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freakin fundoscopic exam

Discussion in 'Clinical Rotations' started by realruby2000, Apr 19, 2004.

  1. realruby2000

    realruby2000 Senior Member
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    I hate doing this.... i suck at it so bad...i know its important but whenever i have to do one, i cant see ****!! has anyone ever had a similar experience?? any tips on how I can get better at this without having to blind every patient i try it on??
     
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  3. southerndoc

    southerndoc life is good
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    It only comes with much practice.

    Just hang in there. You'll never be able to see everything, but you should be able to see enough to pick out major things (AV nicking, papilledema, etc.).

    I've heard the new panoptics are nice, but I haven't used them that much. The standard ophthalmoscope works for me without problems. Of course it would be better with dilated pupils, but I can see reasonably well without.
     
  4. Jaded Soul

    Jaded Soul Proloxil > Zoloft
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    Practice, practice, and practice some more. Getting the room as dark as possible helps, but you can't always control that. Have you looked into dilated eyes so you know exactly what you are supposed to be seeing? When I was learning, I had no idea what I was doing the first dozen times or so until I did an exam on dilated eyes.

    An ophtho resident taught me to start 30 degrees off midline, head at the same level as the patient's, while patient gazes straight ahead. As you advance towards the pupil, you will usually land on the optic disk without having to trace any vessels. Maybe that'll help.

    Don't worry. You'll get it.
     
  5. Weil-Felix

    Weil-Felix Super Flying Squirrel
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    Relax. Most of my classmates at one point or another have complained that the fundoscopic exam is one of the hardest parts of the physical exam. The only thing that finally got me to the point of being comfortable with the fundoscopic exam was to actually do an ophtho rotation. If you are so inclined, I would highly recommend doing an elective in it to improve your eye exam skills. If you don't do get to do an ophtho rotation (or if it really does not appeal to you), just do what the other posters said and practice on as many patients as you can. Maybe even get your family/friends/roommates/(pets!) to let you practice on them.

    By the way, you do NOT have to have the light on full brightness to get a good look at the landmarks on the retina. If you turn it down a few notches, that will help you keep from blinding people. Also, you may not be standing close enough to the patient. That was my biggest problem in the beginning. I was too shy about invading the patient's personal space. That's something you need to get over when doing a fundoscopic exam. One of the ophtho attendings I worked with always said "If you're not close enough to kiss the patient, you're not getting a good look!"
     
  6. pikachu

    pikachu Senior Member
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    I'm on a Neuro rotation (probably only second to Ophtho in the number of funduscopics done -- and with a disadvantage since they don't often use dilating drops) right now and even some of the attendings can't get the fundus from time to time. It is probably the most technically difficult part of the physical exam. You run into a big problem because you're shining a bright light into someone's eyes so the pupils constrict and make the fundus even harder to see. I never saw the fundus until I saw a dilated exam so you're not the only one. I suspect there are many fakers out there who pretend they have seen the fundus when in fact they have not. So keep trying.

    Interestingly, I was at the eye doctor the other day and saw the afterimage of my own retinal vessels after a dilated slit-lamp exam. Does this happen to everyone?
     
  7. BassDominator

    BassDominator Senior Member
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    Often when I go to the optometrist, I can see the reflection on the microscope lens.
     
  8. denali

    denali Senior Member
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    I noticed that during my last eye exam too! :thumbup:
     
  9. Pilot

    Pilot Senior Member
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    I think I saw a fundus once. I treated it with Lotrimin. ;)
     
  10. BPKurtz

    BPKurtz Heck Of A Guy
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    Two ways to avoid this are to try to save looking at the macula until the very end of the exam, make the room dark, and use the ophthalmoscope on about half brightness.

