Neurological assessment paper: Drooping of the face
Patient initials: CF
Age: 33
Gender: F
Ethnicity: African American
SUBJECTIVE DATA
Chief complaint: Drooping on the right side of the face and excessive tearing.
History of presenting illness: The patient is an African American aged 33 years.
She came to the clinic today with complaints of drooping of the face on the right side. The patient states that she noticed the drooping on the face in the morning when she woke up. She also states that her right eye started watering since the morning that she woke up, and there is no sense of pain.
Medications
- 2 PO Tylenol 325mg four hourly.
- 2 PO Ibuprofen 200mg (PNR)
- PO Valtrex 500mg (TDS)
- Multivitamin (OD)
Allergies: No history of allergies
Past Medical History: History of genital herpes in 2015
Past Surgical History: Dental surgery in 2011
Sexual and Reproductive History: She started her menarche at the age of 14 years; the menstrual cycle is regular and takes 29 days, and the flow takes three days. She experiences mild cramping during menstruation, which response well with ibuprofen.
Personal and Social History: Denies alcohol drinking and cigarette smoking.
Immunization History: According to her immunization schedule, it is up to date. She received yellow fever and Influenza immunization six months ago.
Significant Family History: Her mother died due to diabetes; her father was recently diagnosed with hypertension. She had the firstborn daughter at 18 years.
Lifestyle: She is married and lives with her family. She exercises once in a while, and she is much involved in the dietary decisions of the family. Her eating pattern and diet are healthy. She does an annual checkup from her preferred health care facility. She had a PAP smear done last year. Her support system is excellent and is composed of her family members, workmates, and friends.
Review of Systems
General: A 33-year-old female whose age is appropriate to her outlook, seated in the chair. She has excellent communication skills and a good historian.
HEENT: She did her last examination of the eyes one year ago. No vision or hearing changes. No tinnitus, no ear infection, no discharge from the eyes and the ears. No epistaxis, no polyps, no sinus inflammation, no gingivitis, no dental appliances, and no gum bleeding.
Neck: No masses, no color change, no breast size change
Respiratory system: No chest pain, no fast breathing, no breathing difficulty, no hemoptysis
Cardiovascular system: no dyspnea, no distension of the jugular vein, no palpitations, no chest pain, history of murmurs.
Gastrointestinal system: No nausea nor vomiting, no abdominal pain, cramping, no abdomen distention, no diarrhea.
Genitourinary system: No urine retention, no color change in urine, no incontinence, no pain on urination.
Musculoskeletal system: Range of motion is normal rated 5/5, muscle strength is normal, and the muscle bulk is appropriate, she can carry her weight.
Psychological: no history of suicidal thoughts, no sleep or appetite disturbances, no history of depression nor anxiety.
Neurological system: No seizures, no headaches, no gait disturbances, no tics, and tremors.
Integumentary system: No bruises, no reddening of the skin, skin turgor is normal. She states that she keeps her skin moist by using a lotion.
Endocrine system: No hormonal therapies
Immunological system: Has no allergic reactions. She did her last HIV test three months ago.
Objective Data
Vital signs: BP 118/72, pulse 74, temperature 98.7, respiratory rate 18, Weight 116lbs, height 5.2 feet and BMI 22
HEENT: Excessive tearing of the right eye and drooping of the right side of the face.
Neck: no jugular vein distention, normal range of motion
Chest: no wheezes, normal breath sounds
Heart: No murmurs
Abdomen: no enlargement, no splenomegaly nor hepatomegaly.
Musculoskeletal: muscle bulk is symmetrical, full range of motion and muscle strength and tone normal.
Neurological: all cranial nerves are intact. Difficult in making a facial expression, paresis on the right side of the face.
Skin: no cyanosis, no reddening, no rashes, no palpable nodes.
