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Medical Instruments I

Medical Instruments I. Practical Use of the Ophthalmoscope and Otoscope Amanda Kocoloski, OMS IV Primary Care Associate/DFM Fellow. Objectives. Understand how to use the following equipment: Ophthalmoscope Otoscope Learn the fundoscopic exam and introduce the ear exam

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Medical Instruments I

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  1. Medical Instruments I Practical Use of the Ophthalmoscope and Otoscope Amanda Kocoloski, OMS IV Primary Care Associate/DFM Fellow

  2. Objectives • Understand how to use the following equipment: • Ophthalmoscope • Otoscope • Learn the fundoscopic exam and introduce the ear exam • Begin to appreciate normal eyes and ears by practicing on colleagues and instructors

  3. Ophthalmoscope Basics • Ophthalmoscope Anatomy • Ophthalmoscope Operation • Red Reflex • Examination of the Fundus

  4. Ophthalmoscope Anatomy View of the scope from the doctor’s perspective

  5. Ophthalmoscope Anatomy (Continued) View of the scope from the patient’s perspective

  6. In the Office/SP Lab

  7. Ophthalmoscope Operation • Turning it on: • Depress button and rotate • Adjust to about mid-brightness

  8. Ophthalmoscope Operation • Use the large, round, white beam • Smaller may be helpful if pupil is not dilated • Set the wheel used for changing the lens at zero diopters

  9. Eye Anatomy

  10. Red Reflex • Reflection of light off of retina • Pink to red in color • Should be equal in both eyes • Presence indicates there are NO opacities within the following areas: • Tear Film • Cornea • Anterior Chamber – Aqueous Fluid • Lens • Vitreous Fluid

  11. Conditions With Absence of the Red Reflex • Cataracts • Opacity of the lens • Detached retina • Retinoblastoma • Artificial globe/eyeball

  12. Ophthalmoscopic Exam: Red Reflex • Have your patient look up and over your shoulder • To visualize the red reflex, stand about 15 inches from your patient’s eye

  13. Ophthalmoscopic Exam: Fundus • Your right eye to patient’s right, your left to patient’s left • Place your free hand on the patient’s shoulder or forehead for stabilization • Beginning from the temporal aspect move in toward your patient’s eye to begin examination of the fundus • Keyhole phenomenon • Focus by adjusting the diopter if necessary • Should be unnecessary if neither you nor the patient have uncorrected refractive errors

  14. Ophthalmoscopic Exam: Fundus • Identify Vessels • Veins: Large darker vessels • Artery: Smaller brighter vessels • Optic disk • Located on nasal aspect • Sharp margins; nasal may be blurred • Yellow/orange • Physiologic optic cup • Macula and Fovea • Located on temporal aspect • Best visualized: stare directly at the light

  15. Ophthalmoscopic Exam: Fundus • A:V ratio • Arteries are 2/3 to 4/5 the diameter of veins • AV nicking (”Gunn sign”) • Associated with hypertension • Pathological arterial circulation impedes venous flow at their intersection • Cup to disk ratio • Cup is caused by central depression • Divide width of physiologic cup by the disk • Normal ratio is ≤ 0.5

  16. Ophthalmoscopic Exam: AV Nicking

  17. Ophthalmoscopic Exam:Fundus • Spontaneous venous pulsations • Normal as veins emerge from disc • May be reduced or absent in with elevated pressure • Papilledema • Optic nerve swelling • Often associated with increased intracranial pressure • Almost always bilateral

  18. Ophthalmoscopic Exam: Right Fundus Photo and corresponding diagram of a normal fundus. Note that the retinal vessels all stop short of and do not cross the fovea.

  19. Ear Exam

  20. Examination of the External Ear • Inspect the auricle for deformities • Skin tags/pits • Lymph nodes • Epidermoid cyst • Squamous/basal cell CA • Pain, discharge, or inflammation? • Perform the tug test

  21. Otoscopic Basics

  22. Otoscopic Examination of the EAC and TM • Straighten the ear canal • Adults- pull superior and posterior • Children– pull posterior and maybe inferior • Hold otoscope between your thumb and fingers; rest hand on patient’s face • Handle may point downward or toward patient’s eyebrow • Right hand when looking in the right ear, left hand when looking in the left ear

  23. Otoscopic Examination of the EAC and TM • Under direct visualization: Insert the speculum into the ear canal, directing it forward and downward • Inspect the canal with insertion • Inspect the tympanic membrane • color • contour • anatomical structures

  24. Otoscopic Examination of the EAC and TM Incus Pars flaccida Incus Malleus Umbo Pars tensa Pars tensa Cone of light Normal right ear Normal left ear

  25. References • Bates’ Guide to Physical Examination, Chapter 5. • http://emedicine.medscape.com/article/1201779-overview http://www.medicine.ucsd.edu/clinicalmed/introduction.htm • Vaughan & Asbury's General Ophthalmology, 17e

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