Drooping of Face – Episodic/Focused SOAP
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Drooping of Face – Episodic/Focused SOAP
Patient Information:
BM, 33-years old F African American
S.
CC:
Drooping on the right side of the face.
HPI:
BM is a 33-year old African American female who presents to the clinic with drooping on the right side of the face. The patient complains that the symptoms started this morning upon waking up. The right eye has constantly been tearing. She cannot stop drooling. She denies any pain.
Current Medications:
Multivitamin daily
Valtrex 500mg PO * 3 daily
Tylenol 325mg PO as needed
Ibuprofen 20mg PO
PMH:
Asthma at childhood
Genital herpes, 2013.
PSH:
Cholecystectomy 2005
Teeth extraction 2000
Sexual/Reproductive History
Heterosexual
PAP in June 2017 with normal results
G1P1AO
Soc Hx:
The patient works at a local restaurant and lives in the suburbs. She is a widow after the death of her husband two years ago. She occasionally drinks during events or with friends. She denies alcohol use disorder or substance abuse. She attends a local church service weekly. The patient lives with the daughter.
Immunization History:
All the immunization records are up to date. She receives tetanus, influenza, and flu shot six months ago.
Fam Hx:
She has two brothers. One, 44, is diagnosed with hypertension, while another died five years ago. The daughter, 14, is healthy with no significant medical history. The husband, 35, died in a car accident with a history of hypertension and diabetes.
Lifestyle:
She lives with her daughter in an area with a low rate of crime. She does not exercise daily but tries to keep fit. She takes a medical checkup annually. The patient has healthy support from family and friends.
ROS:
GENERAL:
The 33-year-old female patient has no body changes, including weight loss of gain, for the last one year. She appears worried that her condition may get worse.
HEENT:
Eyes: No changes or problems in vision. She took an eye examination a year ago. The report shows no problems in vision but has complications, including tearing.
Ears: No ear infections or discharge. No hearing difficulties.
Nose: Sense of smell is intact with no nasal congestion or running nose.
Throat: Tonsils are not enlarged, and no difficulty in swallowing.
NECK:
No history of pain injury or dislocation.
BREASTS: No changes in the size or history of lesions.
Respiratory:
Skin: No rashes or significant skin conditions.
CARDIOVASCULAR: No chest discomfort, murmurs, orthopnea, or edema.
RESPIRATORY:
No breathing challenges, sputum, or coughing. Clear lung sounds.
GASTROINTESTINAL:
The patient had no complaints of nausea, vomiting, or changes in the bowel patterns.
GENITOURINARY:
No changes in urinary patterns, pain, or incontinence. She has regular menses but is not sexually active currently.
NEUROLOGICAL:
No dizziness or paresthesia, thinking or memory problems, twitching falls, or seizure.
MUSCULOSKELETAL:
No history of fractures, gout or arthritis.
HEMATOLOGIC:
No excessive bleeding or blood disorder.
LYMPHATICS:
No history of swollen lymph nodes.
PSYCHIATRIC:
No history of depression, anxiety, delusions, or suicidal thoughts.
ENDOCRINOLOGIC:
No history of excessive thirst or abnormal sweating.
ALLERGIES:
NKDA
O.
Physical exam:
Vital signs: T 98.8F orally, 120/80, left-arm sitting, RR 18, P 76 regular, wt 110lbs, ht 5’1, BMI 21.
General: A&O *3 NAD, looks comfortable.
HEENT: Oronasopharynx is clear, excessive tearing, drooping of the right side of the face, mild nasolabial flattening.
Neck: Carotid no bruit, JVD.
Chest/lungs: CTA AP&L.
Heart: No murmur
ABD: Benign tabs *4, no suprapubic tenderness.
Genital: No cervical motion tenderness or external genitalia intact.
Musculoskeletal: Symmetrical muscle development.
Neuro: CN II-XII and DTR intact, paresis on the affected side of the face, and difficulty making facial expressions.
Skin/lymph: No edema or cyanosis.
A.
