Ophthalmology, ENT, and dermatology
Station 51 Vision and the eye examination(including fundoscopy) 139
• Ask the patient if he has any questions or concerns.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a vision and the eye examination station
• absent red reflex; on approaching ophthalmoscope the lens may look like cracked ice.
• drusen (characteristic yellow deposits) in the macula, exudative changes resulting from blood
• stage I: arteriolar narrowing and tortuosity.
• stage II: AV nicking, silver-wiring.
• stage III: dot, blot, and flame haemorrhages, microaneurysms, soft exudates (cotton wool
• background: microaneurysms, macular oedema, hard exudates, haemorrhages.
• pre-proliferative: cotton-wool spots, venous beading.
• proliferative: neovascularisation, vitreous haemorrhage.
• increased cup-to-disc ratio (> 0.5), haemorrhages.
Central retinal artery occlusion:
• pale retina with swelling or oedema, markedly decreased vascularity, cherry red spot in the
Central retinal vein occlusion:
• widespread haemorrhages throughout the retina with swelling and oedema, sometimes
described as a ‘stormy sunset’.
• blurring of disc margins, cupping and swelling of the disc, haemorrhages, exudates, distended
Hearing and the ear examination
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Sit him so that he is facing you and ensure that he is comfortable.
Ask the patient if there has been any loss of, or change in, hearing. If there has, assess its:
• Characteristics (bilaterality, onset, duration, severity, impact on the patient’s life).
• Associated features (tinnitus, vertigo, pain, discharge, weight loss).
• Possible causes (noise exposure, trauma, infection, antibiotics, family history).
• Impact on the patient’s life.
• Previous ear problems and ear surgery.
slightly louder. If you suspect hearing loss, seek out a full audiological assessment.
Use a 512 Hz tuning fork, and not the larger 128 Hz or 256 Hz tuning forks used for
• The Rinne test. Place the base of the vibrating tuning fork on the mastoid process of each ear.
Once the patient can no longer ‘hear’ the vibration, move the tuning fork in front of the ear.
If the tuning fork can be heard, air conduction is better than bone conduction, and there is
therefore no conductive hearing loss. The test is said to be positive. If the tuning fork cannot be
heard, there is a conductive hearing loss, and the test is said to be negative.
The false negative Rinne test: if the Rinne test is performed on a deaf ear, it may appear
negative because the vibration is transmitted to the opposite ear.
• The Weber test. Place the vibrating tuning fork in the middle of forehead, just inferior to the
hairline. If hearing is normal, or if hearing loss is symmetrical, the vibration should be heard
equally in both ears, that is, in the centre of the head. The Weber test is most informative in
patients presenting with a ‘good’ and a ‘problem’ ear.
• If there is sensorineural deafness in one ear, obviously, the vibration is best heard in the other
Ophthalmology, ENT, and dermatology
Station 52 Hearing and the ear examination 141
• Examine the pinnae for size, shape, deformities, pre-auricular sinuses.
• Look behind the ears for any scars.
• Palpate the pre-auricular, post-auricular, and infra-auricular lymph nodes.
• Affix a speculum of appropriate size onto the auroscope.
• Using your thumb and the proximal part of your index finger, gently pull the pinna upwards
and backwards so as to straighten the ear canal and, holding the auroscope like a pen (see
Figure 33), introduce it into the external auditory meatus.
If examining the right ear, use your right hand to hold the auroscope/otoscope.
If examining the left ear, use your left hand. This is so that your little finger (also called
digitus auricularis because historically it was used to clean out the ear) can act as a guard,
preventing you from plunging your tool too deep into the ear canal.
• Through the auroscope, inspect the ear canal (discharge, foreign body, wax, exotosis, otitis
externa) and the tympanic membrane (normal anatomy, colour (normally pearly grey), shape
(normally concave), light reflex (normally present), effusions, cholesteatoma, perforations,
Figure 32. The Rinne (A, B) and Weber (C) tests.
142 Station 52 Hearing and the ear examination
Figure 33. Holding the auroscope.
