HA Lab: Module 4 Head/Face/Neck/Eyes/Ears/Neurological- Cranial Nerves

Describe the appearance of a normal tympanic membrane- where is the cone of light? 7 o'clock 5 o'clock

A normal tympanic membrane is shiny and pearly gray. The "cone of light" 7 o'clock in the left ear, 5 o'clock in the right ear.

How do we evaluate patient's neck's range of motion?

Ask him to look up, then down, then turn his head to each side.

How do we test CN VII (facial nerve) function? How do we know it is intact?

Ask the patient to change his facial expression by smiling, frowning, raising his eyebrows, or puffing out his cheeks. Symmetrical movements demonstrate that cranial nerve VII is intact.

How to test cranial nerve XII (hypoglossal)?

Ask the patient to stick out his tongue while you look for midline protrusion. Ask the patient to repeat "light, tight, dynamite"; the ability to articulate these words also indicates that cranial nerve XII is intact.

How do we check cranial nerve XI (spinal accessory)?

Ask the patient to turn his head to each side while you provide resistance with the palm of your hand. Then ask him to elevate or "shrug" his shoulders against resistance. If he can complete both of these actions, cranial nerve XI is intact.

Why are CN V (trigeminal) and VIII (facial) often tested simultaneously?

Because they both affect sensation and movement of the facial structures.

How do we begin our eye assessment?

By assessing eyebrow and eyelash fullness/distribution. The eyebrows normally extend the full width of the eye, and the eyelashes should curve outward from each lid. Look for any drooping of the upper lids or sagging of the lower lids.

How does cerumen differ cross-culturally? In which ethnicities are cerumen impactions more common?

Cerumen is generally moist and tan in Caucasians and African Americans, but it is dry, flaky, and gray in Asians and American Indians. Cerumen impactions more common in Caucasians and African Americans.

Which cranial nerves are intact if a patient's pupils are equal, round, and reactive to light and accommodation?

Cranial nerves I and III- document "PERRLA"

Describe neck inspection.

Examine your patient's neck, checking for contour and symmetry. Palpate the groove between the trachea and the sternocleidomastoid muscle to determine whether or not the trachea is midline. Note the contour of the trachea, looking for any enlargement of the thyroid gland, located in the lower half of the neck. Normally, the thyroid contours are not visible.

How do we check for function of cranial nerve I?

Finally, check cranial nerve I by asking the patient to identify a scent such as mint or coffee. Do not use a noxious odor, such as an alcohol wipe.

What will a patient's ear look like if they swimmer's ear?

For patients who have otitis externa, or swimmer's ear, manipulation of the external ear is usually painful.

What do we need to keep in mind when palpating the carotid arteries?

Gently palpate and only do so one at a time- doing both at once can disrupt cerebral blood flow.

Cranial nerve ________or the _________ nerve is best tested by testing visual acuity.

II, optic

How do you examine the throat?

If the patient's tongue obscures your view of the throat, it's best to moisten the tongue depressor before using it to apply tongue pressure. Place the tongue depressor far back enough on the tongue to allow viewing of the throat, but not so far back that you make the patient gag. Look for redness or any exudate on the tonsils or trickling into the throat from the sinuses above. If the uvula rises in the midline with phonation, you do not need to test the gag reflex.

How do we test cranial nerves IX (glossopharyngeal), X (vagus)?

If the uvula does rise and if the patient can swallow, then cranial nerves IX and X are intact. With an unresponsive patient, however, you might touch the posterior part of the throat near the tonsils to check for the gag reflex, which again demonstrates intact cranial nerves IX and X.

How can you evaluate whether a pulsation during JVD test is due to carotid pulse or JVD?

If you do see a pulsation, determine whether it is generated by a carotid pulse or it reflects JVD. An easy way to tell is to palpate the radial pulse while watching his neck. If you see a single pulsation in his neck that coincides with the radial pulse, you are not observing JVD; you are seeing just the carotid pulse. Gently pressing over the vessel proximal to the neck pulsation may also be useful. Jugular pulsation is easily obliterated by gentle pressure, while a carotid pulse is not- make sure to only do one side.

How do we inspect and palpate the face and skull at the beginning of our head/face/neck assessment?

