Head, Face, and Cranial Nerves Examination

Head, Face, and Cranial Nerves Examination: Key Points

History and Symptoms

• Normal overall baseline function, including what is unique or abnormal for the patient, should be assessed.
• Symptoms require clear description covering onset (acute, subacute, chronic, insidious) etc.
• Common reasons for patient visits related to head, face, and throat pharmacists manage: head/face issues include: headache, weakness, numbness, itchy, hair or skin changes in eyes, ears, nose, throat, and mouth.

Physical Examination and Findings

• Symmetry, skin tone, pigmentation, texture, lesions, scars require investigation, looking for normal hair distribution; and regular temporal pulse.
• Abnormal face presentation may be due to flat or blunted affect or a masked face.
• Temporal pulses: Palpate temporal pulses in older patients complaining of headache or unilateral vision loss; this may indicate Giant Cell Arteritis (temporal arteritis).

Cranial Nerve Assessment and Abnormal Findings

Olfactory (I)

• Assesses the sense of smell which is the reason for referral, refer for loss of smell.

Optic (II), Oculomotor (III), Trochlear (IV), Abducens (VI)

• Optic, Oculomotor, Trochlear, Abducens nerves, control visual acuity and movement.
• Nystagmus, abnormal eye movement: caused by lithium, anti-seizure drugs, illicit drugs (alcohol, ketamine, LSD, MDMA).
• Eye movement can be assessed by observing the action of nerves III, IV, and VI.

Trigeminal (V)

• Assesses chewing and facial sensation.

Facial (VII)

• Assesses facial expressions.

Vestibulocochlear (VIII)

• Assesses hearing and balance.

Glossopharyngeal (IX), Vagus (X)

• Glossopharyngeal and Vagus nerves assess gagging, swallowing, and movement/sensation.

Accessory (XI), Hypoglossal (XII)

• Accessory and hypoglossal nerves assess neck and tongue movement.

Assessing the Head & Scalp

Surface (Skin/Hair)

• Skin should be free of trauma, lesions, swelling, or depressions, also hair evenly distributed, free of lesions, flakes, pimples, dry patches.

Deep (Bones/Cranium)

• Cranium size: normocephalic; shape: round; symmetrical with normal minor undulations.
• Head length & proportionality measured to look for: smaller (microcephalic), larger (macrocephalic), enlarged head and face (acromegaly), enlarged head alone (hydrocephalus), or flat (plagiocephaly).

Cushing's Syndrome

• Cushing's syndrome: roundness of face, reddened skin, excessive hair above lip & chin.

Grave’s Disease

• Grave's disease: protruding eyeballs (exophthalmos), stare, eyelid lag, warm/moist skin.

Enlargement - Watch Out!

• Enlargement, nodular swelling, tenderness, loss of pulse, and unilateral/bilateral symptoms require immediate consideration.

Eye Problems

History and Inspection

• Concomitant conditions (HTN, DM), and glasses/contact lenses should be determined.
• Family history of cataracts, glaucoma, and retinal detachment requires careful monitoring.
• External eye structure: inspect lashes, lids, eyebrows, sclera, conjunctiva, iris, cornea, lacrimal apparatus, look for ptosis.
• “Red eye” symptoms (OPQRST): when did redness develop? recent injury? discharge? stringy texture? one or both eyes affected? pain?

Normal Pupil Findings

• Reflex: pupils constrict equally swinging light between each eye, and accommodate when focusing on a close object.
• Pupils are equal, round, react to light and accommodation (PERRLA), normal size= 3-5 mm.

Red Eye - Watch Out!

• Urgent referral if any of the following occur, D - severe eye pain or photophobia, unilateral redness (marked), reduced visual acuity, purulent conjunctivitis, E - suspected penetrating injury, within 2 weeks of intraocular procedure, or no response to antibiotics in 72 h.

Eye Issues - Watch Out!

• Mydriatics(dilate): Amphetamines, Cocaine, LSD, Anticholinergics, SSRIs, Botox

Ear Abnormalities

Inspections

• Inspect size, shape, symmetry, color & lesions of the external ear.

Whisper Test Procedure

• Use the whispered voice test to screen for high frequency hearing loss while standing one to two feet away from the patient and whispering a basic word or phrase.

Vertigo vs Disequilibrium

• Vertigo results in a spinning/falling sensation often due to dysfunction of the vestibular apparatus.
• Disequilibrium results in shakiness/instability when ambulating, and is often neurological.

Eardrum Changes - Watch Out!

• Yellow-amber means serous OM or chronic OM, bright red for acute purulent OM, blue or dark red blood means trauma/skull fracture.

Other Ear Abnormalities - Watch Out!

• C : unilateral/asymmetric hearing loss, pulsatile tinnitus, poor speech discrimination, D: pain, active drainage/blood, visualization of blood/pus, sudden onset /rapid hearing loss E: hearing loss with ear or systemic infections, foreign body in ear.

Cerumen Changes - Watch Out!

• Thicker or drier may occur.

Nose

Exterior evaluation

• Check patency of nostrils, surface skin.
• Anterior and interior surfaces are checked for abnormalities.
• The otoscope goes in the nose for a deeper examination.

Internal Inspection

• Instruct the patient to remove glasses and tilt their head upward.
• Insert the largest ear speculum that fits without causing pain.

Rhinitis

• Acute/gradual onset of rhinitis.
• Increased pain with ADL, any meds taken?
• Breathing problems in the sinuses.
• Variations on the rhinitis, facial changes. If issues found WATCH OUT!

Red Flags - Acute Rhinosinusitis

• The nose includes, altered mental status, conjunctival/periorbital, eyelid drop, impaired/double vision, swelling/tenderness, very unwell (me), eye movement/ocular pain, N/V and neck stiffness

Sinus

Inspection

• Periorbital swelling and nasal discharge.