Figure 34. The normal right ear drum.
• Ask the patient if he has any questions or concerns.
• Summarise your findings and offer a differential diagnosis, e.g. excessive ear wax, otitis media
with effusion (‘glue ear’), perforated ear drum.
Ophthalmology, ENT, and dermatology
Station 52 Hearing and the ear examination 143
Figure 35. Common ear problems.
(A) Wax: excess or impacted wax, can occlude the ear canal.
to infection or occlusion of the ear canal.
of the tympanic membrane, disintegration of the light reflex, effusions, perforation.
or retraction of the ear drum, can lead to impairment of hearing.
Reproduced with permission from Michael Saunders, Bristol Royal Infirmary.
144 Station 52 Hearing and the ear examination
Conditions most likely to come up in a hearing and the ear examination station
• commonly caused by wax, foreign bodies, exostoses, otitis externa, otitis media, trauma or
damage to the ear drum or ossicles.
• may be caused by noise exposure, degenerative changes (presbyacusis), trauma, infection,
aminoglycoside drugs such as gentamicin, Ménière’s disease, acoustic neuroma.
Figure 35. Common ear problems – continued.
(H) Grommet: small tube inserted in chronic otitis media to drain and ventilate the middle ear.
Reproduced with permission from Michael Saunders, Bristol Royal Infirmary.
145Ophthalmology, ENT, and dermatology
Smell and the nose examination
Specifications: This station may involve a model of a nose in lieu of a patient.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Position him so that he is sitting in a chair facing you.
• Ensure that he is comfortable.
• Briefly establish the nature of the problem.
• If there is obstruction of the nasal passages, determine its:
– characteristics (nasal passage affected, onset, duration, timing, severity)
– associated symptoms (facial pain, inflammation, itching, rhinorrhoea, sneezing, snoring,
– possible causes (asthma, hay fever, other allergies, trauma, surgery, other)
– impact on everyday life e.g. difficulty breathing, changes in smell or taste
• Observe the external appearance of the nose from the front, from the side, and from above.
Look for evidence of deformity, inflammation, nasal discharge, skin disease, and scars.
with the help of a Thudicum speculum and head or pen torch. Hold the speculum at the bend
with the thumb and index finger of your non-dominant hand, and place your middle and ring
fingers on either side of the limbs. Holding this position, insert the speculum into the nostril,
moving your middle and ring fingers apart to spread the flanges and open up the nasal cavity.
• Look into the mouth — a large nasal tumour can sometimes be visible at the back oropharynx.
• Use an otoscope to assess the nasal septum and the inferior and middle turbinates. Make sure
A more detailed view of the nasal cavities can be obtained using a flexible (fibre-optic)
• Assess inspiratory flow by occluding one nostril and asking the patient to sniff. Repeat for the
146 Station 53 Smell and the nose examination
• With your thumb, press over the supra- and infra-orbital areas to elicit tenderness. Tenderness
in these areas is likely to indicate inflammation of the frontal and maxillary sinuses (sinusitis).
• Ask the patient if he has any questions or concerns.
• Offer to examine the throat and ears.
• Summarise your findings and offer a differential diagnosis.
Reproduced from www.askdrshah.com with permission from Dr Rajesh Shah.
Conditions most likely to come up in a smell and the nose examination station
• Congenital or trauma-induced deviated nasal septum.
• Septum perforation secondary to cocaine use, nose picking, or granulomatous disease.
• Anosmia secondary to viral infection or head injury.
147Ophthalmology, ENT, and dermatology
Lump in the neck and thyroid examination
• Introduce yourself to the patient.
• Confirm his name and date of birth. Bear in mind that age and sex have an important bearing
on the differential diagnosis of a goitre.
• Explain the examination and obtain his consent.
• Ask him to expose his neck, including unbuttoning his shirt and tying back long hair to fully
expose the neck and clavicles.
• Sit him in a chair positioned such that you can stand behind it.
• Ask for a glass of water for the patient to sip from when required.
horizontal and may be hidden in a skin crease.
