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Please Use The Episodic Soap Note (Head-to-Toe) Physical Assessment Drooping of Face A 33-year-old female comes to your clinic alarmed about sudden "drooping" on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.

Primary Diagnosis: Bell’s Palsy

Differential Diagnosis:

1. Mastoiditis

2. Lyme disease

3. Stroke

4. Parotid tumor

5. Guillain-Barre Syndrome

6. Tetanus

References (please give 4 references):

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's Guide to Physical Examination: An Interprofessional Approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Paper For Above instruction

Introduction

The presentation of sudden unilateral facial drooping is a common clinical scenario requiring prompt and accurate assessment to differentiate among various potential causes. The primary diagnosis in this case is Bell’s Palsy, a idiopathic facial paralysis, but several other conditions such as stroke, infections, tumors, and neurological syndromes need to be considered. A comprehensive head-to-toe physical assessment following the episodic SOAP note format aids clinicians in systematically evaluating the patient to establish an accurate diagnosis and initiate appropriate management.

Subjective Data

The patient, a 33-year-old woman, reports an abrupt onset of right-sided facial drooping that started the morning of her visit. She describes her symptoms as partial paralysis affecting her face, with noticeable drooling and excessive tearing, particularly on the affected side. She denies any recent trauma, fever, or upper respiratory symptoms prior to the onset. No history of similar episodes, recent infections, or travel. She has no significant comorbidities and is not on any medication.

Objective Data

Physical examination should begin with vital signs, noting blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation to identify systemic illness or neurological compromise. The following assessment concentrates on cranial nerves, particularly the facial nerve (cranial nerve VII).

- General appearance: Alert and oriented, no distress.

- Head: Normocephalic, atraumatic.

- Face: Asymmetry observed with drooping of the right side of the face. The patient has difficulty smiling, raising her eyebrows, and closing her eye on the affected side.

- Cranial nerve assessment:

- Cranial nerve I (olfaction): Intact.

- Cranial nerve II (optic): Visual acuity and fields normal.

- Cranial nerve III, IV, VI: Extraocular movements intact.

- Cranial nerve V (trigeminal): Sensory examination intact; proprioception preserved.

- Cranial nerve VII (facial): Weakness noted on the right side with incomplete elevation of the eyebrow, inability to fully smile or puff the cheeks, and drooping of the mouth.

- Cranial nerve VIII (vestibulocochlear): Hearing grossly intact.

- Cranial nerves IX and X (glossopharyngeal and vagus): Uvula midline, swallowing normal.

- Cranial nerve XI (accessory): Shoulder and neck strength symmetrical.

- Cranial nerve XII (hypoglossal): Tongue midline, movement intact.

- Neck and lymph nodes: No tenderness or swelling.

- Additional systems: No relevant abnormalities.

The physical exam confirms facial paralysis confined to the right side with preserved other cranial nerve functions, suggesting a peripheral facial nerve lesion, consistent with Bell’s Palsy.

Assessment and Differential Diagnosis

The sudden unilateral facial paralysis with the peripheral pattern strongly suggests Bell’s Palsy, a diagnosis of exclusion after ruling out other causes. Differential diagnoses include:

1. Stroke: Typically involves upper and lower face contralateral to the lesion, with associated neurological deficits such as limb weakness, speech difficulty, or altered consciousness. In this case, the isolated facial weakness favors peripheral etiology.

2. Mastoiditis: Usually presents with ear pain, swelling, fever, and erythema, which are absent in this patient.

3. Lyme Disease: Can cause facial palsy, often with a history of tick exposure and erythema migrans.

4. Parotid Tumor: Usually presents with a painless swelling in the parotid region, with facial nerve involvement as a late feature.

5. Guillain-Barre Syndrome: Typically presents with ascending weakness, areflexia, and bilateral facial involvement.

6. Tetanus: Rare and usually characterized by muscle rigidity and spasms, not isolated facial paralysis.

Based on history, physical findings, and presentation, Bell’s Palsy is the most probable diagnosis.

Management Plan

The management should include corticosteroids such as prednisone to reduce nerve inflammation, antiviral therapy if herpes simplex virus is suspected, and eye protection measures like artificial tears and eye patches to prevent corneal dryness. Patient education about the condition and prognosis is essential, with reassurance that most recover fully. Further evaluation with neuroimaging like MRI may be warranted if symptoms worsen or if other neurological signs develop.

Conclusion

A systematic head-to-toe assessment utilizing the episodic SOAP note format is vital in evaluating sudden facial drooping. Recognizing the distinguishing features of Bell’s Palsy among differential diagnoses enables clinicians to provide timely management, optimize outcomes, and prevent complications such as corneal damage. Thorough clinical evaluation combined with appropriate investigations ensures accurate diagnosis and tailored treatment.

References

1. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's Guide to Physical Examination: An Interprofessional Approach (9th ed.). Elsevier Mosby.
2. Hall, J. E. (2016). Guyton and Hall Textbook of Medical Physiology (13th ed.). Elsevier.
3. Ropper, A. H., & Samuels, M. A. (2019). Adams and Victor's Principles of Neurology (11th ed.). McGraw-Hill Education.
4. Miller, M. A., & Halm, K. (2020). Clinical assessment of cranial nerve palsies. Primary Care: Clinics in Office Practice, 47(2), 233-245.