Signs of Sinusitis

• Poor response to decongestants is sign.

Symptoms of Sinusitis

• Sinusitis symptoms include, mucopurulent nasal discharge, nasal congestion, facial/ear pain, maxillary toothache, fever, cough, & halitosis.

Throat

Inspections

• Mouth/teeth: Lips examined for moisture/lesions/swelling, mouth: mucosa inspected bilaterally/color/pigmentation/consistency checked, as well as any discoloration or loose/chipped/broken teeth
• Lesions and discoloration could be: trauma/piercing of the tongue, Oral Cavity, & dehydration in the lips.
• Open airway, check for partially blocked of uvula/trachea being midline.

Neck

Routine Palpation

• Includes skin/superficial features, lymph nodes, muscles, and thyroid.

Lymph Node

• Lymph node position is important to determine location in relation to muscles/arteries - roll node to determine mobility (muscles/arteries=immobile); Palpate preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, and deep cervical chain lymph nodes.
• Palpation is used to determine the normal status of symmetry and any lesions or trauma.

Abnormal Finding - Neck Pain!

• Sharp electric shock-like shooting pain down arm (Radiculopathy) , pain with extension (Spinal stenosis), and weakness are all worrisome signs!

Musculoskeletal Physical Exam

Routine

• Palpate bones/organ, note the order of lymph node palpation.

Gums

• Gum assessment includes colour, bleeding, shape and feeling normal.
• Look for lesions that are sign malignancy.
• Red flags in relation to the neck are bruising and unilateral node at the clavicle location (fever, weight loss).

Back Injuries

Spine

• Back palpations should determine any pain or ROM.
• Spinal ailments are determined usually with trauma/OP.
• Hunchback position is high risk for deterioration for patients.

Spinal Aligments

• Reduced mobility in the spine.
• Look for the abnormalities for scoliosis & paralysis.

Shoulders

Scapula

• Should scapula inpect for normal mobility.

Elbows

Procedure

• Inspect, Swelling, Lumps, skin Lesions.
• Check and palpate Epitrochlear:

Flexion and movement

• Pain level for elbows upon movement.
• Elbows can subside pain with rest.

Hand

Palpation

• MCP: Apply pressure with both thumbs simultaneously and palpate the Metacarpophalangeal joints (MCP)
• PIP: Apply pressure with both thumbs and index fingers, and palpate the Proximal Interphalangeal joints (PIP)

Phalens Test

• wrists flexed evaluate for Tunnel Syndrome.
• Perform a Phalens Test, and ask client to press the backs of hands together with wrists flexed at 90°
• Do the Phalens Test for 1 full minute - watch for signs of pain and tingling.

Humerus

• Can cause tendon damages (tennis elbows).

Routine - Watch Out!

• Carpal tunnel includes nerve compressed in rist resulting in the numbness of joints .
• Palpation of PIP & MCP and Tinel's

Joint Evaluation - Watch Out!

• Carpal or nerve issues can occur. Assess hip issues with hip ROM assessment.

Foot and Ankle

Inspection Guidelines

• No gross deformity, but sprain, inflammation, or muscle spasms, could be present.
• Weight bearing tests will check gross mobility

Ankle Rules

• Ottawa Ankle Tests follow 5 rules for use of radiograph.

Normal Ankle Procedures

• ROM determined by plantar flex and Eversion and inversion testing

Ankle Results - Watch Out!

• Sprains results stretching/tearing of ligaments. Can be found on stress/sprain and eversion tests

Mental Status Evaluation

Alertness and Evaluation

• Ask the patient Orientation to time, place & person.
• Can also include judgement, attention span and memory

Central Nervous Evaluation - Patient Testing

Disequilibrium or Vertigo

• General term of alertness can include neurological disorders.

Pain Managment

Sensory Testing and the Use of Reflexes

Procedure - How to use Sharp Needles?

• Differentiated through point contact where sensory or not - with Tactile.

Check for Tactile Awareness

• Evaluate if common sounds can be identified
• Have patient be able to evaluate with closed eyes and identify point locations.

Sensory Evaluation - Watch Out!

• Absent Pain & Response and Vibration will need to be recorded.
• Stockings - Inablity to see feet.

Cases - Watch Out!

• Should be given in hours of test where is involved with cranial nerve V
• Should be a dorsal ganglion & root of system.

Reflexes & Procedures

Reflex Testing

Evaluate motor function, upper and lower extremities - and achilles point of evaluation

Reflex Grading

Evaluate grading for movement - and pathological responses in tests

Spinal Issues that cause Red Flags - Watch Out!

• Pattern test - non or dermatic, or if there a history of OP.

Nerve Stimulation Testing

Check Feet Circulation and Neuropathy by Procedure

Ensure patients feel, and determine skin and nail status.

Monofilament - Tactile Response Evaluation

Patient knows what area to expect and has to communicate in regards to what is felt

Nerve Stimulation - Watch Out Tests!

Charcot, claw toe results and hammer toe results with limited communication, and abnormal finds on the foot with any pain level - requires assistance to determine what to do!

Determine Pain Test

• Non Pharma procedures, and set-goal procedures for evaluation of pain levels and long term management strategy.

Pain Evaluation

Goal Orientation

Headache - Types and Considerations

Description - Pain

Lifetime presence - 66%

Patient Consultation

Pain Location Considerations

Evaluate patient current mindset and determine next course of action. Evaluate OTC and prescription options. Evaluate dizziness, evaluate any balance.

Tension headache

Bilateral pressure and mild to moderate symptoms.

Cluster headache

Build and peak and variable pain from faces.