Assessment
It is essential to perform various diagnostic tests to help in ruling out different disorders. From the history taking and physical examination of the patient with drooping of the face, one would easily make a diagnosis of Bell’s palsy. Some of the critical laboratory tests that should be done to this patient include:
Laboratory tests:
Cerebral fluid analysis
Complete blood count
Monospot test
Erythrocyte sedimentation rate
Thyroid function test
HIV screening
Rapid plasma regain
Serum blood glucose
Diagnostics:
CT scan: It is done on the facial structures and helps in identification of the abnormalities in the brain structures that could cause facial muscle weakness. Therefore, it can be used to diagnose Mastoiditis and the tumor of parotid.
MRI: Used to identify the injuries on the bone structures of the skull that could lead to the weakness of the facial muscle. As well, it identifies the development of cysts or tumor in the brain structures that causes muscle weakness on the face (Osborn et al., 2015). Therefore, it can be used to diagnose Mastoiditis, tetanus and the tumor of parotid.
Electroneurography: A non-invasive test used to check on the nerves of the face to identify any weakness of the muscles (Osborn et al., 2015). The procedure will be useful in diagnosing the cause of facial muscle weakness. Therefore, it will help in diagnosis of Bell’s palsy and Guillain-Barre Syndrome.
Glasgow Coma Scale: It is used to check the level of consciousness of the patient and the effects that an injury or disease has on the nervous system. The patient is assessed in response to specific stimuli.
NIH stroke scale: According to (Osborn et al., 2015) NIH stroke scale is used to assess any kind of muscle weakness that could be associated with stroke. This procedure will be used to diagnose stroke.
Primary diagnosis:
Bell’s palsy is a neurological disorder that causes the paralysis of the face with difficulty in eye closure (EBM Consult, 2015). Besides, it causes tearing of the eyes and sensory changes on the affected side. The cause of the disease is unknown. However, it is associated with compression of the nerves, herpes simplex type-1, and autoimmunity (Eviston et al., 2015). The diagnosis is made on this patient because of the symptoms that presented acutely.
Differential diagnosis
Stroke: Stroke always present with the drooping of the eyes, and it causes paralysis of one side of the body. According to (EBM Consult, 2015), stroke is ruled out when the patient can raise their eyebrows generally while the other parts of the face are paralyzed.
Guillain-Barre Syndrome: This is a neurological disorder that affects the nerves in the body. Andary, (2017) argues that the disease causes paresthesia which from the body extremities and which later ascend to cause pupillary disturbances, drooping of the face, dysarthria, dysphagia, and diplopia.
Tumor of the parotid: It presents as a mass on the parotids, and it causes the weakness and paralysis of the face.
Mastoiditis: This is a disease that is caused by bacteria. According to (Devan, 2016) the bacteria cause inflammation of the temporal bone, and it causes facial palsy. Besides, it causes tenderness and swelling of the mastoid area, otorrhea, and otalgia.
Tetanus: It rarely occurs, but in cases of trauma to the facial structures or infection of the ears in can occur (Bevilacqua et al., 2015). Cephalic tetanus causes palsy of the cranial nerves, which at times can localize and cause paralysis of the face.
References
Andary, M. (2017). Guillain-Barre Syndrome. Retrieved from http://emedicine.medscape.com/article/315632-overview
Devan, P. P. (2016). Mastoiditis clinical presentation. Retrieved from http://emedicine.medscape.com/article/2056657-clinical#b3
EBM Consult. (2015). Stroke vs. bell’s palsy. Retrieved from http://www.ebmconsult.com/articles/anatomy-stroke-vs-bells-palsy
Eviston, T. J., Croxson, G. R., Kennedy, P. G. E., Hadlock, T., & Krishnan, A. V. (2015). Bell’s palsy: Etiology, clinical features, and multidisciplinary care. Journal of Neurology, Neurosurgery, and Psychiatry, 86(12), 1356. DOI: http://dx.doi.org/10.1136/jnnp-2014-309563
Bevilacqua, V., D’Ambruoso, D., Mandolino, G., & Suma, M. (2015, May). A new tool to support the diagnosis of neurological disorders by means of facial expressions. In 2011 IEEE International Symposium on Medical Measurements and Applications (pp. 544-549). IEEE.
Osborn, A. G., Salzman, K. L., Jhaveri, M. D., & Barkovich, A. J. (2015). Diagnostic imaging: brain E-book. Elsevier Health Sciences.
