Ophthalmology clinical examination
Case one
I was asked to examine the anterior segments of a 7 year old boy. I started with observation and as the room was dark I asked for the room light to be turned on (do not assume that the examination environment is always made ideal for you). The child had asymmetrical corneal diameter with the right eye having a larger diameter.
I mentioned that I would begin by examining the lids and conjunctiva. The examiner asked me to skip this and go straight for the cornea. As expected, the patient had breaks in the right Descemet's membrane. However, these were oblique rather than horizontal as described in standard textbook for Haab's striae. On the temporal cornea near the limbus, there was corneal scar which I assummed was from goniotomy. The left eye was normal. I mentioned to the examiner that I would like to examine the posterior segment in the right eye for any optic disc cupping.
At this point, the examiner stopped me and asked what the diagnosis was. I mentioned congenital glaucoma but remarked on the orientation on the breaks which may also occur with injury from forcep delivery.
The examiner asked me the treatment of congenital glaucoma and the complications seen in congenital glaucoma.
Case two
I was asked to examine the pupil reaction of a 70 year old man. I began as usual with observation and noted that the patient had no evidence of anisocoria, ptosis or heterochromia (this should suggest the possibility of relative afferent pupillary defect).
The eyes responded normally to direct and consensual light testing. There was a right afferent pupillary defect with swinging light test. I mentioned to the examiner that I would normally like to complete the examination by testing the pupil reaction to accommodation but as the light response were normal the accommodation reflex was unlikely to be defective.
I mentioned the differential diagnosis of a afferent pupillary defect and volunteered to examine the right fundus for abnormal optic disc (some examiner likes spontaneity).
The patient had a right pale disc. I inspected his forehead for evidence of temporal artery biopsy scar but found none. I told the examiner that I liked to listen to the carotid artery for bruit. The examiner asked me if I thought carotid artery auscultation was useful in excluding carotid artery stenosis. The question then led on to the use of duplex ultrasound and echocardiogram in the investigation of central artery occlusion. The examiner finished by asking about the benefit of endarterectomy for carotid artery stenosis and its indication.
Case three
I was asked to examined the eyes of a 80 year old woman who had had 20 year history of glaucoma. I began with inspection and noted both her eyes were meiosed and suggested that she might be on pilocarpine.
Slit lamp examination revealed adrenochrome in the right lower fornix (this may be missed if the lower or upper lids were not everted). She also had a right trabeculectomy. The bleb appeared flat and fibrosed (comment on the bleb and says if you think it is functioning or non-functioning). Both pupils were unreactive to light. I checked for any evidence of secondary glaucoma but there were no signs of pseudoexfoliation, iris transillumination etc. I mentioned that I would like to examine the posterior segments for the state of the optic discs. However, I could not get any good view with my 78D indirect lens. The examiner offered me a 90D lens but I still could not see any fundal view. I mentioned that in the clinic situation I would dilate the eyes with phenylephrine to get a good view.
The examiner then asked the cause of adrenochrome and finished by asking about the actions of alphagen and latanoprost and their complications
Case four
I was asked to examine the posterior segments of a 65 year old man on a slit lamp with a 78D lens. Inspection was not helpful. The right eye was pseudophakic and showed signs of vascular sheathing and some vitreous cells. The left eye had a dense cataract. I was asked the differential diagnosis of a posterior uveitis and the most likely cause in this case. I was unable to give a definite diagnosis. Then, the examiner mentioned that the patient had a right penetrating injury involving the left sclera but this was not obvious on slit-lamp.
The questions then moved on to sympathetic ophthalmia and the complications of immunosuppressive drugs.
Case five
I was asked to examine the right fundus of a 40 year old man with a 20D indirect lens. The patient had a right inferotemporal retinoschisis. I mentioned that I like to examine the other eye as retinoschisis is often bilateral.
I was asked the histopathology of retinoschisis. Further
questions centred on differentiating it from retinal detachment and how
I would manage the patient.
General medicine and neurology
Case one
I was asked to examine the fundi of a 40 year old woman with a direct ophthalmoscope. I did not notice any useful physical signs on inspection.
The fundi were not dilated. As the room was bright, I asked for it to be dimmed. Fundoscopy revealed bilateral pale discs. I was asked the differential diagnosis. I mentioned I like to perform cerebellar examination for the possibility of demylinating disease. The patient had no eye movement disorder but had a moderate right disdianochokinesia.
Case two
I was asked to perform cover/uncover test on a 50 year old woman. I began with inspection but notice no obvious abnormality. Corneal light reflex revealed a right exotropia. I asked the patient to cover each eye in turn and ascertained that each eye could see the fixating target. She appeared to be seeing normally. I performed the cover/uncover test and could not detect any tropia. The ocular motility appeared full. I asked the examiner about her visual acuity and was told that there were normal in both eyes. I was then asked about the kappa angle which may give the patient an apparent tropia.
I was told the patient also had thyroid problem and would I examine the patient's thyroid status. I began with the hands checking for warmth, tremor and tachycardia/bradycardia. Then I moved on to the thyroid glands and got the patient to swallow a glass of water next to her; I also listened to the thyroid for bruit. I moved to the eyes and looked for lid lags. Finished by examining the tendon reflexes. My conclusion was that the patient was euthyroid
Case three
'Examined this patient's right fundus with a direct ophthalmoscope'. The patient was about 70 years old. Fundoscopy revealed right proliferative diabetic retinopathy with recent photocoagulation scars (the laser burnts were still white).
'What other parts of the patient would you like to examine?' I asked the patient to take his shoes off and there were amputation of right toes and left foot ulcer covered with plaster. I examined the feet for evidence of vascular insufficiency and also sensory neuropathy. The examiner stopped me before I finished.
Case four
' This 70 year old lady had a sudden right visual loss. Would you like to examine her cardiovascular system?' I immediately thought of embolic phenomenon and expected to find atrial fibrillation with or without valvular lesions.
I got the patient to expose her chest and inspected her from the end of bed for cyanosis and breathlessness which were absent. |However, she had a valvectomy scar under her left breast. Pulse examination revealed controlled atrial fibrillation.
Auscultation over the apex with diaphragm revealed diastolic murmur which was best heard with the patient turning to the left side and listened with the bell.
I mentioned the physical findings and the examiner stopped me before I finished the full examination.