A goitre, or enlarged thyroid gland, is seen as a swelling below the cricoid cartilage, on
• Ask the patient to take a sip of water. The following structures move upon swallowing: thyroid
gland, thyroid cartilage, cricoid cartilage, thyroglossal cyst, lymph nodes.
• Ask him to stick his tongue out. A midline swelling which moves upwards when the tongue is
protruded is a thyroglossal cyst.
• Ask the patient whether there is any tenderness in the neck area.
• Putting one hand on either side of his neck, examine the anterior and posterior triangles with
lump tender to touch? Note that the normal thyroid gland is often not palpable.
• Ask him to take a sip of water and then to swallow while you feel for any movement of the lump.
• If a palpable midline lump is present, ask him to stick his tongue out while you feel for upward
• Palpate for tracheal deviation in the suprasternal notch (see Station 17: Respiratory system
• Percuss for the dullness of a retrosternal goitre over the sternum and upper chest.
148 Station 54 Lump in the neck and thyroid examination
is sometimes heard in thyrotoxicosis.
Assessment of thyroid function/status
If you are asked to examine the thyroid, a recommended approach is to perform a full examination of
the neck paying particular attention to the thyroid gland, and then to ask the examiner whether you
• Ask him to hold out his hands and inspect for a fine resting tremor.
• Inspect his eyes for the eye signs of Graves’ disease: exophthalmos, lid retraction, and chemosis
(conjunctival oedema). Exophthalmos is protrusion of the eyeballs from the orbit such that the
• Now ask him to keep his head still and follow your finger with his eyes. As he does this, look out
for lid lag (lagging of the upper eyelid on downward rotation of the eye) and ophthalmoplegia
(indicated by reduced eye movements). These too are signs of Graves’ ophthalmopathy.
• Ask to take the patient’s hands and notice if they are warm and sweaty, or cold and dry.
• Look for clubbing of the nails associated with Graves’ disease (thyroid acropachy).
• Palpate the radial pulse, assessing for tachycardia and atrial fibrillation (pulse is irregularly
• Elicit reflexes: hyperthyroidism is associated with hyper-reflexia, hypothyroidism with slow
• Palpate the lower legs for pre-tibial myxoedema (discoloured induration on the anterior
aspects of the lower legs), which is also associated with Graves’ disease.
• Auscultate the heart, listening specifically for a systolic flow murmur (hyper-dynamic circulation
associated with hyperthyroidism).
Ophthalmology, ENT, and dermatology
Station 54 Lump in the neck and thyroid examination 149
• Offer to help the patient to put his clothes back on.
• Ensure that he is comfortable.
• Ask him if he has any questions or concerns.
• Offer a diagnosis or differential diagnosis.
Signs of hyperthyroidism: enlarged thyroid gland or thyroid nodules, thyroid bruit, hyperthermia,
diaphoresis, dehydration, tremor, tachycardia, arrhythmia, congestive cardiac failure, onycholysis.
• Graves’ disease (commonest cause of hyperthyroidism): uniformly enlarged smooth thyroid
gland usually in a younger patient; lid retraction, lid lag, chemosis, periorbital oedema,
proptosis, diplopia, pre-tibial myxoedema (non-pitting oedema and skin thickening, seen in
<5% of cases), thyroid acropachy (finger clubbing, seen in <1% of cases).
• Toxic multinodular goitre: enlarged multinodular goitre in a middle-aged patient.
• Toxic nodule and de Quervain’s thyroiditis are less common.
Signs of hypothyroidism: hypothermia and cold intolerance, weight gain, slowed speech and
bradycardia, and hyporeflexia.
• Hashimoto’s thyroiditis (commonest cause of hypothyroidism): moderately enlarged rubbery
thyroid gland, usually in a female patient aged 30–50 years; initial hyperthyroidism that
progresses to hypothyroidism and, if untreated, to myxoedema.
[Note] Iodine deficiency can also cause a goitre but this is rarely seen in developed countries.
Figure 37. Anatomy of the normal thyroid gland.
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