Medicine (MD/DO)
Internal Medicine
History & Physical Exam Skills
Head, Face and Neck Assessment

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Head, Face and Neck Assessment

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Head, Face and Neck Assessment

Head, Face, Neck and Assess-man
The head, face and neck assessment begins with an inspection of the size and shape of the skull. An examiner palpates the contours and prominent features of the skull, as well as bilateral palpation of the temporal artery. Assessing the face includes observation of facial features which often correspond to the patient’s mood, emotions or affect. Assessing the face’s structures and symmetry can also reveal important clinical information about the patient. Following the head and face is a neck assessment, noting symmetry of the neck’s muscles and head position. Observe any limitations or pain during range of motion exercises of the neck. Inspecting and palpating lymph nodes of the face and neck is important to understand underlying pathology. The thyroid gland is often difficult to palpate, but unexpected findings and a palpable thyroid gland can indicate illness or pathology. Finally, confirm the trachea is midline through inspection to conclude this assessment.
Inspect Size and Shape of Skull
Size and Shape of Skull

Inspect and palpate the skull to note general size and shape. A patient who is normocephalic denotes a round, symmetric skull with size corresponding appropriately to body size. Microcephaly or macrocephaly may be found and indicate unexpected or indicative size differences respective to the patient’s health. During palpation, note expected protrusions at the forehead, bilateral parietal bone, the occiput and the bilateral mastoid process. Tenderness upon palpation is unexpected and indicative of underlying pathology.

Palpate Temporal Artery
Paw Temple Artery-archer

Palpate the temporal artery above the zygomatic (cheek) process, located between the eye and the top of the ear. A tender, firm lesion found upon palpation in an older adult female could indicate temporal arteritis, a pathologic condition.

Observe Facial Expression
Facial Expression

The patient’s facial expressions can communicate emotion, behavior or mood. The nurse can assess the patient’s facial expressions to determine the presence of anxiety (a worried or distracted expression), hostility (tense, rigid), depression (flat affect, distracted, downward gaze) or many other expressions.

Inspect Facial Structures and Symmetry
Facial Structures and Symmetry

Facial structure is dependent upon genetics and ancestry, but features are expectedly symmetric bilaterally. Asymmetry in eyebrows, palpebral fissures (corners of eyes), or sides of the mouth could indicate an underlying neuromuscular pathology like Bell’s palsy (damage to cranial nerve VII, the facial nerve) or a central brain lesion (e.g. stroke).

Look for Symmetry
Neck Symmetry

Start by observing head position and posture with the patient sitting up. Head position is expectedly found midline, and the accessory neck muscles should be symmetric. Asymmetry or spasms of the neck muscles could indicate pathology like osteoarthritis of the cervical spine.

Check Range of Motion
Range of Motion

Instruct the patient to actively turn their head from side to side, touch their chin to their chest and look at the ceiling or sky. Also, instruct them to tilt their head and touch their earlobes to their shoulders without elevating their shoulders. These movements are expectedly smooth and not limited in range of motion. Unexpected findings include pain with movement, difficulty with motion, or radiating pain or numbness to the shoulders or upper extremities. Also, testing the muscle strength of cranial nerve XI, the accessory nerve, can be performed at this time by placing your hands on the patient’s shoulders and assessing their muscle strength while performing a shrug motion.

Inspect Lymph Nodes and Thyroid Gland
Lymph-limes and Thigh-droid Thyroid

Inspect the lymph nodes of the face and neck by palpating with your fingertips for tenderness and/or lymphadenopathy or enlarged lymph nodes. Expected findings on palpation are generally non-palpable lymph nodes. A palpable lymph node will vary in size and diameter, from >0.5cm to larger sizes like 3 cm, and indicate pathology to certain areas. After assessing the lymph nodes, move to the thyroid gland. This gland is often difficult to palpate, especially if there is no unexpected pathology like nodules, masses or goiter. Start asking the patient to slightly extend their neck with a mild gaze upward. Stand behind or to the side of the patient, and use both fingers or thumbs to find the thyroid cartilage. Asking the patient to swallow a small sip of water while palpating can assist in finding the expectedly soft, spongy thyroid gland to the inferior distal sides of the thyroid cartilage. If palpable, expected findings are a rubbery, smooth in tone and shape thyroid gland without enlargement.

Confirm Trachea is Midline
Trachea in Midline

Expectedly, the trachea is observed midline and non-deviated when the patient is slightly extending their neck (chin up). A tracheal shift can occur if there is a mass pressing against the trachea and moving it to the unaffected side, such as with a significant, unilateral thyroid enlargement. Classically, a significant pneumothorax can also push the trachea to the unaffected side. This sign occurs late in the disease process.


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