Case Study Soap Note Bell Palsy

Week 10 SOAP Note

SUBJECTIVE DATA:

        Chief Complaint (CC):  “I can’t move the right side of my face.”

History of Present Illness (HPI):   A 16 year-old Caucasian female presents complaining of right-sided facial paralysis with associated eye and mouth drooping.  Symptoms began suddenly, were present when she awoke this morning, and have been constant without relief or exacerbation since.  She has tried massaging her face, but it did not relieve symptoms.  The patient denies facial pain and sensory deficit.  She also denies weakness or paralysis of right extremities and says paralysis is localized to her face only.  The patient denies visual disturbances, double vision, headache, gait pattern change, fever, dysphagia, and neck pain or swelling.  There was no recent or previous head or facial trauma.  Her mother says the patient has had no change in level of consciousness or confusion.  The patient reports pain behind her right ear that started two days prior, drooling from the right side of her mouth, and excessive tearing of the right eye.  She has never smoked or taken oral contraception, exercises daily, eats a healthy diet, and avoids trans fats, sugar, and fried foods.  Her mother denies a family history of hyperlipidemia, heart attack, and stroke.

Medications:  

1. Claritin (loratadine) 10mg daily
2. Nitrofurantoin 100mg HS

Allergies:  No known drug allergies

Past Medical History (PMH):

Seasonal allergic rhinitis

Vesicoureteral reflux diagnosed at 6 months old—resolved by age 3

Chronic urinary tract infections

Past Surgical History (PSH):  No previous surgeries

OB/GYN History:  No history of contraceptive use.  Patient has never been sexually active.

Personal/Social History:  Patient has never used tobacco, alcohol, or illicit drugs.  She plays several sports and exercises daily.  The patient eats a healthy and balanced diet.  She does not drink caffeine or sugar and consumes water and calorie-free Gatorade only.  The patient avoids sugary foods, trans fats, and fried foods.  All the food her mother prepares is baked or grilled.  

Immunizations:  

• Tdap and Hepatitis A at age 11
• Menactra at age 11 and a booster 6 months ago
• Gardasil 9 series between the ages of 11 and 12
• Flu immunization yearly, last was October 2017
• All other immunizations are up-to-date

Family History:  Father, mother, sister, and brother are alive and have no significant medical history.  No other family members have a history of cancer or unexplained death before the age of 50.  All four grandparents are living and were diagnosed with hypertension after the age of 65.  There is no family history of myocardial infarction, stroke, clotting disorders, blood clots, and hyperlipidemia.

Review of Systems:

        General:  Patient denies fever, fatigue, decreased appetite, fatigue, and is feeling well.

        Skin:  Denies new lesions, rash, pruritus

HEENT:  Patient denies visual disturbances but reports right eyelid drooping and excessive tearing of the right eye.  She denies sensory facial sensory deficit, ear pain inner and outer, ear drainage, decreased hearing, sore throat, headache, and runny nose.  The patient reports drooling from the right side of her mouth with associated drooping.  

        Neck:  Patient denies neck pain, swelling, or masses.

        Respiratory:  Patient denies cough, dyspnea, and wheezing.

        Cardiovascular:  Patient denies chest pain, palpitations, syncope, dizziness, and edema.

        Gastrointestinal:  Patient denies abdominal pain, diarrhea, constipation, N/V

Musculoskeletal:  Patient denies muscle pain or weakness, joint pain, stiffness, and

weaknss.

Genitourinary:  Patient denies urinary frequency, urgency, dysuria, episodes of incontinence, burning on urination, bladder spasms, and dysuria.

Neurological:  Patient denies sensory deficit of the face but reports paresthesia of the right side of the face with right eye drooping and right mouth drooping.  She also denies numbness, tingling, and weakness of extremities and all other parts of the body.  Her and mother deny change on level of consciousness, confusion, and syncope.

OBJECTIVE DATA:

General:   132 lbs, 5’5’’ tall, BMI 22.0, BP 106/64, P 64, T 97.2, RR 16, Pulse Ox 99% on room air

SKIN:  No rashes, skin lesions, skin temperature changes, or discoloration.

HEENT:  Head is normocephalic and symmetrical, PERRLA.  No scalp abnormalities, lesions, or lacerations.  No sclera or conjunctival erythema, inflammation, or discoloration.  Snellen examination reveals 20/20 OS, 20/20 OD, and 20/20 OU, uncorrected.  Visual fields intact, no EOM, and eye movement is symmetrical without limitation or weakness bilaterally.  Right eye lid drooping with excessive tearing.  There is no purulent eye drainage bilaterally.  Left eye lid has no drooping or excessive tearing.   Right side of the mouth drooping, and there is associated drooling.  Speech is slightly slurred.  Oral mucosa pink and moist, and there is no tongue swelling.  Pharynx and tonsils are free of erythema, inflammation, and exudate.  TMs free of erythema, inflammation, and there is no effusion.  Auditory canals free of exudate, erythema, and inflammation.  External auditory canals free of inflammation and erythema, and there is no tenderness or erythema of the pinna, external auditory canal, or over the mastoid.  

Neck:  No lymphadenopathy, tenderness, or masses palpated,

Chest/Lungs:  Lungs clear all lobes with no adventitious sounds including wheezes, rales, and rhonchi.  Symmetrical chest wall expansion with inhalation and expiration.

Heart/Peripheral Vascular:   HRR with S1 and S2 sounds.  No S3, S4, gallops, rubs, or murmurs auscultated.

Abdomen:  Abdomen is symmetrical and non-distended.  No tenderness on palpation, bowel sounds normoactive x4 quadrants, no splenomegaly or hepatomegaly.

Musculoskeletal:  Normal ROM in all extremities, and there is no muscle or joint redness or swelling.  Strength 5/5 in all extremities and equal bilaterally.  Gait without deficit.