H&P # 1
Date of Exam: 2/11/23
Source of history: patient is the primary source of information and is a reliable historian
Subjective /CC: “I’m here for a referral for therapy.”
Present Illness: 58 y/o white male present to the office today for referral for physical therapy and refill for pain medication. Pt reports he was diagnosed with Bell’s Palsy 6 months ago. Pt has left facial droop with asymmetrical facial movement. He states that he is in a lot of pain, pain is at the left side of his face especially around the ear radiating up to the forehead. Pain is constantly at 10/10 and is a sudden onset. The pain is described as stiff and pulling to one side and he is unable to move his forehead. He takes oxycodone 5mg every 8 hrs with relief. He expresses he is so saddened with the diagnosis and can’t wait for it to be resolved. Pt states “I can’t even close my left eye.” Pt states he believes going to therapy will hasten his recovery. He also shared that with his job he is embarrassed of his facial appearance.
Past Medical Hx:
HTN
Psoriasis
Sarcoidosis
Bell’s Palsy
Depression
Facial Cell Carcinoma
Acute Sinusitis
Squamous Cell Carcinoma of skin (left cheek)
Past Surgical Hx:
Removal of Squamous Cell Carcinoma 1/5/19
Fractured nose 30 yrs ago
Medication:
Amlodipine Besylate 5mg oral tab
Trazodone HCL 100mg oral at HS
Prednisone 20mg oral tab po bid (tapering doses)
Oxycodone HCL 5mg oral tab po Q 8 hrs PRN
Lotrison 1-0.05% external cream
Gabapentin 300mg oral caps at HS
Allergies:
Penicillin (hives)
Family Hx:
Mother-GERD, AFIB, HTN
Father-Psoriasis, DM
Social Hx:
Pt does consultation for interior design. Pt states he works for a large successful cooperation. He has worked with them for 25 yrs. Pt states, “This is all I know and I can’t go around looking like this.” Pt is divorced for 2 yrs, 2 children, both away for college, currently in a relationship for 2 yrs, and his significant other is very supportive.
Alcohol:
Denies substances abuse or any illicit drugs
Denies smoking, vaping
Immunization:
Pnumococcal-23 1/11/20
Hepatitis B (completed) 8/11/20
Influenza 10/10/22
Coved vac 11/22 last Booster
Review of Systems
General/Constitutional: (+) Fatigue, has lost 15lbs within the past year
Skin: Hx of facial Squamous Cell removed on left side of face, old surgical scars appear, pt denies lumps, itching, dryness or changes in color. Last dermatological exam 12/2022
Head: (+) Left side pain, (-) dizziness, unable to move forehead
Eyes: (+) Corrective lenses for the past 3 yrs, reports no change in vision, (-) pain, reports last eye exam and last optometrist exam 8/13/22
Ears: (+) Pain around outer ear, (-) infection, discharge or loss of hearing
Nose: (-) recent cold, congestion, discharge, itching, hay fever or nose bleeds
Neck/Throat: (-) Lumps, pain, neck stiffness or swelling
Mouth: Difficult when eating, twisted to the right side of the face, last dental exam 7/7/22
Pulmonary: (-) Shortness of breath, non-productive cough, DOE, hemoptysis, wheezing or pleuritic pain
Cardiac: Hx of high blood pressure on medication, (+) left side head pain, (-) palpitation, dyspnea, orthopnea, angina or edema, last EKG 9/2022 normal
Gastrointestinal: (-) Pain to the umbilical area, nausea, vomiting, dysphagia, hemorrhoids, melena, constipation or diarrhea, bowel habits are unchanged, last bowel movement this am
Urinary: (-) Incontinence of urine, dysuria, incomplete emptying of bladder, burning on urination
Reproductive: (-) Testicular pain or penial discharge, no family hx of prostate disease, sexually active. Pt is in a monogamous relationship with the use of condoms
Peripheral Vascular: (-) Leg cramps, varicose veins or hx of blood clots, no temperature changes to the leg or ulcers
Musculoskeletal: (-) Edema, ulcers, heat, redness, deformity, myalgia’s, weakness, bone fractures, gout, back ache, sciatica, falls, hx of nose fracture
Neuro: (-) Seizures, (+) weakness, left facial paralysis, Bell’s Palsy and headache
Hematology: (-) Hx of anemia, easily bruising or bleeding, never had blood transfusion or DVT
Endocrine: (-) Intolerance of heat and cold, thyroid disease, goiter, changes in voice, excessive sweating, polyphagia, polydipsia, or hirsutism
Psych: (+) Depression, (-) hx of mental illness or suicidal attempt
Objective/ Physical Exam:
Vital: BP: 122/80, (Sitting) HR: 75, Temp: 97.6 Oral, Wt: 240lbs, Ht: 6’0”, BMI 34.4 O2 SAT 95% on RA
General/Constitutional: This is a well-dressed, well-nourished male sitting on the table with left facial paralysis and in severe pain to the left side of face. Speech is slurred, memory remote and intact and questions answered appropriately. On exam the left side of face is paralyzed including the forehead. Pt have difficulty forming different facial expressions, which is indicative of CN VII alteration or mal function.
