want to use for the light source is about the medium size. So medium size light source, about medium intensity of light here.
[7:14] Now what I'm going to check first is Frank's pupillary response. And as I said, I would typically dim the lights here, but I'll keep them bright, so if you can look against the opposite wall, here. What I'm doing is I'm shining the light in one eye here, to see that the pupil is constricting. And while this pupil, the right pupil, is constricting, the other one should also be constricting.
[7:48} And then I'll go over and check the left pupil. And see that the left pupil is constricting, at the same time that the right pupil is constricting, that's normal, for both pupils to constrict, even though light is shining just in one pupil.
Now the other part of this is the swinging flashlight test, or checking to make sure that pupils stay constricted. So I shine on this eye, then I move over here just for a few seconds,
I've finished vital signs, now I'll move into an assessment of head and hair. I'm going to look at Steve's hair, make sure there's no thinness, or loss, or any abnormalities of the hair and the scalp.
Now the other part of this is the swinging flashlight test, or checking to make sure that pupils stay constricted. So I shine on this eye, and then I move over here just for a couple of seconds, and back over here. I’m looking at both pupils as I’m doing that, to see that both pupils are staying constricted, as I move the light back and forth, as a way to check that the eyes are both getting the same information from the optic nerve.
Now the next part of this is also to check the optic disc. The main purpose of checking the optic disc is to be able to see the end of the optic nerve, and to see the disc itself. The remainder of the retina is made up of blood vessels and the background of the retina. In PDS, it may be hard for you to identify the optic disc, and so what I want you to be able to do in your first year and into your second year is to be able to identify a blood vessel, and as you get more comfortable with evaluating blood vessels, then you what to be able to focus in and find the optic disc. So, I’ll show you how I would recommend that you do this. First, if I’m examining Frank’s right eye first, I’m gonna hold the ophthalmoscope in my right hand. I’m going to use my right eye, and my left hand will be to stabilize myself with my hand on Frank’s forehead, so that I can tell how far away I am from Frank’s eye, ‘cause I need to get fairly close with this ophthalmoscope, and I need to have some sign to myself of where I am in space. So, what I’ll do first is I’ll put my hand on your forehead Frank here, and I’m going to hold this over my right eye, and I’m looking and Franks’ eye and what I’m seeing here is a red reflex as I’m starting about this far away. I’m a little bit off center here, looking in Frank’s eye. And then I’m gonna come in closer here. And as I come in closer, I’m looking for a blood vessel, that’s a red line across a pale-ish or orange-ish field. And as I find one of those blood vessels, you see, I focus in and I see it right about at this distance. So, you can see about how far away I am from Frank’s eye. That’ll vary a little bit depending on your vision and the patient’s vision as to how close you need to get. And then once I find the blood vessel, then I follow it. And I follow it to a yellowish disc which is the optic disc. As I said, that’s a more advanced skill. If you find a blood vessel right away, see if you can follow it to the center and see an optic disc.
Now, I’ll move to the other eye. So, what I’m gonna do is I’m gonna bring this behind the patient. I’m gonna now hold this in my left hand. I’m gonna look at Frank’s left eye, and I’m using my left eye, and then I’ll use my right hand to stabilize on his forehead. So, I’ll come in through this direction. Again, identifying the red reflex, and then coming in closer. And then I see blood vessels, and then I can move in, again, to the optic disc.
And that concludes the eye exam today. We will now move on to the ear exam. First with the ear exam is always inspection. Looking at the ear itself, and also folding the ear forward and looking behind, to make sure there are no abnormalities behind the ear. And I would do the same thing on the other side also, checking the ear on the other side. Again, looking around the ear, looking at the soft cartilage and the lower part of the ear, the earlobe. And then again looking back behind the ear to make sure there are no abnormalities. The top of the ear is a common place for men to develop skin cancer because that part is exposed to the sun quite a bit. So, making sure to look around the ear is important.
After inspection, then you want to move on to assessing auditory acuity. Steve can you block your left ear with your hand. I’m going to say a word in your right ear, and I want you to tell me what it is. Cupcake. It’s important to use a two-syllable word where each syllable is about equally weighted. Now an alternative way to do this -- can you block your left ear again? -- is you can rub your fingers together, you can click your fingers, there’s different ways you can do this. The standard that we teach in PDS is that we use the two-syllable word. Now I’ll move to the other side and you can block your right ear. And I’ll say a word again here too. Cowboy. Alright, great. So normal hearing on both sides.
