Head Examination - Patient Management

Head

Headache

·         Recent onset of severe headache: the most common cause is idiopathic

·         Ask about associations/antecedents 

·         Red flags: fever, change in mental status/personality, fits, focal neurological signs, sudden and severe, affected by postural change, normally headache free, waking at night or in the morning with a headache

·         Types of headache:

o   Tension headaches, eg chronic daily headache, gradual onset (chronic), sleep not disturbed, treat by ¯stress (massage, relaxation). ? Depression. Types: post-coital, ergotamine misuse

o   Cluster headache: clusters of extreme, recurrent non-throbbing deep pain in and around an eye, spreading onto the face. Eye typically becomes swollen and watery

o   Migraine: visual symptoms, unilateral, throbbing, nausea, aura

o   Facial structure: eg TMJ dysfunction, sinusitis, NOT teeth

o   Neuralgic: eg idiopathic, trigeminal neuralgia

o   „True vascular headache‟: associated with TIA/stroke, artery dissection, giant cell arteritis

o   Associated with ­ICP: focal lesions, venous thrombosis, meningitis, severe hypertension

o   Acute: ?meningitis, sinusitis, head injury

o   Associated with post Lumbar puncture

·         Treatment: Ongoing unchanged tension or migraine headache: TCAs

·         Differential of morning headache:

o   ­ICP

o   ­CO₂ (eg sleep apnoea)

o   Diabetic going hypoglycaemic overnight

Eyes

·        Jaundice: primary liver disease, liver congestion secondary to heart failure

·        Anaemia: pale conjunctiva – especially anterior border just inside eye lid

·        Sclera not affected by hypercarotenaemia

·        Puffiness below eye: early nephritis (before feet oedema), myxoedema of hypothyroidism

Mouth

·        Mouth: Foetor hepaticus, ulceration, pigmentation, telangiectasia, gingivitis/hypertrophy, glossitis

·        Ulcers: aphthous, drugs (e.g. gold), trauma, Crohn‟s, infection (HVZ, HS)

·        Pigmentation: heavy metals (lead, iron), drugs (anti-malarials), Addison's, Melanoma, Kaposi‟s sarcoma

·        Snotty nose = coryza

Throat

Bacterial : Viral

High fever          : Runny nose

Pus/exudate      : Red raw throat

Productive cough (if any) :    Persistent dry cough

·        Whitish-yellow membrane over tonsils - ?EBV

·        Patches of exudate on mucosa - candida

·        Differential: Bacterial sore throat, viral URTI, glandular fever, rheumatic fever, quinsy (peri-tonsillar abscess, can lead to airway obstruction)

Acute Pharyngitis:

 ·         Clinical signs: fever, respiratory distress, cervical lymphadenopathy, pharyngeal erythema, pharyngeal exudates

 Diagnosis

·         Throat swabs:

o   For routine bacterial culture: especially to confirm/exclude Strep Pyogenes

o   Low sensitivity (?30%) and specificity (?75%)

o   40 – 50% of people with sore throats have bacteria isolated

o   Lots of variability: swab-taking technique, delays in transport, etc

o   Worth it for $18?

·         Nasopharyngeal washings (kids): Antigen detection by immunoflouresence for RSV, Influenza A & B, Parainfluenza 1 – 3 and adenovirus

Lymph Nodes

·        Occipital Nodes: scalp infections, bad nits, infected cradle cap, rubella

·        Mastoid and posterior auricular

·        Parotid: mumps

·        Posterior sternomastoid

·        Anterior sternomastoid: sore throat

·        Jugulodigastric

·        Submandibular and Submental: tooth infection, glandular fever

·        Superior, deep and lateral cervical (internal jugular) nodes

·        Supra & sub-clavicular: lung and lung surface infections, Tb, lung metastasis

·        Enlarged lymph nodes and oral thrush ® ?AIDS