Presenting Complaints:

A 34-year-old female presents with sudden onset of facial weakness on the right side of her face. She reports difficulty in closing her right eye, drooping of the right corner of her mouth, and difficulty in speaking clearly. She also complains of a decreased sense of taste on the anterior two-thirds of her tongue.

History of Presenting Complaints:

The patient woke up one morning with these symptoms. She noticed her symptoms when she tried to drink from a glass and realized that the liquid was dribbling out of her mouth. She also had trouble blinking her right eye and noticed that her right eyelid would not close completely. The facial weakness seemed to have appeared overnight without any warning signs.

Chief Complaints:

Facial weakness on the right side, inability to close the right eye, drooping of the right corner of the mouth, speech difficulty, and decreased sense of taste.

Past Medical and Surgical History:

The patient has a history of seasonal allergies and occasional migraines. She has never had any surgeries or significant medical conditions.

Family History:

There is no significant family history of neurological disorders or Bell’s palsy.

Socioeconomic Status:

The patient is employed full-time in an office setting. She has a stable income and health insurance coverage.

Present and Pre-morbid Functional Status:

Before the onset of symptoms, the patient was leading a normal and active lifestyle. She had no functional limitations and was able to perform her daily activities without any difficulty.

General Health Status:

Overall, the patient is in good health. Apart from her allergies and migraines, she has no chronic medical conditions.

Vitals:

Vital signs are within normal limits.

Aggravating Factors:

The patient reports that cold winds seem to exacerbate her symptoms, causing more pronounced facial weakness.

Easing Factors:

Rest and avoiding exposure to cold weather provide some relief from her symptoms.

Examination:

Physical examination reveals asymmetry of the patient’s face, with the right side showing reduced movement compared to the left. She is unable to raise her right eyebrow, close her right eye fully, or smile symmetrically. The forehead wrinkles are absent on the right side when she raises her eyebrows. There is also decreased tearing in the right eye.

Sleep and 24-hour Pattern:

The patient reports that her symptoms do not worsen during sleep, but she sometimes wakes up with a dry and irritated right eye.

Duration of Current Symptoms:

The patient has been experiencing these symptoms for 5 days.

Mechanism of Injury/Current Symptoms:

The exact cause of Bell’s palsy is not fully understood, but it is thought to be related to inflammation and swelling of the facial nerve, often triggered by viral infections. The patient’s symptoms suggest involvement of the facial nerve on the right side, leading to weakness and dysfunction of the muscles that control facial expression.

Progression Since the Current Episode:

The patient reports that her symptoms have remained relatively stable since their onset. There has been no significant improvement or worsening.

Significant Prior History:

The patient has no history of previous facial nerve disorders or similar symptoms.

Previous Treatment:

The patient has been using artificial tears to manage the dryness in her right eye. She has not received any specific treatment for the facial weakness yet.

Diagnostic Test/Imaging:

No imaging has been performed at this point. A clinical diagnosis of Bell’s palsy is often based on the characteristic symptoms and physical examination findings.

Differential Diagnosis:

Other conditions that can cause facial weakness and mimic Bell’s palsy need to be considered, such as stroke, Lyme disease, and Ramsay Hunt syndrome.

Postural Observation:

The patient’s posture appears normal; however, asymmetry of the face is noticeable during facial expressions.

Precaution and Contraindications:

The patient should avoid exposure to cold winds as they can exacerbate her symptoms. She should also protect her right eye from dryness and irritation.

Functional Movement Analysis (Sign):

Inability to fully close the right eye and raise the right eyebrow, asymmetrical smile, and absence of forehead wrinkles on the right side during eyebrow elevation.

Quick Screening Tests/Clearing of Additional Joint Structures:

No additional joint structures need to be assessed in this case.

Range of Motion (ROM):

Facial movements are limited on the right side compared to the left.

Special Tests:

No special tests have been conducted yet.

Assessment:

The patient presents with classic symptoms of Bell’s palsy, characterized by sudden onset of facial weakness on the right side.

Problem List/Complaints:

Facial weakness on the right side

Inability to close the right eye

Drooping of the right corner of the mouth

Speech difficulty

Decreased sense of taste on the anterior two-thirds of the tongue

Treatment:

The patient will be started on a course of corticosteroids to reduce inflammation and promote nerve recovery. Artificial tears will continue to manage the dryness in the right eye. She will also be advised to perform facial exercises to maintain muscle tone and prevent contractures.

Prognosis:

The prognosis for Bell’s palsy is generally good, with the majority of patients experiencing significant improvement within a few weeks to a few months. Some residual weakness or facial asymmetry may persist in some cases.

Goals:

Improve facial muscle strength and function

Restore the ability to close the right eye

Alleviate speech difficulty

Restore the sense of taste on the anterior two-thirds of the tongue

Interventions:

Corticosteroid medication to reduce inflammation

Artificial tears to manage dry eye

Facial exercises to maintain muscle tone and prevent contractures

Patient Education:

The patient will be educated about the nature of Bell’s palsy, the expected course of recovery, the importance of taking prescribed medication, performing facial exercises, and protecting the right eye.

Patient/Family Education:

The patient’s family will be educated about the condition, its self-limiting nature, and the supportive measures needed during the recovery phase.

Discharge Plan:

The patient will be provided with a prescription for corticosteroids and advised to follow up with the healthcare provider in two weeks for a re-evaluation of her symptoms. She will also be given information on how to perform facial exercises and manage her dry eye. If any new symptoms or complications arise, she will be instructed to seek medical attention promptly.