NU 685 Comprehensive Medical Assessment I (Full Comprehensive Medical Assessment)
Date of Examination: February 11, 2023
Source of Medical History: The patient is the primary source of information and is a reliable historian.
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Subjective / Chief Complaint: “I’m here for a referral for therapy.”
Present Illness: A 58-year-old white male presents to the office today seeking a referral for physical therapy and a refill for pain medication. The patient reports a diagnosis of Bell’s Palsy six months ago, presenting with left facial droop and asymmetrical facial movement. He describes experiencing severe pain, primarily on the left side of his face, radiating from the ear to the forehead. The pain is constant, rated as 10/10, and had a sudden onset. He characterizes the pain as stiff and pulling to one side, rendering him unable to move his forehead. The patient reports using oxycodone 5mg every 8 hours, which provides some relief. He expresses sadness regarding his diagnosis and eagerly anticipates its resolution. He mentions, “I can’t even close my left eye.” Additionally, he believes that therapy will expedite his recovery and is motivated by concerns about his facial appearance in his job.
The Role of Healthcare policies in safeguarding the health and well-being of our population
Past Medical History:
Hypertension (HTN)
Psoriasis
Sarcoidosis
Bell’s Palsy
Depression
Facial Cell Carcinoma
Acute Sinusitis
Squamous Cell Carcinoma of the skin (left cheek)
Past Surgical History:
Removal of Squamous Cell Carcinoma on January 5, 2019
Fractured nose 30 years ago
Medications:
Amlodipine Besylate 5mg oral tablet
Trazodone HCL 100mg oral tablet at bedtime
Prednisone 20mg oral tablet twice daily (tapering doses)
Oxycodone HCL 5mg oral tablet every 8 hours as needed
Lotrison 1-0.05% external cream
Gabapentin 300mg oral capsules at bedtime
Allergies: Penicillin (causing hives)
Family History:
Mother – GERD, Atrial Fibrillation (AFIB), HTN
Father – Psoriasis, Diabetes Mellitus (DM)
Social History: The patient works in interior design consultation for a large successful corporation. He has been with this company for 25 years. Although divorced for 2 years, he is in a 2-year relationship with a significant other who is very supportive. He has two children, both away at college.
Alcohol: Denies substance abuse or illicit drug use. Denies smoking or vaping.
Immunizations:
Pneumococcal-23: Received on 1/11/2020
Hepatitis B (completed): Received on 8/11/2020
Influenza: Received on 10/10/2022
COVID-19 vaccine: Received last booster on 11/22
Review of Systems:
General/Constitutional: Reports fatigue and a 15lb weight loss over the past year.
Skin: History of facial Squamous Cell carcinoma removed from the left side of the face. Old surgical scars are evident. Denies lumps, itching, dryness, or changes in skin color. Last dermatological examination was on 12/2022.
Head: Experiences left-sided pain but denies dizziness. Unable to move the forehead.
Eyes: Uses corrective lenses for the past 3 years, with no recent change in vision. Denies eye pain. Reports the last eye examination and optometrist examination on 8/13/2022.
Ears: Reports pain around the outer ear but denies infection, discharge, or hearing loss.
Nose: Denies recent cold, congestion, discharge, itching, hay fever, or nosebleeds.
Neck/Throat: Denies lumps, neck stiffness, or swelling.
Mouth: Has difficulty eating and experiences twisting to the right side of the face. Last dental examination was on 7/7/2022.
Pulmonary: Denies shortness of breath, non-productive cough, dyspnea, hemoptysis, wheezing, or pleuritic pain.
Cardiac: History of high blood pressure for which he is on medication. Experiences left-sided head pain but denies palpitations, dyspnea, orthopnea, angina, or edema. Last EKG was on 9/2022 and was normal.
Gastrointestinal: Denies pain in the umbilical area, nausea, vomiting, dysphagia, hemorrhoids, melena, constipation, or diarrhea. Bowel habits are unchanged. Last bowel movement was this morning.
Urinary: Denies incontinence of urine, dysuria, incomplete emptying of the bladder, or burning on urination.
Reproductive: Denies testicular pain or penile discharge. No family history of prostate disease. Sexually active and in a monogamous relationship with condom use.
Peripheral Vascular: Denies leg cramps, varicose veins, a history of blood clots, temperature changes in the leg, or ulcers.
Musculoskeletal: Reports joint tenderness and weakness on the left side of the face. Denies neck or lower back pain. Muscle strength in upper and lower extremities is 5/5.
Neuro: Denies seizures. Reports weakness, left facial paralysis, Bell’s Palsy, and headaches.
Hematology: Denies a history of anemia, easy bruising or bleeding, blood transfusions, or deep vein thrombosis (DVT).
Endocrine: Denies intolerance to heat and cold, thyroid disease, goiter, changes in voice, excessive sweating, polyphagia, polydipsia, or hirsutism.
Psych: Reports depression but denies a history of mental illness or suicide attempts.
