INITIAL EVALUATION

GENERAL INFORMATION
Pt.’s Name: J.N.G
Age: 28
Sex: F
Address: 490 Pureza Street Sta. Mesa Manila
Civil Status: Single
Handedness: R
Occupation: Dentist
Referring Doctor: Dr. A
Referring Unit: UERMMMCI
Rehab Doctor: Dr. B
Date of Referral: March 15, 2018
Date of Consultation/Admission: March 15, 2018
Date of IE: March 17, 2018
Diagnosis: L Bell’s palsy

SUBJECTIVE:
A. Chief Complaints (c/c):
Pt c/o minimal difficulty in moving the L side of her face especially the lip area as manifested by feeling
of asymmetric lip deviation upon waking up in the morning

B. Patient’s Goal:
 To be able to regain normal symmetry and strength of facial muscles

C. History of Present Illness:

~ March 14, 2018 pt felt a loud ringing sound in her L ear and twitching of her L upper eyelid
while watching movie, she disregarded it and thought that she was just tired. When she got home the loud
ringing sound in her L ear and twitching of her L upper eyelid no longer manifested.

~On the morning of March 15, 2018 when pt. woke up she felt the paresis and drooping of the L
side of her face and she cannot talk and chew properly, there’s a drooling on the L side of her face. Pt. cannot
close her eyes tightly and felt dryness of her eyes. She was immediately rushed to the ER. Dr. A performed a
Clinical Examination such as Otoscopy, Serologic Testing and Electromyography to confirm the suspected dx
of the pt. and after the tests was then diagnosed as Bell’s palsy

D. Past Medical History:

(-) HTN
(-) DM
(-) CVA
(-) Heart Condition
(-) Pulmo Condition
(-) Trauma

E. Familial medical History:

MOTHER FATHER
HTN (-) (+)
DM (+) (-)
CVA (-) (-)
Heart Condition (-) (-)
 Pulmonary Condition (-) (-)
Trauma (-) (-)

F. Personal/Social History:
 Type of Personality: Type A
 Diet: Healthy and Controlled Diet
 Lifestyle: Active
 Non- Smoker
 Alcoholic Beverage Consumption: Occasional
o Type of Alcoholic Beverage: Tequila, Beer

G. Home/ Work/ School Situation:

Upper extremity:
Lower extremity:

H. Laboratory Procedure:
Date Laboratory Test Results
March 15th 2018 Otoscopy (+) Redness
(+) Swelling
March 15th 2018 Serologic Test (-) Measles
(-) HIV
(-) Rubella
(-) Syphillis
March 15th 2018 Electromyography (+) Nerve Damage

Findings:
Significance:

I. Medications:

Medication Dosage / Frequency Indication

Prednisolone 50mg 2x a day steroid medication used to treat certain types
of allergies, inflammatory conditions,
autoimmune disorders.
Eye Drops 2-3 drops/ PRN For eye lubrication

OBJECTIVE:
A. Vital Signs

BP: 120/80 mmHg

RR: 18 cpm
PR: 86 bpm
Temp: 36 °C/°F

Findings: pt’s VS are all WNL

Significance: for baseline purposes during the PT treatment

B. Ocular Inspection
 Amb s AD
 Mesomorph
 Not in apparent pain/distress
 Alert, Coherent, Cooperative
 (+) ptosis of L eye
 (+) facial asymmetry
  (+) nasolabial fold asymmetry L>R
 (-) drooling
 (-) redness on face, B UE, LE and trunk
 (-) trophic skin changes on face, B UE, LE and trunk

C. Palpation
 Normothermic on all exposed
 (-) tenderness on face, B UE and LE
 (-) ms spasm on face, B UE and LE
 (-) edema on face, B UE and LE

D. Neurological Evaluation
a. Superficial Sensory Testing
Pt was assessed as to pin prick, light touch and thumb for pressure respectively and all areas of face were
found to be 100% intact. Sugar was used for checking of the taste sensation.
Area Stimulus R L
Forehead Cotton (light 100% 100%
touch)
Pointed pin 100% 100%
(pain)
Thumb 100% 100%
(pressure)
Cheeks Cotton (light 100% 100%
touch)
Pointed pin 100% 100%
(pain)
Thumb 100% 100%
(pressure)
Chin Cotton (light 100% 100%
touch)
Pointed pin 100% 100%
(pain)
Thumb 100% 100%
(pressure)

Findings: Pt has intact sensation as to light touch, pain, and pressure on all areas of the face and intact
taste sensation
Significance: to r/o trigeminal nerve affectation and CNS affectation
++ ++
b. Reflex Testing
 DTR/MSR
o Jaw (trigeminal) ++ ++ ++ LEGEND:
++ 0 Absent
o Biceps (C5, C6) + Diminished (hyporeflexia)
o Triceps (C7, C8) ++ ++ ++ Average (normal)
o Hamstrings (L5, S1, S2) ++ ++ +++ Exaggerated (brisk)
++++ Clonus, very brisk (hyperreflexia)
o Patellar (L2, L3, L4)
o Ankle (S1, S2)

Findings: Normoreflexia on B UE and LE

Significance: Intact reflex arc

c. Cranial nerve testing

 CN MATERIAL PROCEDURE Response

I Item to smell 1. Ask them if they smell something (COFFEE) Can smell

II Something to read 1. Hold penlight to their eye Even pupil constriction

Penlight 2. Make pt read something Can read

III Pen light 1. Make pt follow PT’s finger c their eyes. (UP, Eye follows finger
DOWN, IN)
Pupil reacts
2. Make pt open their eyes, shine light on it,
check for pupil reaction.

