Posted: October 3rd, 2022

MY ASSIGNED CASE
CASE STUDY three: Drooping of Face

A 33-year-old feminine involves your clinic alarmed about sudden “drooping” on the correct facet of the face that started this morning,. She complains of extreme tearing and drooling on her proper facet as properly.

Utilizing the Episodic/Targeted SOAP Template:
· Create documentation or an episodic/centered observe in SOAP format concerning the affected person within the case examine to which you have been assigned.

· Present proof from the literature to help diagnostic exams that might be applicable on your case.–

Glorious 45 (45%) – 50 (50%)
The response clearly, precisely, and completely follows the SOAP format to doc the affected person within the assigned case examine. The response completely and precisely offers detailed proof from the literature to help diagnostic exams that might be applicable for the affected person within the assigned case examine.
Good 39 (39%) – 44 (44%)
The response precisely follows the SOAP format to doc the affected person within the assigned case examine. The response precisely offers detailed proof from the literature to help diagnostic exams that might be applicable for the affected person within the assigned case examine.
Truthful 33 (33%) – 38 (38%)
The response follows the SOAP format to doc the affected person within the assigned case examine, with some vagueness and inaccuracy. The response offers proof from the literature to help diagnostic exams that might be applicable for the affected person within the assigned case examine, with some vagueness or inaccuracy within the proof chosen.
Poor zero (zero%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to doc the affected person within the assigned case examine. The response offers incomplete, inaccurate, and/or lacking proof from the literature to help diagnostic exams that might be applicable for the affected person within the assigned case examine.
· Checklist 5 completely different attainable situations for the affected person’s differential analysis, and justify why you chose every.–

Glorious 30 (30%) – 35 (35%)
The response lists 5 distinctly completely different and detailed attainable situations for a differential analysis of the affected person within the assigned case examine and offers a radical, correct, and detailed justification for every of the 5 situations chosen.
Good 24 (24%) – 29 (29%)
The response lists 4 to 5 completely different attainable situations for a differential analysis of the affected person within the assigned case examine and offers an correct justification for every of the 5 situations chosen.
Truthful 18 (18%) – 23 (23%)
The response lists three to 4 attainable situations for a differential analysis of the affected person within the assigned case examine, with some vagueness and/or some inaccuracy within the situations and/or justification for every.
Poor zero (zero%) – 17 (17%)
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Pattern Reply Drooping of Face – Episodic/Targeted SOAP

Drooping of Face – Episodic/Targeted SOAP
Affected person Info:
BM, 33-years previous F African American
S.
CC:
Drooping on the correct facet of the face.
HPI:
BM is a 33-year previous African American feminine who presents to the clinic with drooping on the correct facet of the face. The affected person complains that the signs began this morning upon waking up. The proper eye has consistently been tearing. She can not cease drooling. She denies any ache.
Present Drugs:
Multivitamin each day
Valtrex 500mg PO * three each day
Tylenol 325mg PO as wanted
Ibuprofen 20mg PO
PMH:
Bronchial asthma at childhood
Genital herpes, 2013.
PSH:
Cholecystectomy 2005
Tooth extraction 2000
Sexual/Reproductive Historical past
Heterosexual
PAP in June 2017 with regular outcomes
G1P1AO
Soc Hx:
The affected person works at an area restaurant and lives within the suburbs. She is a widow after the loss of life of her husband two years in the past. She sometimes drinks throughout occasions or with associates. She denies alcohol use dysfunction or substance abuse. She attends an area church service weekly. The affected person lives with the daughter.
Immunization Historical past:
All of the immunization information are updated. She receives tetanus, influenza, and flu shot six months in the past.
Fam Hx:
She has two brothers. One, 44, is identified with hypertension, whereas one other died 5 years in the past. The daughter, 14, is wholesome with no vital medical historical past. The husband, 35, died in a automotive accident with a historical past of hypertension and diabetes.
Life-style:
She lives along with her daughter in an space with a low fee of crime. She doesn’t train each day however tries to maintain match. She takes a medical checkup yearly. The affected person has wholesome help from household and associates.
ROS:
GENERAL:
The 33-year-old feminine affected person has no physique modifications, together with weight lack of achieve, for the final one 12 months. She seems frightened that her situation might worsen.
HEENT:
Eyes: No modifications or issues in imaginative and prescient. She took a watch examination a 12 months in the past. The report reveals no issues in imaginative and prescient however has issues, together with tearing.
Ears: No ear infections or discharge. No listening to difficulties.
Nostril: Sense of scent is unbroken with no nasal congestion or working nostril.
Throat: Tonsils usually are not enlarged, and no problem in swallowing.
NECK:
No historical past of ache harm or dislocation.
BREASTS: No modifications within the dimension or historical past of lesions.
Respiratory:
Pores and skin: No rashes or vital pores and skin situations.
CARDIOVASCULAR: No chest discomfort, murmurs, orthopnea, or edema.
RESPIRATORY:
No respiratory challenges, sputum, or coughing. Clear lung sounds.
GASTROINTESTINAL:
The affected person had no complaints of nausea, vomiting, or modifications within the bowel patterns.
GENITOURINARY:
No modifications in urinary patterns, ache, or incontinence. She has common menses however will not be sexually energetic at the moment.
NEUROLOGICAL:
No dizziness or paresthesia, pondering or reminiscence issues, twitching falls, or seizure.
MUSCULOSKELETAL:
No historical past of fractures, gout or arthritis.
HEMATOLOGIC:
No extreme bleeding or blood dysfunction.
LYMPHATICS:
No historical past of swollen lymph nodes.
PSYCHIATRIC:
No historical past of despair, nervousness, delusions, or suicidal ideas.
ENDOCRINOLOGIC:
No historical past of extreme thirst or irregular sweating.
ALLERGIES:
NKDA
O.
Bodily examination:
Important indicators: T 98.8F orally, 120/80, left-arm sitting, RR 18, P 76 common, wt 110lbs, ht 5’1, BMI 21.
Basic: A&O *three NAD, appears to be like snug.
HEENT: Oronasopharynx is obvious, extreme tearing, drooping of the correct facet of the face, gentle nasolabial flattening.
Neck: Carotid no bruit, JVD.
Chest/lungs: CTA AP&L.
Coronary heart: No murmur
ABD: Benign tabs *four, no suprapubic tenderness.
Genital: No cervical movement tenderness or exterior genitalia intact.
Musculoskeletal: Symmetrical muscle growth.
Neuro: CN II-XII and DTR intact, paresis on the affected facet of the face, and problem making facial expressions.
Pores and skin/lymph: No edema or cyanosis.
A.
Lab exams to rule out numerous issues
CBC
Monopost take a look at
HIV screening
Serum blood take a look at
Thyroid blood take a look at
Cerebrospinal fluid Assessment
Erythrocyte sedimentation fee