Inspect your patient's head for size, shape, and hair distribution. Note the placement of facial features. Normally, the top part of the ears is at the same level as the eyes. When examining the patient's face, look for symmetry of his facial features. This is easier if you focus on the palpebral fissures, or eye openings, and the nasolabial folds between the nose and the corner of the mouth. Be sure to note the skin of the patient's face as well, checking for skin color, dryness, presence of lesions, and any involuntary movements. Palpate the patient's skull, noting the bony contours and checking for any lesions or areas of tenderness. Palpate his hair as well, noting color, texture, and distribution and also checking for any infestations, such as lice.

What abnormalities we looking for in a patient's ear canal? What can be present that prevents us from being able to see tympanic membrane?

Look for any redness, open areas, or foreign bodies. A small amount of ear wax, or cerumen, is normal. EXCESS CERUMEN- cerumen impactions are more common in Caucasians and African Americans and can prevent you from seeing the tympanic membrane

How do we test the pupils for accommodation? If the patient passes this test, how do we document it?

Next, hold your finger a few inches from your patient's eyes and ask the patient to look alternately at your finger and in the distance. Observe the pupils for accommodation. They should dilate with far gaze and constrict with near gaze. A patient whose pupils are equal, round, and reactive to light and accommodation has intact cranial nerves II and III. Document "PERRLA" for this patient.

How do we test the six cardinal fields of gaze in a patient?

Next, holding your finger about 14 inches from the patient's eyes, ask him to follow your finger as you move it through the six cardinal fields of gaze. Starting in the center of the patient's visual field, move your finger up and to the right, then back to midline, then laterally to the right, then midline, and finally down and to the right and back to midline. Repeat this on the left side.

How do we check hearing? What are the implications of this test?

Next, test hearing by rubbing your fingers together inches from each ear, or by standing behind the patient, having him plug one ear, and then testing his ability to hear a few whispered words. The ability to hear with either of these tests indicates that cranial nerve VIII is intact.

Describe penlight test for pupils. What should be the patient's normal response?

Next, with your patient looking in the distance, use your penlight to shine light obliquely onto each pupil. The pupils should constrict in response to light. Note both the direct response, that of the same eye, and the consensual response, that of the opposite eye.

How do we test cranial nerve II in practice?

Not distance vision test- that is using a Snellen chart and is rarely part of a general physical exam. But you can test close vision easily in most settings- using near-vision screening card (Rosenbaum or Jaeger). If not you can use a functional test of visual acuity- have patient read newspaper or count the fingers you hold up.

After assessing eyebrows, eyelashes, and eyelid skin, what is our next step in eye assessment? i.e. describe the inspection of the size, color, etc. of parts of the eye.

Note the color of the sclera, or white part of the eye, and look for defects or inflammation of the bulbar conjunctivae, the thin membranes that cover the sclerae. Gently retract the lower lids to note the palpebral conjunctivae. Inspect each iris and note the size and shape of the pupils, which should be round, without cloudiness, and equal in size. The pupils are measured in millimeters.

What common group of patients often has impaired cranial nerve 7 (facial)?

Patients who have had a stroke or cranial-nerve problems often have asymmetrical facial features, such as a drooping eyelid or a flattened nasolabial fold.

How do we test for the function of cranial nerve V (trigeminal)

Test cranial nerve V by asking the patient to bite down and feeling for contraction of the temporal muscle (at the temple) and the masseter muscle (just in front of the ear). Be sure to check the sensory branch of cranial nerve V as well by asking the patient to close his eyes and report when he feels light touch as you touch his forehead, each cheek, and his chin with cotton.

How do we palpate the lymph nodes of face and neck and what are we looking for?

There are many chains of lymph nodes in the head and neck. Palpate them by pressing with your fingertips and making small circular motions over these chains. Normally, you cannot feel these lymph nodes. In response to infection, however, they may become enlarged, firm, and tender. Palpate the preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, deep cervical, supraclavicular and infraclavicular nodes.

Why do we assess the appearance of the lips and oral mucosa?

