A 23-year-old female college student is eating lunch with friends when she suddenly senses that the right side of her tongue doesn’t seem to be working. She mentions it to her friends, who tell her that the whole right side of her face is drooping. Alarmed, she runs to the bathroom, looks in the mirror and thinks, I have had a stroke. She has her friend call 9-1-1 and sits down to wait for the ambulance.
After establishing the patient’s level of consciousness, securing the airway and monitoring circulation, if the patient is able to answer questions, ask the usual OPQRST and SAMPLE history questions.
For trauma patients with injuries like a blow to the head or a fall, ask if the symptoms started before or after the traumatic event. Ask the patient to describe exactly what happened.
If it’s a medical condition, ask whether it has ever happened before. Was onset sudden or gradual, over minutes or days? Note the quality of her voice and whether there is any hoarseness or difficulty speaking.
Specific history questions and findings include:
- Did she lose consciousness? Consider the possibility if the patient is unable to describe the event. Did the loss of consciousness occur before the injury or after? If a blow to the head resulted in unconsciousness and the patient is conscious now, consider the possibility of an epidural bleed. The brief return to consciousness—the “lucid interval”—in an epidural bleed is quickly followed by a diminishing level of consciousness, unconsciousness, seizure activity and death.
- Are hazardous conditions, such as exposure to toxic chemicals, involved?
- Does the patient have a history of seizures; could a seizure be involved?
- Does the patient complain of visual disturbances? “Double vision” (diplopia), flashes of light or tunnel vision may indicate pressure on the optic nerve. Kaleidoscope vision may indicate an optical migraine. Extreme light sensitivity (photophobia) may indicate a migraine or, more ominously, intracranial hemorrhage.
- Has there been nausea or vomiting, particularly projectile vomiting, which is a sign of increasing intracranial pressure?
- Does the patient have a headache? A sudden, severe headache in a patient who has never had one like it before can signal a serious medical problem like a subarachnoid hemorrhage. SAH often presents as a sudden, severe, debilitating headache—the “thunder-clap headache”—followed rapidly by neck stiffness, loss of consciousness and cardiac arrest. Patients who complain of headache should be asked to describe it in terms of location, severity, character (constant, throbbing, aching, dull, sharp, pounding) and duration.
- Has the patient drunk alcohol or taken any recreational drugs?
Nausea or vomiting, changes in vision, pain with bright lights (photophobia), neck pain or stiffness, fever, weakness, dizziness or other symptoms may be signs of increasing intracranial pressure.1
Examining the Head
While still taking the history, begin the physical examination.
Look at the patient’s head. Does it appear to be normally developed with normal features? Note any deviations that could signal a genetic or developmental disorder.
Inspect and palpate the skull. Look for symmetry, bleeding and bruises. Place your hands on the skull and feel for swelling or indentations in all regions. Does palpation produce pain? Look for bruising behind the ear (Battle’s sign) and bruising around the orbits (“raccoon eyes” or “panda eyes”), but keep in mind that these may take a while after injury to develop. If present, they may signal a skull fracture.
Inspect the ears for discharge and note whether it is bloody or clear. Inspect the eyes for pupillary size, shape, reaction to light and movement. (See our article in the May issue on assessment of the eye.)
Inspect and palpate the face for symmetry and obvious signs of trauma, and note any pain on palpation. Facial asymmetry indicates a problem with one or more cranial nerves. Is there facial droop on one side? Ask the patient to close her eyes as tightly as possible and note any differences in eyelid closure. Have her wrinkle her forehead and raise her eyebrows, noting any differences in left and right sides. Ask her to whistle, if she can, and to clench her teeth and smile as broadly as possible. Is the smile symmetrical or asymmetrical? Is there drooling? Ask her to wrinkle her nose and pout her lips, and look for any abnormalities.
Have the patient open her mouth and waggle her tongue. Note any weakness. Can she curl her tongue? Look at the uvula. Is it hanging down in the center of the oropharynx or deviated to one side? The tongue and uvula will deviate to the side away from the location of a stroke. Does the patient have an “open bite” that may suggest a maxillary or mandibular fracture?
Inspect and palpate the neck. If trauma is involved, this should be done before applying a cervical collar. Inspect the front of the neck while your partner holds the patient’s head steady. Look at the jugular veins to see if they are flat, full or distended. Jugular veins should be full but not distended when a patient is lying supine. Flat jugular veins may indicate hypovolemia or hemothorax, and you will need to look elsewhere for injuries. Look for swelling that would indicate bleeding into the tissues or subcutaneous emphysema from damage to a lung or another part of the airway.