    Other strategies to get better:
    Practice using the ophthalmoscope (at less than full brightness) on friends and family. Start with small goals that literally anyone can get and become more ambitious as your skills progress. 1) First focus on actually seeing ONE vessel and getting a feel for how to focus the ophthaloscope. 2) The next step is to get used to following the vessels to the disc. 3) Then get used to looking at the key features of the disc. 4) With practice, you can get the important stuff you need to know about the disc with only one to two seconds of looking at the disc (once you've found the disc). I'd argue getting this far is the minimum competency medical students need with an ophthalmoscope so that they can pick up big problems like papilledema or other optic nerve edema, high cup:hungover:isc ratio in glaucoma, etc. If you become comfortable with this you can move on to 5) more subtle things like A-V nicking, looking at the whole retina for small hemorrhages or other signs.

    I'm not going into ophtho but I recommend doing a rotation in it because not only do you get practice in the fundus exam, you get an attending there either verifying or correcting your exam. If you practice without someone giving you feedback about whether what you think you see is right, it's much harder, I would think.

    Regarding the panoptic ophthalmoscope: I bought one, it's very cool and it's easier to see stuff, true. But I have found that in kids under the age of about 16 it's much easier to see a disc with the old kind because if they don't comply with holding still and looking in one direction you can't see much at all with the panoptic. So if you're going into peds, I'd say don't spend the money.

    bpkurtz
     
  11. ericdamiansean

    ericdamiansean High Profiler
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    I heard even clinical students find it hard to do..and some doctors as well..guess since it doesn't get tested much in clinical exams while in med school since it's quite uncomfortable to patients, we don't practice much of it
    and we're not allowed to dilate them
     
  12. Practice, practice, practice. I know that's what everyone says, but many clinical skills (looking at the fundus, feeling the thyroid, checking for consolidation, hearing murmurs, palpating the liver, feeling the popliteal pulses) just take practice. You'll learn in third year to do a brief heart, lung and abdominal exam on EVERY SINGLE PATIENT (besides in psych, most likely :) ), so you'll get tons of practice there. After performing approximately 150-200 exams during the first half of third year (25 weeks total of Medicine, OB/GYN and Surg) and about 150 more in the second half (7 weeks of Family Practice), I'm finally starting to feel more confident in these skills.
     
  13. Well, there IS the USMLE Step 2 CS now. :)
     
  14. dermatome S5

    dermatome S5 Junior Member
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    As everyone has said, practice is definitely the key. One of the 4th years at my school told me to volunteer to do physical exams for a summer camp for practice. I did and it really helped me more than anything Ive done the first two years. Doing 75 quick H and P's in a day without anyone looking over your shoulder or without the pressure of practicing on a patient really speeds up the learning process. Also, at our school they let you go in groups to the eye clinic where you and a partner can each dilate your non dominant eye and practice the exam on each other---highly recommended if they will let you.
     
  15. ERMudPhud

    ERMudPhud Back for a visit
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    Spend a week in the optho clinic just looking at everyone who has already been dilated for their exam. In a busy clinic you could get 100's of trys in a week. Start with small goal like BPkurtz said and build up from there.
     
  16. MD2b06

    MD2b06 Senior Member
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    Screw the traditional opthalmoscope. Get the panoptic. I did, and it's awesome!!! I could never see a damn thing when doing fundscopic exam, and now it's so easy. Even on undilated pupils.
     
  17. Tazmaniac

    Tazmaniac 2 min. from a nice nap
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    The panoptics are quite sweet. Otherwise I call ophtho. You notice even they don't use regular ophthalmoscopes...they have those giant headlamp covert ninja spy gadget thing.

    -Todd MS-IV USC
     
  18. BPKurtz

    BPKurtz Heck Of A Guy
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    Well, that's so they can see the anterior chamber. You can't see it without the fancy prisms they have (and the light source which they wear as a headlamp, I assume that's what you mean?). No one can see the anterior chamber without a slit lamp exam or the equivalent, which is beyond the realm of a med student. But to conclude "I can't see the disc, it must not be worth seeing" is flat out wrong. You really can see the disc, if you try hard enough. Don't give up! Practice! You can get it if you try!

    bpkurtz
     
  19. cookypuss3

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    Ah, the fundoscopic exam. One of a handful of procedures that I have managed to avoid completely throughout 3rd year, and hope to continue to evade till graduation (do not pass go, proceed directly to pathology). Among other skills I have managed to avoid: Holding the laparoscope. Placing anything other than simple interrupted instrument tie sutures. One hand knots. Two hand knots. Vaginal exams on the laboring woman. Sports physicals. Hernia checks. God bless America.
     

