Master Head, Face and Neck Assessment with Picmonic for Medicine

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 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.

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.

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).

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.

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 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.

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.