Diagnostics
CT scan
MRI
Chest X-ray
EKG
EMG
Glasgow comm]a scale
NIH stroke scale
Main Prognosis
Bell’s palsy – it’s a sudden feebleness of the muscle mass on the facet of the face. It causes the nerve to help the facial muscle mass to malfunction. The situation results in a drooping face. The situation resolves by itself inside six months (Heckmann et al., 2019). Psychotherapy is important to Help cease additional contraction of the muscle mass. It causes extreme tearing and the problem dropping eyes. The rationale for choosing Bell’s palsy as the first analysis is the presenting signs of sudden facial palsy (Cooper et al., 2017). Out there literature reveals that the reason for the situation is unknown. Analysis relates the situation to nerve compression or herpes simplex kind 1 (Cooper et al., 2017). One more reason for the first analysis is that the affected person has a historical past of genital herpes associated to the situation.
Differential Diagnoses:
a) Mastoiditis:
The situation happens after an an infection of the mastoid. One of many main causes of the illness is an ear an infection. The situation can result in pus-filled cysts. Some widespread signs embrace redness, swelling, tenderness, fever, and discharge (Induruwa et al., 2019). Antibiotics can be utilized to clear the situation, however in extreme instances, surgical procedure is important.
b) Lyme illness:
The situation is attributable to Borrelia bacterium. Ticks unfold the micro organism. It causes an increasing erythema migrans. It may trigger flu-like signs, bull’s eye sample, joint ache, and weak spot (Induruwa et al., 2019). The situation can clear with antibiotics. The illness has numerous phases, and the signs will deteriorate because it progresses throughout its three phases.
c) Parotid tumor:
The situation is a painless swelling of the jaw. It causes numbness and a pricking sensation. A few of the illness’s main causes embrace smoking, publicity to radiation, and dehydration (Zimmermann et al., 2019). Sufferers require surgical procedure to take away the tumor. The aim of eradicating the non-cancerous cells is that they’ll proceed rising and undermine a person’s well being.
d) Stroke:
Stroke happens when the mind’s blood provide is disrupted, thus stopping the mind cells from receiving adequate oxygen. It may trigger mind cells to die inside minutes. It requires emergency medical consideration (Zimmermann et al., 2019). Some widespread signs embrace paralysis of muscle mass, strolling difficulties, momentary lack of imaginative and prescient, fatigue, and light-headedness (Mueller et al., 2017). Some kinds of stroke embrace ischemic, hemorrhagic, and transient hemorrhagic stroke.
e) Guillain-barre syndrome:
Guillain-barre syndrome is a uncommon illness. It happens when the immune system intervene with the nerves. A few of the causes of the situation are acute bacterial or viral an infection. The signs current as tingling and weak spot of legs (Mueller et al., 2017). It impacts the opposite physique components progressively. The situation can result in paralysis. It’s a uncommon neurological dysfunction that requires therapy to keep away from issues.
Tetanus:
Tetanus is attributable to an an infection that upsets the nervous system. It results in aching muscle contractions. In some instances, it will probably undermine the respiratory system’s functioning, thus threatening life (Cooper et al., 2017). Some signs embrace jaw cramping, muscle spasms, muscle stiffness, headache, fever, sweating, and seizures.

References
Cooper, L., Branagan-Harris, M., Tuson, R., & Nduka, C. (2017). Lyme illness and Bell’s palsy: an epidemiological examine of analysis and danger in England. British Journal of Basic Observe, 67(658), 329-335.
Heckmann, J. G., City, P. P., Pitz, S., & Guntinas-Lichius, O. (2019). The Prognosis and Remedy of Idiopathic Facial Paresis (Bell’s Palsy). Medical Journal, 116(41), 692.
Induruwa, I., Holland, N., Gregory, R., & Khadjooi, Okay. (2019). The affect of misdiagnosing Bell’s palsy as acute stroke. Medical Medication, 19(6), 494.
Mueller, S. Okay., Iro, H., Lell, M., Seifert, F., Bohr, C., Scherl, C., … & Traxdorf, M. (2017). Microcystic adnexal carcinoma (MAC)-like squamous cell carcinoma as a differential analysis to Bell´ s palsy: evaluate of tips for refractory facial nerve palsy. Journal of Otolaryngology-Head & Neck Surgical procedure, 46(1), 1-5.
Zimmermann, J., Jesse, S., Kassubek, J., Pinkhardt, E., & Ludolph, A. C. (2019). Differential analysis of peripheral facial nerve palsy: a retrospective medical, MRI and CSF-based examine. Journal of Neurology, 266(10), 2488-2494.

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