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Eye Exam - Preparation Notes:

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
1. Set ophthalmoscope at A0" 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
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
S pneumoniae
H influenza nontypeable
Moraxella catarrhalis
Acute onset
Decreased hearing
Bulging or obscured landmarks
Evidence of effusion =
TM mobility by bulb insufflation or tympanogram

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

Treatment - After 3 days of clinical failure

Amoxicillin-clavulanate (Augmentin) 90 mg/kg/day of amoxicillin x 10
days OR
Ceftriaxone - IM 50mg/kg/day for 1-3 days
Pneumotic Otoscopy Group session to learn Bulb Insufflation = Pneumatic Otoscopy
$Insert speculum into the ear canal to form a tight seal
$Slowly and Gently press and release bulb.
$Assess mobility of the ear drum as pressure is applied and release.
$Pressing on the bulb applies positive pressure
$Letting up applies negative pressure.
$With normal mobility the ear drum moves inward and then back.
$In cases of acute otitis media, the middle ear is filled with purulent material.
The drum bulges toward the examiner and moves minimally.

Causes of minimal mobility or no mobility

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

Tympanogram see below

Observed Physical Exam- HEENT

Preparation of Patient
G Introduced self G Outlined agenda
G Washed hands
G Obtained name and age of patient
Skin - discoloration, allergic salute,
edema, lesions
Facial dysmorphism, symmetry
Eyes - ptosis, discharge, discoloration
Auricle and Pinna - position, shape,
Nose - flaring, discharge, discoloration,
swelling, swelling

Hydration Status
Capillary Refill
Pres nail bed to occlude blood
Color should return to the nail in
less than 3 secnds
Skin Turgor
Pinch the skin between the thumb
and finger
Release skin
Skin fold should return to original
position within one second
(Persistence of pinched fold = loss
of turgor)



G shape
G scalp
G hair distribution
G pain on palpation of face
G circumference (cm)__________% graphing________
G anterior landmark (supraorbital ridge) G posterior landmark occipital ridge
G conjunctiva/sclera - discharge, color (erythema, pallor)
G PERRL - direct, consensual
G corneal light reflex
red reflex cover-uncover

G external ear - pain, swelling, discharge, lesions, discoloration (erythema, bruising)
G EAC - pain, cerumen, foreign body, color, discharge
Tympanic Membrane - color, translucency, landmarks, bulging, mobility
G septum - midline, intact/perforation
mucosa/ turbinates - color, swelling, discharge
Oropharynx - move anterior to posterior; do not put your hands in the mouth or gauze on the tongue
G anterior - lips, buccal mucosa (moisture, exudates, inflammation)
G middle - tongue (color, exudates, hydration, lesions); check for frenulum attachment
G middle - dentition (discoloration, caries, fillings), gums (inflammation, pain, bleeding)
G posterior - palate integrity, midline uvula
G posterior - tonsils (grading, exudates, inflammation)
G Palpation - masses, swelling, tenderness
G Lymph nodes - auricular (pre, post), cervical (ant, post), mandibular, submaxillary,
submental, occipital
G Range of motion - supple/rigid (flexion, extension, lateral)
G Clavicle palpation - crepitus, tenderness, masses