Assessing Neurological Symptoms
SOAP NOTE
Patients initial: KL Age: 33 Gender: Male
SUBJECTIVE DATA:
Chief Complaint: The patient complains of ‘drooping on the right side of the face’
HPI: KL is a 33-year-old patient who presents at the clinic with a drooping on the right side of the face. She states that she had the signs and symptoms when she woke up in the morning. The additional symptoms reported by the patient include constant tearing.
Medications
The patient takes Tylenol for occasional migraines.
Allergies: No known allergies
Past Medical History: The patient suffered pneumonia as a child.
Past Surgical History: No history of surgery reported.
Social History: The patient occasionally drinks when she is out with friends. The patient denies exposure to secondary smoke and denies the use of drugs and other substances.
Immunization History: The patient received all the childhood vaccines as required. She received a flu shot in 2018.
Family History: The patient’s grandfather succumbed to hypertension. The patient’s mother has a history of diabetes.
Review of Systems
General: The patient is alert and oriented to time and place. She looks worried because of her presenting symptoms.
HEENT: The patient denies complications in the head, ears, nose, and throat. She is however concerned about the drooling and tearing that she has been experiencing since morning.
Neck: The patient reports no pain in the neck region.
Respiratory: The patient has no difficulty breathing.
Cardiovascular: Negative for chest discomfort, murmurs, or heart palpitations.
Gastrointestinal: Negative for nausea and vomiting. The bowel movements are normoactive.
Genitourinary: Negative for dysuria or inconsistency.
Musculoskeletal: Normal range of motion. Negative for arthritis.
Psychological: Negative for depression or anxiety.
Neurological: The patient has no history of dizziness and changes in memory. Her coordination is normal.
Integumentary: No rushes or bruising on the skin
Endocrine: No endocrine symptom complications.
OBJECTIVE DATA:
Physical Examination:
Vital Signs: BP 122/83, P77, Temp 99, RR 19, Wt: 114lbs, HT 5’1
General: The patient is alert and oriented
HEENT: Positive for excessive tearing in the right eye, positive for drooping in the right side of the face
Cardiovascular: No murmurs or gallop.
Skin: Negative for edema, palpable nodes, or cyanosis.
Musculoskeletal: The patient reports no pain in the muscles. Normal range of motion
Neurologic: positive for difficulty making facial expression, paresis on the right side of the face.
ASSESSMENT:
Diagnostic Tests: A specific test for the diagnosis of Bell’s palsy does not exist. The physician may tell the patient to make facial expressions. However, it is important to conduct other tests to eliminate conditions such as Lyme disease and stroke (Butler & Grobbelaar, 2017). Electromyography may be performed to check for cases of nerve damage. Imaging scans such as MRI OR CT scans may be performed to eliminate the chances of pressure on the facial nerves.
Primary Diagnosis: According to the presented history and review of systems, Bell’s palsy is the most likely condition. The condition may result from a viral infection (Zimmermann et al., 2019). It is characterized by muscle weakness that results in the drooping of one side of the face. The onsets of paralysis on the patient’s face point to the diagnosis.
Differential Diagnosis
- Lyme disease: The disease is caused by bacteria hosted by ticks. The condition may cause Bell’s palsy because of the effect on the nervous system (Gagyor et al., 2017).
- Stroke: An individual suffering from stroke often presents with facial drooping (Butler & Grobbelaar, 2017). It is however important to note that stroke affects a side of the body.
- Mastoiditis: The bacterial infection equally presents with facial palsy, swelling, and tenderness (Somasundara & Sullivan, 2017). It is important to conduct further tests to ascertain that the patient is suffering from the condition.
- Tetanus: The patient could be suffering from cephalic tetanus which is associated with facial palsy (Kotani et al., 2017). The condition is uncommon but should not be ruled out.
- Traumatic Brain Injury: Head injury associated with skull fracture may lead to the damage of facial nerves thus leading to facial palsy (Zimmermann et al., 2019).
References
Butler, D. P., & Grobbelaar, A. O. (2017). Facial palsy: what can the multidisciplinary team do?. Journal of multidisciplinary healthcare, 10, 377.
Gagyor, I., Madhok, V. B., Daly, F., & Sullivan, F. (2019). Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews, (9).
Kotani, Y., Kubo, K., Otsu, S., & Tsujimoto, T. (2017). Cephalic tetanus as a differential diagnosis of facial nerve palsy. Case Reports, 2017.
Somasundara, D., & Sullivan, F. (2017). Management of Bell’s palsy. Australian prescriber, 40(3), 94.
Zimmermann, J., Jesse, S., Kassubek, J., Pinkhardt, E., & Ludolph, A. C. (2019). Differential diagnosis of peripheral facial nerve palsy: a retrospective clinical, MRI, and CSF-based study. Journal of neurology, 266(10), 2488-2494.