[#10] OBSERVED HEENT [#10]

Eye Exam - Preparation Notes:

CORNEAL LIGHT REFLEX
1. Have the child look straight ahead
2. Project a penlight into cornea of both eyes simultaneously
3. The normal exam will show symmetrically centered reflections
4. An abnormal exam will show a corneal light reflex that is not centered over
the pupil - this is indicative of muscle deviation or misalignment

RED REFLEX
1. Set ophthalmoscope at "0" diopters

2 Hold the ophthalmoscope 10-12 inches in front of the eye

3. Aim the light at the pupil

4. A normal exam will produce a red/orange hue from the pupil; it simply means
that there are no major obstructions between the cornea and retina

COVER-UNCOVER
1. Have the patient fixate on a distant object
2. While the patient is fixating, cover one eye - watch the uncovered eye
3. A normal test will be indicated by steady staring of the uncovered i.e. no
sudden jump
4. Next move the occluder to the previously uncovered eye - watch the newly
uncovered eye - a normal test would be indicated by no sudden correction
jump of the newly uncovered eye

HEENT Exam Tips and Images:

At the SOM Blackboard Site go to Pediatric Clerkship

.. Click on left-sided menu click Study Guides

.. Select Study Guide #10

.. Review powerpoint presentation images

Otitis Media
Pathogens
S pneumoniae

- H influenza nontypeable

- Moraxella catarrhalis

- Acute onset
Pain

Decreased hearing

- Inflammation

Bulging or obscured landmarks

- Evidence of effusion : : .:

~ TM mobility by bulb insufflation or tympanogram

Treatment - Initial
Amoxicillin 80-90 mg/kg/day div Q12 (or q 8 hr)
1M 50mg/kg/day x one dose

- Treatment After 3 of clinical failure

Amoxicillin-clavulanate (Augmentin) 90 mg/kg/day of amoxicillin x 10
OR
Ceftriaxone - 1M 50mg/kg/day for 1-3

session to rn Bulb Insufflation::::.: Pneumatic Otoscopy

Technique
-Insert speculum into the ear to form a tight seal
- Slowly and Gently and bUlb.
1"""\>:).;:)<;:;;:,>:) mobility of the ear drum as pressure is applied and

on the bulb applies positive pressure

\I) Letting up applies negative
-With normal mobility ear drum moves inward and then back.
-In cases of acute otitis middle ear is filled with purulent material.
The drum bulges toward examiner and moves minimally.

Causes of minimal mobility or no mobility

-Acute Otitis Media
.Occluded EAC (cerumen, foreign object)
otitis/effusion
Perforated ear drum

Tympanogram see below

 11/28/2016

Tympanometry

Measures the compliance of the tympanic

membrane

Normal and Flat Tympanogram

Gp. =Dq D d".P,

~Jr~ 0I.l
" ...
L;

1 :::'~~
;
.0...' *. ,
-200 0 200
F'R ES ':- I) ~'E - de. '"

Norm al Tympanogram
I dic ares nc'mally iunc Honing middle EAC Obstruction
ear system Perforated TM
Otitis Media
Effusion

1
 CHECKLIST

o Introduced Outlined agenda

Washed hands
Obtained name and age of patient nail bed to occlude blood
blow
"Color should return to nail
Skin - discoloration, allergic salute, in less than 3 secnds
edema, lesions Skin Turgor
dysmorphism, symmetry .. Pinch the skin between the
- ptosis, discharge, discoloration thumb and finger
Auricle and Pinna - position, shape, " skin
pits/dimples "Skin fold should return to
Nose - flaring, discharge, discoloration, original position within one
swelling, swelling second (Persistence of
pinched fold = of turgor)

shape scalp hair distribution

pain on palpation of face

circumference (cm) graphing_ _ __

o anterior landmark (supraorbital ridge) posterior landmark occipital ridge

D conjunctiva/sclera - discharge, color (erythema, pallor)

D PERRL - direct, consensual EOM
corneal light reflex red reflex cover-uncover

external ear - pain, swelling, discharge, lesions, discoloration (erythema, bruising)

- pain, cerumen, foreign body, color, discharge
Tympanic Membrane - color, translucency, landmarks, bulging, mobility

septum - midline, intacUperforation

mucosa/ turbinates - color, swelling, discharge

move anterior to posterior; do not put your hands in the mouth or gauze on the tongue
anterior - lips, buccal mucosa (moisture, exudates, inflammation)
D middle tongue (color, hydration, lesions): check for frenulum attachment
o middle - dentition (discoloration, caries, fillings), gums (inflammation, pain, bleeding)
D posterior - palate integrity, midline uvula
posterior tonsils (grading, exudates, inflammation)

Palpation - masses, swelling, tenderness

Lymph nodes auricular (pre, post), cervical post), mandibular, submaxillary,

submental. occipital
Range of motion - supple/rigid (flexion, extension, lateral)
Clavicle palpation crepitus, masses