Skin: Old surgical scar on left side of face, no lumps or open area
HEENT:
Alert and oriented to person, place and time. Appropriate behavior and speech. No gross focal deficit
Cranial nerves 1-2 grossly intact
CN I: Olfactory nerve intact, able to identify alcohol swab, peppermint and coffee
CN II: Fundoscopic exam is normal with sharp discs, good red reflex and no vascular changes. Venous pulsation is present bilaterally. Pupils are 3mm and briskly reactive to light and accommodation Vision 20/20 both eyes (+) dryness
CN III, IV, VI: On observation, no eye deviation at primary gaze. The right eye does not adduct nor gaze up when the patient is gazing to the left, negative for diplopia in all direction of gaze. Extra ocular movement intact, no ptosis, nystagmus, PEERLA
CN V: Reports positive sensation with sharp and dull stimulation bilaterally. On observation corneal responses are intact. Able to open mouth, clench teeth. With palpation able to clench with masseter and temporal muscles. Good muscle strength and resistance present. Negative jaw jerk test
CN VII: Face asymmetrical facial droop with abnormal Ipsilateral unable to raise left brow and has asymmetric smile, unable to puff cheeks or poke lips out
CN VIII: Hearing is normal to rubbing fingers. Rinne and Webber test are with desired requirements. AC>BC in both ears. Romberg’s test is negative (+) external pain
CNVIIII, X: Palate elevates symmetrically. Uvula rises in midline on phonation. Swallow and gag reflex intact
CNXI: Head movement and shoulder shrug normal
CN XII: Tongue is not at midline when protrude, no tremor or atrophy
Nose: Septum midline and patent, no discharge or epistaxis, no septal deviation, perforation or polyps
Neck/Throat: Teeth in good repairs, buccal and lingual mucosa pink and moist, no lesion or halitosis, uvula rises on phonation and its midline gag reflex present
Mouth:
Pulmonary: Symmetrical thorax, no tenderness, lungs clear on auscultation and percussion, no adventitious sounds, wheezing, no hemoptysis, dyspnea, no cough or pleuritic pain
Cardiac: S1 S2 regular rate, no murmurs, no gallops, no rubs, no carotid bruits, upstroke brisk, PMI non-displaced and tapping to palpation, and no edema, last EKG 1/
Abdomen: Round, symmetrical, soft non-tender, no rebound, no guarding, peristalsis and bowel sounds in all 4 quadrants, no abdominal bruit with auscultation, no lesions or scars
Genitourinary: Urine sample in the office shows no visual hematoma, no edema or swelling to scrotum or testicle
Musculoskeletal: (+) Joint tenderness and weakness to the left side of face, (+) limited ROM, no neck or lower back pain, muscle strength and upper and lower extremity 5/5 throughout
Neuro: Pt A+O x 4, (+) slurred speech, memory intact, no pins and needles, tremors or involuntary movement to the extremities
Psych: Depression scale used, pt answered questions within normal range
(Assessment)
Diagnostic Test: The diagnosis is made by physical examination. There isn’t any diagnostic test for the diagnosis. But the electromyogram can be helpful to determine the extent of the nerve damage
Most Likely Diagnosed:
Bell’s Palsy-Characterized by facial paralysis, frequently resolving completely without treatment. Unilateral paralysis of the face. The etiology is uncertain, but the paralysis is thought to be due to an inflammation of CN VII, secondary to a viral infection, a large percentage being herpes simplex virus
Differential Diagnosis
Bell’s Palsy
CVA-The medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel
Trigeminal Neuralgia-Nerve disorder that causes a stabbing or electric-shock-like pain in parts of the face
Plan:
Continue all schedule medications
Amlodipine Besylate 5mg oral tab
Trazodone HCL 100mg oral at HS
Prednisone 20mg oral tab po bid (tapering doses)
Oxycodone HCL 5mg oral tab po Q 8 hrs PRN
Lotrison 1-0.05% external cream
Gabapentin 300mg oral caps at HS
Start- artificial tears to effected left eye
Supportive care counseling
continue with life style changes (diet and exercise)
PT referral
Neuro evaluation
Continue with Neuro follow up
Follow up with office in 2 wks
in the event of emergency please go to the ER