If there is no trauma involved, check for range of motion. Can the patient touch her chin to her chest and touch her ears to her shoulders without elevating the shoulder? Is the neck supple or stiff? Stiff neck can indicate meningitis.
Palpate the neck and underside of the jaw for swollen lymph nodes. Lymph nodes are found in many places in the head and neck, but are particularly easy to palpate in the occipital region of the head, the posterior cervical region and under the jaw.
Swollen lymph nodes may indicate an infection.
Feel the trachea with your thumb and first finger. It should be in the midline. Normal respirations will cause the trachea to move down a little, while a simple pneumothorax may cause it to “tug” in the direction of the pneumothorax. As pressure builds in a tension pneumothorax, the trachea will deviate away from the affected side, but this is a very late sign.
Medic 92 arrives on scene and begins to assess the patient. The crew finds her lucid, interacting with her environment and able to answer all questions appropriately. She can state her name, where she is, the date and time, and describe her condition to them.
They determine that her day has been unremarkable prior to onset of symptoms, with no ingestion of alcohol or recreational drugs, and no neurological or other symptoms prior to this event, but she now complains of an earache in her right ear and says she seems to have lost her sense of taste. She has no chronic illnesses and takes no regular medications other than oral contraceptives. She is physically fit, and her vital signs are within normal range. She appears normocephalic, there are no apparent injuries, and her pupils are round, equal and reactive.
The Cincinnati Stroke Scale reveals no arm drift, but there is somewhat slurred speech and pronounced right-sided facial droop. She cannot close her right eye completely, and cannot wrinkle her forehead or raise her eyebrow on that side. She cannot curl her tongue or whistle. When she attempts a broad smile, the right side of her mouth does not respond and she cannot show her teeth on that side. She is also observed to be drooling from that side of her mouth.
The medics decide that the differential diagnoses are stroke and Bell’s palsy (caused by a disturbance of cranial nerve VII, the facial nerve). They remember that Bell’s palsy presents with paralysis that includes the entire face on the affected side, including the forehead and lower aspect of the face. Stroke patients are typically able to move their forehead muscles and arch their eyebrows; Bell’s palsy patients are not. The medics relate their findings to online medical control, who agrees with them that their patient is most likely experiencing Bell’s palsy. They transport normal traffic to the ER, where the physician confirms their findings. She is sent home for follow-up with her personal physician.
Conditions involving the head and neck can be life-threatening or relatively benign. Bell’s palsy usually resolves within 8–12 months without treatment. Current thinking is that it may be caused by herpes simplex virus (HSV), but not all agree.
Cases like this can be challenging, and you must always consider the worst-case scenario of stroke or bleeding into the brain. However, the savvy medic who can distinguish stroke presentation from Bell’s palsy can make the difference between calling a stroke alert and a normal transport.
Patients with either stroke or Bell’s palsy may be terrified by what is happening to them. You can do a lot to alleviate stress by explaining things to the patient. If unsure about the cause of symptoms, err on the side of caution. It is better to occasionally call a stroke alert unnecessarily than to not call one when a stroke is present.
For a good overview of Bell’ palsy, see http://emedicine.medscape.com/article/1146903-overview#a0101.
1. LeBlond RF, Brown DD, DeGowin RL. DeGowin’s Diagnostic Examination, 9th edition. New York, NY: McGraw Hill Publishers, 2008.
2. Much of the information for this article is taken from Jarvis C, Physical Examination and Health Assessment 3rd edition, pp. 267-296, Philadelphia, PA: W. B. Saunders, 2000; Bickley LS, Bates’ Guide to Physical Examination and History Taking, Lippincott Williams & Wilkins Publishers, 2002; DeGowin’s Diagnostic Examination, ibid; and Seidel HM, Ball JW, Dains JE, Flynn JA, Mosby’s Guide to Physical Examination, St. Louis, MO: Mosby Elsevier Publishers, 1999. We highly recommend that all EMS providers have access to a comprehensive text on physical examination and history taking, but don’t recommend any particular text.
3. eMedicine. Bell’s Palsy. http://emedicine.medscape.com/article/1146903-overview#a0101.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and
urban settings. He lives in Tucson, AZ.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.