  20. :laugh: :laugh:
     
  21. Wow, that's amazing. How'd you get through OB without doing vaginal exams in L&D? Or hernia checks or tying knots in Surg?
     
  22. doctor7

    doctor7 Member
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    i know a grip of people who think the exam is absolute bull****, so they fake it whenever they are required to do it on a standardized patient (for evaluation purposes). i highly DO NOT recommend faking it on real patients, just try for a red reflex and let the optho guys do the rest. so much for your $500 flash light. ophto completely disregards your findings anyways "you can't do an optho exam without dilation and a slitlamp".

    i have a panoptic, which helps, but even then it's still tough.
     
  23. southerndoc

    southerndoc life is good
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    This is hilarious considering you are the person who poked fun of my wanting an electronic stethoscope due to a hearing deficit. Let's see here, what were your words? Ah yes, something to the effect of looking like a dork on the wards.

    Look who's toting their panoptic...
     
  24. cookypuss3

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    I'm good. I'm motivated. I'm lucky. A combination of things. My school has a weird setup for clinicals -- it's hard to explain -- but all the students end up with different doctors all over so there's really no consistency or "syllabus" of activities, if you will. So all I have to do is walk in, go "I'm Cooky, and I'm going into pathology," and everyone leaves me alone. I think having a student who's not butting into everything and trying to do everything and ends up causing more work in the end anyway might be a somewhat welcome relief. Therefore I get no backtalk. They don't ask, and I don't offer.

    Other activities I forgot to mention being on my **** list are IV insertions, NG tube insertions or removals, anything to do with a central line of any kind, inserting a Foley. I've made it all the way through third year now unscathed.

    Don't get me wrong - some stuff is fun - I'll inject people's joints or place blocks and peel off yucky toenails or cut off weird moles or take skin biopsies any day of the week. I'm a SELECTIVE slacker. :sleep:
     
  25. AUdacious

    AUdacious ASA Member
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    There are eye models that you can buy to practice on that are actually pretty helpful and cost like 10 bucks. After you master that, my friend and I just took turns on each other until we got pretty comfortable with it. I agree with the advice about not turning the light up to high b/c that makes the patient uncomfortable and makes it harder for you to see. The red reflex is easy. Then go in at at about a 20 degree angle, find a vessel, and focus. Take your time with focusing b/c if you get it right, you shouldnt have a problem seeing most things. Save the macula for last if you are going to have the patient look into the light. Unfortuantely, it just takes patience and practice. The panoptics are pretty cool also if you just cant get it. You can go to an equipment store with a friend and try them out to see what you think. Good luck.
     
  26. You also don't want the light too bright (the room light or the ophthalmoscope light) because that will make the pupil constrict.
     
  27. gugu0911

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    Any idea where you can buy eye models to practice ophthalmoscopy ?
     
  28. Doctor Bob

    Doctor Bob EM/CC
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    Depends on what city you live in; you could find some on certain street corners... rent a seedy motel room and with a lot of cash in small bills you can have a steady stream of eye models.

    Or maybe get some cow eyes from the butcher and practice all you want at home.

    Or seriously... just ask your friends.
     
  29. akwho

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    I had an ophthalmologist that had been practicing for 50-years tell me he had never gotten an accurate referral based off of a fundoscopic exam. So in summary, let the eye dentists do their eye things.
     
  30. Pinkertinkle

    Pinkertinkle 2003 Member
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    As an ophthalmologist I dont know how to use that thing
     
  31. Psai

    Psai Snitches get zero vicryl
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    Yeah but how many of your friends are going to accommodate for you
     
  32. alpinism

    alpinism Give Em' the Jet Fuel
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    Unless you dilate beforehand the exam is next to useless.

    Ocular U/S is much better at looking for things like papilledema etc...

    Haven't used one since 2nd year of med school.
     

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