Objective/ Physical Exam:
Vital Signs: BP: 122/80 (sitting); HR: 75; Temp: 97.6°F (oral); Weight: 240lbs; Height: 6’0″; BMI: 34.4; O2 SAT: 95% on room air
General/Constitutional: The patient is a well-dressed, well-nourished male with left facial paralysis and severe pain on the left side of his face. Speech is slurred, memory is intact, and questions are answered appropriately. The left side of the face is paralyzed, including the forehead. The patient has difficulty forming different facial expressions, indicative of CN VII alteration or malfunction.
Skin: An old surgical scar is visible on the left side of the face. No lumps or open areas
are noted.
HEENT (Head, Eyes, Ears, Nose, Throat):
Alert and oriented to person, place, and time. Appropriate behavior and speech. No gross focal deficits.
Cranial Nerves (CN) I and II: Grossly intact. CN I (Olfactory) is intact, and the patient can identify various scents. CN II (Optic) shows normal fundoscopic examination, with sharp discs, good red reflex, and no vascular changes. Vision is 20/20 in both eyes, and the patient reports dryness.
CN III, IV, and VI: No eye deviation at primary gaze. Extraocular movement is intact, and there is no diplopia. No ptosis, nystagmus, or relative afferent pupillary defect (RAPD).
CN V: Reports positive sensation with sharp and dull stimulation bilaterally. Corneal responses are intact. The patient can open his mouth and clench his teeth. Masseter and temporal muscles exhibit good strength and resistance. The jaw jerk test is negative.
CN VII: The patient displays an asymmetrical facial droop with an abnormal ipsilateral inability to raise the left brow and an asymmetric smile. The patient is unable to puff his cheeks or protrude his lips.
CN VIII: Hearing is normal to finger rubbing. Rinne and Weber tests meet desired criteria. Air conduction (AC) is greater than bone conduction (BC) in both ears. Romberg’s test is negative, indicating no balance issues.
CN IX and X: The palate elevates symmetrically, and the uvula rises in the midline during phonation. Swallow and gag reflexes are intact.
CN XI: Head movement and shoulder shrugging are normal.
CN XII: The tongue is not at the midline when protruded, and no tremor or atrophy is noted.
Nose: The septum is midline and patent, with no discharge or epistaxis. There is no septal deviation, perforation, or polyps.
Neck/Throat: The teeth are in good repair, and the buccal and lingual mucosa appear pink and moist. No lesions or halitosis are present. The uvula rises on phonation, and it is in the midline. The gag reflex is present.
Mouth:
Pulmonary: The thorax is symmetrical with no tenderness. Lungs are clear on auscultation and percussion, with no adventitious sounds, wheezing, hemoptysis, dyspnea, cough, or pleuritic pain.
Cardiac: Heart sounds (S1 and S2) are regular, with no murmurs, gallops, or rubs. Carotid bruits are absent. The point of maximum impulse (PMI) is non-displaced and has a tapping quality on palpation. There is no edema, and the last EKG was performed on 1/
Abdomen: The abdomen is round, symmetrical, soft, and non-tender. There is no rebound or guarding. Peristalsis and bowel sounds are audible in all four quadrants. No abdominal bruit is detected on auscultation, and there are no lesions or scars.
Genitourinary: Urine sample in the office shows no visual hematoma, edema, or swelling in the scrotum or testicle.
Musculoskeletal: The patient experiences joint tenderness and weakness on the left side of his face. There is limited range of motion (ROM), but the patient denies neck or lower back pain. Muscle strength in the upper and lower extremities is 5/5 throughout.
Neurological: The patient is alert and oriented to person, place, and time. He exhibits slurred speech, but memory is intact. There are no signs of pins and needles, tremors, or involuntary movements in the extremities.
Psychiatric: The depression scale was used, and the patient’s answers fall within the normal range.
(Assessment)
Diagnostic Test: The diagnosis is made primarily through physical examination. There are no specific diagnostic tests for the diagnosis. An electromyogram may be considered to determine the extent of nerve damage.
Most Likely Diagnosis:
Bell’s Palsy: This condition is characterized by facial paralysis, often resolving without treatment. It presents as unilateral facial paralysis and is thought to result from inflammation of cranial nerve VII, typically due to a viral infection, with herpes simplex virus being a common cause.
Differential Diagnosis:
1. Bell’s Palsy
2. Cerebrovascular Accident (CVA): Also known as a stroke, it occurs when blood flow to a part of the brain is interrupted due to a blockage or rupture of a blood vessel.
3. Trigeminal Neuralgia: A nerve disorder causing stabbing or electric-shock-like pain in facial areas.
Plan:
Continue all scheduled medications:
– Amlodipine Besylate 5mg oral tablet
– Trazodone HCL 100mg oral tablet at bedtime
– Prednisone 20mg oral tablet twice daily (with tapering doses)
– Oxycodone HCL 5mg oral tablet every 8 hours as needed
– Lotrison 1-0.05% external cream
– Gabapentin 300mg oral capsules at bedtime
Initiate the use of artificial tears for the affected left eye.
Provide supportive care counseling.
Continue with lifestyle changes, including diet and exercise.
Refer the patient for physical therapy (PT).
Arrange a neurology evaluation.
Schedule a follow-up with the neurologist.
Schedule a follow-up office visit in 2 weeks.
In the event of an emergency, advise the patient to go to the emergency room.
NU 685 History and Physical I (Full H & P)
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
Dont wait until the last minute.
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