IV, Penlight Track pen s head movement Able to follow stimulus

VI

V Cotton Corneal reflex N sensation

(-) Eye blinks

(-) Able to contract mm

VII Something to taste Make pt do random facial expression Able perform facial
expressions
- Eyebrow raising
- Close eyes
- Wrinkling nose
- Pucker lip

VIII PT snaps finger on Locate where the sound came from Able to hear and localize
different direction sound

IX, Swallow Make pt swallow Able to swallow

X

XI None 1. Make pt shrug his shoulders, and resist the No weakness

motion
Able to raise and resist
2. Make pt turn head from side to side (grade 5)

XII None 1. Make pt show his tongue Pt can move tongue

2. Make pt move it in all direction No deviation on either

side

Findings: Pt presents c N or intact CN except CN V absent motor function

Significance: to confirm extent of injury and r/o nerve affectation

E. Range of Motion
All major joints of UE & LE were actively and passively assessed using standard goniometer and all were
found to be WNL, pain free and c N EF.
 F. Facial Muscle Testing
Facial muscles on B sides of the face are tested and were graded (N) / functional, except for the ff.
L levator labii superioris WF
L depressor anguli oris WF

Findings: Pt present c weakness of the ff muscles:

L levator labii superioris
L depressor anguli oris
Significance: findings predisposes the pt to have minimal difficulty in performing facial expressions & also in
feeding. This may also be the cause why pt feels asymmetrical lip deviation upon waking up in the morning.

G. Special Test

Special Test Procedure Result

Bell’s Phenomenon Pt close eyes (+) complete closing c slight
rolling of R eye
Chvostek Sign/Test Tapping R cheek over the parotid (-) twitching of the ipsilateral
gland facial muscles
Marcus Gunn Mouth opening (-) elevation of eyelid
Findings: Pt still presents c (+) Bell’s phenomenon c emphasis to the incomplete to complete closing of eyes
and same findings regarding slight rolling of eyes

H. Activities of Daily Living/ Outcome Measurement

Pt. is independent
 Activities of Daily Living
 Instrumental Activities of Daily Living

ASSESSMENT:
PT Diagnosis:
 Musculoskeletal Pattern C: Impaired muscle performance
 Musculoskeletal Pattern A: Primary Prevention/Risk Reduction for Skeletal Demineralization
PT Impression:

Pt. was medically diagnosed with Bell’s palsy secondary to lower motor neuron lesion, further manifested by (L) facial
muscle weakness, leading to facial asymmetry resulting to difficulty in ADLs such as chewing, talking and closing of the
eye lids.

Prognosis:

Pt. has good prognosis d/t young age, no swelling present. However, slight facial asymmetry is already present. Pt. is
consistent on going to her therapy sessions; also cooperative in all treatment sessions; emotionally, physically and
financially stable with no co-morbidities present.

Problem List:
1. Facial asymmetry
2. WF muscle strength as manifested by the feeling of lip asymmetry upon waking up in the morning
a. L levator labii superioris
b. L depressor anguli oris

Long Term Goal:

Rehabilitative: Pt would be able to have an increased facial muscle strength to correct facial asymmetry and to
express facial expressions within 4 months PT
Participative: Pt would be able to communicate s difficulty using verbal and facial expressions within 4 months of
PT
 Preventive: Pt would be able to prevent further paresis of facial muscles and other secondary complications from
manifested symptoms of difficulty in talking and dysphagia and dryness of eyes within 6 months of PT

Short Term Goal:

1. Pt will exhibit increase in muscle strength of the ff ms p 3 wks of PT session
a. L levator labii superioris
b. L depressor labii inferioris

PLAN:
A. Prescribed PT Management
1. IRR on (L) side of face X 20 mins to promote blood flow and nerve healing of the face
2. ES on (L) motor points X 2mins X on each motor points for muscle stimulation
o Occipitofrontalis
o Corrugator supercilli
o Orbicularis Oculi
o Zygomaticus majot and minor
o Levator labii superioris and levator labii alaeque nasi
o Buccinator
o Orbicularis oris
o Mentalis, depressor anguli oris, depressor labii inferioris
3. Effleurage on B side of face x 10mins for facial muscle relaxation
4. Facial exercises x 10 SH x 10 reps x 3 sets to gain muscle strength of facial ms
o Eyebrow raising
o Drawing eyebrows together
o Eye closing
o Wrinkling of nose
o Depressing angles of mouth
o Smiling with teeth shown
o Smiling c mouth closed
o Pouting
o Drawing lower lip downward
B. Suggested PT Management
 Acupuncture
 Vitamin therapy
 Electromyography (EMG) biofeedback
C. Home/Ward Instruction
1. Facial muscle exercises x 10 reps x 3 sets to maintain muscle mobility
a. Eyebrow raising
b. Drawing eyebrows together
c. Eye closing
d. Wrinkling of nose
e. Depressing angles of mouth
f. Smiling with teeth shown
g. Smiling c mouth closed
h. Pouting
i. Drawing lower lip downward
2. Facial massage: Do self-effleurage on B face c baby powder in front of mirror x 5-10 mins for muscle
relaxation

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Signature over Printed Name