Episodic/Focused SOAP Note: CASE 3: Drooping of Face
Patient Information:
Initials: D.P
Age- 22 years
Sex: Female
Race: African American
S.
CC (chief complaint): “My left side of the mouth slants when I smile.”
HPI: D.P. is a 22-year-old AA female who presents with complaints of the left side of the mouth slanting when she smiles. She first noticed the left-sided slanting today in the morning when she looked in the mirror. D.P. also reports that she has been experiencing some intermittent pounding headaches in the last few days. Besides, she noticed a decreased sense of taste when brushing her teeth in the morning. The face droop and loss of taste had no specific triggering factors, nor have they improved since they started. The client was scared that she could have a stroke which is uncommon at her age.
Current Medications: Albuterol HFA 1-2 puffs during Asthma exacerbations.
Allergies: Allergic to dust mites and pollen. No drug or food allergies.
PMHx: The patient has a history of Asthma since she was six years. She has been admitted thrice due to asthma attacks. The Asthma is controlled, and the last attack was more than five years ago. Her immunization is current; her last TT was in 2019; her last Flu show was in June 2022. No surgical history.
Soc Hx: The patient is an intern at the State Department for Social Protection. She graduated with a degree in Sociology six months ago. She lives with her parents and two younger siblings. Her hobbies include painting and traveling. Her exercise habits include walking to and from work for about 15 minutes which has helped her remain fit. She reports having three meals per day. She drinks 2-3 glasses of vodka on weekends and smokes recreational marijuana. She denies smoking tobacco or using illicit drug substances.
Fam Hx: Her maternal grandmother has HTN and a history of MI. The paternal grandfather had Alzheimer’s dementia. Her parents and siblings are alive and well.
ROS:
GENERAL: Negative for fever, weight changes, chills, or increased fatigue.
HEENT: Reports left-sided face drooping. Eyes: No changes in vision, excessive tearing, or eye pain. Ears: No ear pain, discharge, or hearing loss. Nose: No rhinorrhea or sneezing. Throat: No sore throat or hoarseness.
SKIN: No rashes, bruises, or itching.
CARDIOVASCULAR: No chest pain, palpitations, dyspnea with activity, or edema.
RESPIRATORY: Negative for breathing difficulties, cough, wheezing, or sputum.
GASTROINTESTINAL: No GI discomfort or altered bowel patterns.
GENITOURINARY: Negative for urinary or vaginal symptoms. LMP-2 weeks ago.
NEUROLOGICAL: Positive for headaches, left-sided facial drooping, muscle weakness, and numbness; a decreased sense of taste. Denies dizziness, syncope, numbness, or tingling sensations.
MUSCULOSKELETAL: No muscle pain, joint pain, stiffness, or limitations in movement.
HEMATOLOGIC: No history of bleeding, anemia, or blood transfusion.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No history of mood or anxiety symptoms.
ENDOCRINOLOGIC: No excessive sweating, cold or heat intolerance, acute thirst, or excessive hunger.
ALLERGIES: Positive history of Asthma.
O.
Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e. General: Head: EENT: etc.
Vital Signs: BP- 110/74; RR-16; HR-92; TEMP-98.4; HT-5’4; WT-130; BMI-22.3
GENERAL: AA female client in her early 20s. The patient is calm, alert, and in no distress but is anxious. She is neat and dressed appropriately. Her speech is logical, with a normal rate and volume.
HEENT: Mask-like face appearance. Limited ability to wrinkle the forehead and smile on the left side. The left side of the face is flat and lacks expressions; Eyes: Reduced ability to tear; Inability to close the left eye; PERRLA. Ears: TMs are patent and shiny. Nose: Patent nostrils; well-aligned nasal septum. Throat: Intact Tonsillar glands.
RESPIRATORY: Uniform chest expansion with smooth unaided respirations. Lungs clear bilaterally.
CARDIOVASCULAR: Regular heart rate and rhythm. S1 and S2 noted. No heart murmurs or gallop sounds.
NEUROLOGICAL: Left-sided facial muscle paralysis. Impaired taste sensation. Normal gait and posture.
Diagnostic results:
MRI- This can help detect facial nerve inflammation and rule out tumors that compress or affect the facial nerve.
A.
Differential Diagnoses
Facial paralysis: This is an acute paralysis of cranial nerve VII. It is characterized by abrupt, unilateral peripheral facial nerve palsy. It involves a drawing sensation and paralysis of all facial muscles on the affected side (Yang & Dalal, 2021). Facial paralysis is a presumptive diagnosis based on the paralysis of the patient’s left side of the face. This has caused face drooping, a mask-like face appearance, and limited ability to wrinkle the forehead and smile on the left side. Besides, the left side of the face is flat and lacks expressions, and the client has a reduced taste sensation, which is characteristic of Facial paralysis.
Ramsay Hunt syndrome: This is a rare manifestation of herpes zoster that affects the 8th cranial nerve ganglia and the geniculate ganglion of the facial cranial nerve. Clinical manifestations include severe ear pain with vesicles in the ear, transient or permanent facial paralysis, vertigo, and hearing loss (Jeon & Lee, 2018). The patient’s left-sided facial paralysis is consistent with Ramsay Hunt syndrome.
Lyme disease: This is a systemic infectious disease caused by Borrelia burgdorferi and occurs following a bite of an infected deer tick. If not treated, a patient progresses to complications like meningitis, facial paralysis, and peripheral neuritis (Shor et al., 2019). The patient’s left-sided facial paralysis makes Lyme disease a differential diagnosis.
Guillain-Barré Syndrome (GBS): This is an acute inflammatory demyelinating polyneuropathy that involves the peripheral nervous system. Demyelination of the peripheral nerves causes progressive motor weakness and sensory abnormalities (Malek & Salameh, 2019). This is a differential diagnosis owing to the patient’s facial muscle paralysis and a diminished sense of taste. However, the patient does not have ascending paralysis, which is characteristic of GBS.
Sarcoidosis: This is a granulomatous disorder of idiopathic cause that affects any organ. It causes isolated facial nerve palsy. This makes sarcoidosis a differential diagnosis due to the patient’s left-sided facial paralysis.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Jeon, Y., & Lee, H. (2018). Ramsay Hunt syndrome. Journal of dental anesthesia and pain medicine, 18(6), 333–337. https://doi.org/10.17245/jdapm.2018.18.6.333
Malek, E., & Salameh, J. (2019). Guillain-Barre Syndrome. Seminars in neurology, 39(5), 589–595. https://doi.org/10.1055/s-0039-1693005
Shor, S., Green, C., Szantyr, B., Phillips, S., Liegner, K., Burrascano, J. J., Jr, Bransfield, R., & Maloney, E. L. (2019). Chronic Lyme Disease: An Evidence-Based Definition by the ILADS Working Group. Antibiotics (Basel, Switzerland), 8(4), 269. https://doi.org/10.3390/antibiotics8040269
Yang, A., & Dalal, V. (2021). Bilateral Facial Palsy: A Clinical Approach. Cureus, 13(4), e14671. https://doi.org/10.7759/cureus.14671