Facial PE

Question 1

Facial Trauma Examination

Your next patient is a 25 year old man who has had a traumatic injury to his face 2 hours ago. Primary survey has been done.

Task:
Explain your physical examination to the medical student

Answer 1

I. Introduction
- Introduce yourself
- Explain steps: looking at the face, feeling different parts of his face and head, examine his eyes, ears, nose, mouth
- Get consent
- Offer painkillers
- Wash hands, before starting examination

II. Hemodynamic Stability
- I would like to move the patient to the resuscitation cubicle, and continuously monitor vital signs
- I would like to assess the level of consciousness using the GCS score. This has 3 components, eye opening, verbal and motor response. To assess the GCS, I'll first give a verbal stimulus, if he doesn't respond, I'll give a painful stimulus. 

III. General Appearance
- Audible noisy breathing: stridor

IV. Facial Examination
	a. Inspection
	- Racoon eye: bruising around the eyes
	- Battle sign: bruising on the mastoid/behind the ear (basal skull fracture)
	- Asymmetry
	- Ptosis
	- Clear discharge coming from nose and ear (basal skull fracture)
	b. Palpation
	- Tenderness: I want to palpate the skull, periorbital area, zygomatic arch, mandible
		§ Mandible: TMJ, head, ramus, body

V. Eye Examination
	a. Inspection
	- Enophthalmos: depression in the eye (blowout fracture)
	- Exophthalmos: protrusion of the eyeball (orbital hematoma)
	- Subconjunctival hemorrhage
	- Hyphema: blood in anterior chamber
	- Pupil size, shape & symmetry
	b. Visual Acuity
	- I will be using a Snellen chart, I'll place it at 6 meters, I'll ask the patient to cover one eye, and start reading the top line moving down. I'll assess both eyes. If the patient doesn’t see the top line, I'll move it to 3 meters, then 1 meter, then motion, and lastly perception of light
	c. Eye Movements
	- I'll ask the patient to hold his head still, then ask him to follow the red top pin with only his eyes, which I will move in an H-shape pattern
		§ Look for restriction of eye movements
		§ Ask if he has diplopia (blowout fracture: diplopia on upward gaze)
	d. Pupils
	- Light reflex: I'll shine the light on one eye, and look for constriction of pupil on that eye (direct reflex), and constriction of pupil on the other eye (indirect reflex)
	e. Fundoscopy
	- I'll set the lens to +20 initially examining the cornea, then start lowering the lens to 0 as I am moving closer to the patient, until the retina comes into focus
		§ Look for papilledema (increased ICP)
		§ Look for retinal damages

VI. Nose Examination
	a. Inspection
	- Deviation, swelling, bruise, laceration
	- Epistaxis
	b. Palpation
	- I'll gently palpate the nose and nasal bridge if patient not in pain
	- I'll assess for tenderness, crepitations
	c. Nasal Speculum
	- I'll use a nasal speculum and look inside the nostrils looking for nasal septal hematoma (swelling on the septum) - drain ASAP to avoid necrosis in the septum

VII. Mouth and Mandible Examination
- Ask the patient to open his mouth and examine his throat
- Look for swelling, hematoma (risk for airway obstruction)
- Examine for any broken tooth
- Ask the patient to open and close his mouth to assess jaw movements, looking for restriction and pain

VIII. Ear Examination
- Swelling, redness, bruises, lacerations
- Hematoma
- Otoscopy:
	- Perforated tympanic membrane
	- Hemotympanum: blood behind the tympanic membrane

IX. Neck Examination
- Inspect the cervical spine: swelling, redness, bruises
- Palpate the spinous processes, paraspinal muscles
- Assess the movements: flexion, extension, lateral bending, rotation, looking for restriction and pain

X. Neurological Examination
	a. Cranial Nerve 5
		i. Sensory: I'll use a cottonwool and check sensation on all branches: ophthalmic, maxillary, mandibular on both sides looking for sensory loss or paresthesia
		ii. Motor: I'll ask the patient to clench teeth to check tone and bulk of the masseter and temporalis muscle
	b. Cranial Nerve 7
	- I'll ask the patient to wrinkle his forehead, raise his eyebrows, close his eyes (don't let me open it), puff his cheeks (don't let me empty it), and smile and show me his teeth

XI. Upper & Lower Limb Neurological Examination
- I'll be checking active movements against resistance
	- C5: shoulder abduction
	- C6: elbow flexion
	- C7: elbow extension
	- C8: grip strength
	- T1: finger spread
	- L2: hip flexion
	- L3: knee extension
	- L4: knee flexion
	- L5: dorsiflexion of ankle
	- S1: plantar flexion
- I'll check sensory on dermatomes
	- C5: upper outer arm
	- C6: thumb
	- C7: middle finger
	- C8: little finger
	- T1: medial side of forearm
	- L1: groin
	- L2: anterior thigh
	- L3: anterior knee
	- L4: medial side of leg and big toe
	- L5: lateral side of leg and dorsum of foot
	- S1: heel/sole
	- S2: posterior side of thigh

Question 2

Facial Swelling Examination

7 year old child who has been brought to the ED with unilateral facial swelling. He has toothache and pain on chewing food. He is due for an appointment with the dentist in 1 week. Child has a previous history of egg allergy that has improved. Eye examination is done, and is normal

Task:
1. Explain picture to medical student
2. Describe PE to the medical student

Answer 2

I. Hemodynamic Stability (r/o anaphylaxis)

II. Introduction
- Introduce yourself
- Explain steps to parents
- Get consent
- Wash hands before examination

III. General Appearance
- Level of consciousness
- Respiratory distress
- Wheezing/stridor

IV. Inspection
- Swelling: unilateral, bilateral, what area it is involving
- Redness
- Discharge around the eye
- Rash, insect bites
- Trauma signs: raccoon eye, battle sign
- Swelling involving the lips (anaphylaxis)

V. Palpation
- Check for local rise of temperature

VI. Eye Examination
	a. Inspection
		- Redness, pattern of redness (localized, generalized)
		- Discharge
		- Hypopion (pus in the anterior chamber)
		- Proptosis (in cases of abscess behind the eye)
	b. Palpation
		- Gently palpate around the eye for tenderness
		- Sinus tenderness
	c. Visual Acuity
		- Pediatric Snellen chart
		- Color vision: Ishihara chart
	d. Eye Movement
		- Painful/limited eye movement (orbital cellulitis)
	e. Fundoscopy
	f. Pupils
		- Light reflex: direct and indirect

VII. Parotid Examination
- Palpate for tenderness or enlargement

VIII. Mouth Examination
- Swelling for anaphylaxis
- Swelling & redness around the teeth (dental infection)

Quick ear and respiratory exam

Differential Diagnosis:
- Orbital cellulitis
- Pre-orbital cellulitis
- Dental infection
- Parotiditis, parotid mass
- Cellulitis of skin
Anaphylaxis