Now the next part I’ll move to is looking inside the ear. Now I’ll use the otoscope which has the same adjustment that the ophthalmoscope does in terms of brightness and dimness of light. When I am looking in the ear, or in the mouth, I will always want to keep the light as bright as possible, because there is no need to dim the light in any of these cases. Now back on the wall will be a speculum. This is so that you’re not putting this end of the otoscope in each patient’s ear. This allows you to move with this otoscope from one person to the other. What you do is you place the speculum on top of the otoscope and turn it in a clockwise direction. It clicks in a little bit, and then you know you have it in the right place. And then what I will do - now Steve if you can turn your head back that way - I will pull back on the ear like this, and this straightens out the ear canal. Then I will take the otoscope and place it inside the ear canal, and I’ll look in. And what I’m looking for is the eardrum and the ear bones. And I’ll look for all of that. I’ll move the scope around a little bit if needed, and you want to be careful about this and ask your patient if there’s any soreness, because if I’m pushing up against the ear canal with the speculum it can be somewhat uncomfortable. But I’ll approach that and then bring the speculum back out. And then I’ll go over to the other side, again, bringing the cord behind the patient. And I’ll again pull back on the ear to straighten the canal, insert the speculum, and again I’m looking for the ossicles and the eardrum towards the back. Now if you’re checking a small kid’s ear canal, kids of course don’t want their ears looked at, so you can use your hand to steady your scope against the patient’s cheek, steady the scope against the patient’s cheek, and then look in this direction too. So what I have is more control, so if Steve moves his head then the scope is going to move with him as he’s moving his head. Alright, then I’ll take that back out again. So either way works depending on whether you have a patient who is cooperative or one who is not.
Alright, now we'll move onto the exam of the nose and the sinuses. so first I'm gonna take a look at Steve's nose, and can you tilt your head up just a little bit. I'm looking at the area of the nose and around in the nostrils. Again looking for symmetry. Seeing if there is any skin lesions or lesions that are easily seen on the outside of the nose. Then, I'm going tho go to the inside of the nose and I'll use the otoscope again, and I'll use the otoscope with the light turned up as bright as it will go to help to illuminate anything that's within the nose. I'll also place the speculum on the top and I'll turn it in a clockwise direction until it clicks into place, and then what I'll do is... can you look up to the ceiling? I'll place my hand just tilt up on the nostril or the end of the nose just a little bit and look inside here. I can see what the mucosa looks like and I can also see a little bit of the turbinate. The main way that this helps me is if someone has upper respiratory infection and congestion I can see if there's any changes within the mucosa that might indicate sinus infection versus other infections.
Now bring this over to the other side and I'll look [into] in Steve's' left nostril. Again [kind of] kinda stand off to the side again here. Lifting up the end of the nose and then looking inside. And I'm careful to stay away from the (Septal ?) of the nose which is the most tender portion. Now, once I've completed that part, then I'll check sinuses. I'll check your frontal sinuses. I'll put my finger right up in this area. And Steve is there any tenderness as I'm pressing there?
Now once I've completed that part then I'll check sinuses. I'll check here frontal sinuses, I'll put my fingers right up in this area, and Steve, is there any tenderness as I'm pressing there?
Steve: No.
Presenter: All right. I'll also check here where the maxillary sinuses are, to see if there's any tenderness as I'm pressing in these areas.
Steve: Nope.
Presenter: And that would check for sinus infections in either the frontal or maxillary sinuses. The next part is the examination of the mouth starting with the outside and working in. So first I'll look at lips. Lips and upper part of the, uh, area around that is an area where skin cancer can develop so I'm looking very carefully for any new skin lesions and looking for moisture of the lips, and any changes in the skin of the lips. I'll use the otoscope and I'll turn the light up to the brightest level that it goes to look in the mouth. And the other piece of equipment that I will use here is a tongue depressor. This is a sterile package and I'll take the tongue depressor out. I'm holding at one end and I'll always use the other end to examine the patient's mouth. So Steve, could you open your mouth for me? Now, can you say ah?
Steve: Ahhh.
Presenter: Ah. All right. And what I'm watching as he's saying ah is to make sure the soft palate rises equally on both sides. If I can't see that with no tongue depressor then I can do this: Can you say ah?
Steve: Ahhh.
Presenter: And I am pressing down on the tongue with the tongue depressor. And, uh, if there is--if I see the soft palate rise equally on both sides that's checking for a couple of the cranial nerves, which we'll discuss in a moment. Now, can you stick your tongue out at me? Move it from side to side. All right. Yeah, I can see that he's got good tongue motion and that's checking for another of the cranial nerves. Now, stick your tongue out again and what I'll do is I'll move the side of the mouth to the side a little bit here so I can see on the buccal mucosa of that side. And do the same thing here. And buccal mucosa on that side and also looking on the sides of tongue too, for any lesions as well.
The other thing you can note with the mouth is moisture. Is this patient properly hydrated and is his mouth moist as a basis of good hydration?