They reveal important information about the overall health of your patient. Assess your patient's mouth and lips, looking for color, symmetry, dryness, and cracking of the lips or the angles of the mouth. Next, using a penlight and a tongue blade, inspect the oral mucosa for moistness, inflammation, ulcers, lesions, or white patches. Be sure to assess the color of the mucosa. Pallor, cyanosis, and jaundice are often found here, especially in dark-skinned patients. Also inspect the gums, or gingiva, looking for inflammation, and examine the teeth for any obvious fractures or missing fillings. Finally, check the tongue, throat (or pharynx), and tonsils for redness, lesions, or exudate. Ask the patient to say "aah" and look for the uvula to rise in the midline.

Explain how to inspect the nose.

To assess your patient's nose, look for alignment and check the nostrils, or nares, to see if the septum is midline and whether or not any discharge is present. With a penlight, you can see a bit of the nasal mucosa. Check it for pallor, inflammation, swelling, or discharge. If there is a discharge, note whether it is thin and clear, thick and purulent, or bloody. If a patient is having difficulty breathing, you may see flaring of the nares with inspiration. Ask the patient to occlude each naris, one at a time, and sniff, noting whether or not the nares are open, or patent.

How do we check for jugular vein distention or JVD?

To check for JVD, position the patient supine with his head elevated at about a 45° angle. Then ask the patient to turn his head to one side, while you observe his neck, looking for a pulsation- sign of JVD but not definite.

Why should we not use alcohol wipe as the odor to test the first cranial nerve/olfactory nerve?

Toothpaste is often available and may work, but avoid the temptation to use an alcohol wipe. Noxious odors such as alcohol may stimulate the trigeminal nerve and cause a misleading response.

T/F: Some patients with anosmia, or an impaired sense of smell, can detect noxious odors and stimulate cranial nerve V.

True

Describe the process of examining a patient's ear canal using an otoscope.

Use an otoscope to inspect your patient's ear canals and tympanic membranes. For an adult, attach a 4-mm speculum to the otoscope, twisting it on securely. Turn the light on, then straighten the patient's ear canal by grasping his ear and pulling upward and back. (With young children, you would straighten the canal by pulling downward and back.) Then, handling the scope safely and under direct visualization of the speculum tip, insert the tip about halfway into your patient's ear canal. At that point, look through the viewfinder and inspect the ear canal as you advance the otoscope. You might be able to see landmarks created by the tiny bones behind the tympanic membrane as well. Take care to withdraw the otoscope as carefully as you inserted it to avoid damaging the delicate ear canal.

Cranial nerve __________ is intact if the patient passes either of the two hearing tests (can hear you).

VIII

How do we inspect the ears for shape, placement, discharge, and tenderness?

Visually inspect your patient's ears for shape, placement, and any discharge. Then check for tenderness by palpating the pinna, or helix, of the ear and the tragus, and by percussing over the mastoid process.

Why would jugular vein distention occur?

When blood flow refluxes (flows backward) from right atrium to jugular veins.

What will a patient's ear look like with middle ear infections?

With middle ear infections, the tympanic membrane may be red and bulge into the ear canal, with obliteration of the cone of light. You may even be able to see a perforation or tear in tympanic membrane.

How do you check for the red reflex?

With your patient looking straight ahead, hold the device about 1 foot away and shine the light directly on the pupil of the eye. Look for the red reflex bilaterally.

Why do we check the six cardinal fields of gaze on a patient? What are we looking for? What (3) cranial nerves are we checking the function of?

Your patient should be able to follow your finger with full, smooth extraocular movements and without nystagmus, or "shaky" eye motion. Normal extraocular movements indicate intact cranial nerves III, IV, and VI.

The ________ cranial nerve or _______ nerve has only sensory function. It is a tiny nerve that runs along an irregular bony surface of the skull and is quite easily disrupted with head injury. Testing this nerve, although often omitted, requires having an aromatic, non-noxious scent available. Mint, spices, and coffee will all work but are not always readily available.

first, olfactory

"shaky" eye motion is called __________ and if it occurs during six cardinal fields of vision test, it is an indicator of impaired cranial nerve III, IV, VI function.

nystagmus

The _________ cranial nerve, the ___________, is responsible for pupillary constriction and dilation and for elevation of the upper lid.

oculomotor

The _______ is the projection in front of the external opening of the ear

tragus