Lab tests to rule out various disorders
CBC
Monopost test
HIV screening
Serum blood test
Thyroid blood test
Cerebrospinal fluid analysis
Erythrocyte sedimentation rate
Diagnostics
CT scan
MRI
Chest X-ray
EKG
EMG
Glasgow comm]a scale
NIH stroke scale
Primary Diagnosis
Bell’s palsy – it is a sudden feebleness of the muscles on the side of the face. It causes the nerve to support the facial muscles to malfunction. The condition leads to a drooping face. The condition resolves on its own within six months (Heckmann et al., 2019). Psychotherapy is essential to help stop further contraction of the muscles. It causes excessive tearing and the difficulty losing eyes. The reason for selecting Bell’s palsy as the primary diagnosis is the presenting symptoms of sudden facial palsy (Cooper et al., 2017). Available literature shows that the cause of the condition is unknown. Research relates the condition to nerve compression or herpes simplex type 1 (Cooper et al., 2017). Another reason for the primary diagnosis is that the patient has a history of genital herpes related to the condition.
Differential Diagnoses:
a) Mastoiditis:
The condition occurs after an infection of the mastoid. One of the major causes of the disease is an ear infection. The condition can lead to pus-filled cysts. Some common symptoms include redness, swelling, tenderness, fever, and discharge (Induruwa et al., 2019). Antibiotics can be used to clear the condition, but in severe cases, surgery is necessary.
b) Lyme disease:
The condition is caused by Borrelia bacterium. Ticks spread the bacteria. It causes an expanding erythema migrans. It can cause flu-like symptoms, bull’s eye pattern, joint pain, and weakness (Induruwa et al., 2019). The condition can clear with antibiotics. The disease has various stages, and the symptoms will deteriorate as it progresses across its three stages.
c) Parotid tumor:
The condition is a painless swelling of the jaw. It causes numbness and a pricking sensation. Some of the disease’s major causes include smoking, exposure to radiation, and dehydration (Zimmermann et al., 2019). Patients require surgery to remove the tumor. The purpose of removing the non-cancerous cells is that they will continue growing and undermine an individual’s health.
d) Stroke:
Stroke occurs when the brain’s blood supply is disrupted, thus preventing the brain cells from receiving sufficient oxygen. It can cause brain cells to die within minutes. It requires emergency medical attention (Zimmermann et al., 2019). Some common symptoms include paralysis of muscles, walking difficulties, temporary loss of vision, fatigue, and light-headedness (Mueller et al., 2017). Some types of stroke include ischemic, hemorrhagic, and transient hemorrhagic stroke.
e) Guillain-barre syndrome:
Guillain-barre syndrome is a rare disease. It occurs when the immune system interfere with the nerves. Some of the causes of the condition are acute bacterial or viral infection. The symptoms present as tingling and weakness of legs (Mueller et al., 2017). It affects the other body parts progressively. The condition can lead to paralysis. It is a rare neurological disorder that requires treatment to avoid complications.
Tetanus:
Tetanus is caused by an infection that upsets the nervous system. It leads to aching muscle contractions. In some cases, it can undermine the respiratory system’s functioning, thus threatening life (Cooper et al., 2017). Some symptoms include jaw cramping, muscle spasms, muscle stiffness, headache, fever, sweating, and seizures.
References
Cooper, L., Branagan-Harris, M., Tuson, R., & Nduka, C. (2017). Lyme disease and Bell’s palsy: an epidemiological study of diagnosis and risk in England. British Journal of General Practice, 67(658), 329-335.
Heckmann, J. G., Urban, P. P., Pitz, S., & Guntinas-Lichius, O. (2019). The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell’s Palsy). Medical Journal, 116(41), 692.
Induruwa, I., Holland, N., Gregory, R., & Khadjooi, K. (2019). The impact of misdiagnosing Bell’s palsy as acute stroke. Clinical Medicine, 19(6), 494.
Mueller, S. K., Iro, H., Lell, M., Seifert, F., Bohr, C., Scherl, C., … & Traxdorf, M. (2017). Microcystic adnexal carcinoma (MAC)-like squamous cell carcinoma as a differential diagnosis to Bell´ s palsy: review of guidelines for refractory facial nerve palsy. Journal of Otolaryngology-Head & Neck Surgery, 46(1), 1-5.
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.
