MORNING REPORT

(1stSHORT CASE)

BELL’S PALSY

Presented by : Nur Ekawaty

DEPARTEMEN KEDOKTERAN FISIK DAN REHABILITASI

FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
Data Base (September 21st 2021)
Patient Identity
Name : Mr.Y
Age : 24 y.o
Address : makassar
Religion : Islam
Occupation : driver online (maxim)
Ethnic : bugis
Marital status : married
Insurance : BPJS
Date of examination : 21st September 2021
Referred from Neurology Outpatient Clinic with Bell’s Palsy 2
 Anamnesa
Chief Complain :
the patient's face is tilted to the left

History of present illness :

The patient's face has turned to the left since last week. Initially the patient felt
cramps in the right face around 04:00 pm, finally at 05:00 pm the patient felt a
thick feeling in the facial area and when he looked in the mirror he saw that his
face was tilted to the left. The right eye couldn’t blinked and then couldn’t
closed his right eye properly. His smile is not symmetrical and he difficult to
drinked and gurgling because water leakage to the left lip. He can speak clearly.
There was no weakness at the arms and legs. There was no complain about
bowel and bladder. After a week of treatment with a neurologist, he was finally
referred to PMR for physical therapy and rehabilitation

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HISTORY OF PAST ILLNESS

• History of hypertension, diabetes mellitus, malignancy and trauma were denied
• He did varicella before the complain happen
• diagnosed parese N VII a week ago (improved)

HISTORY OF PSYCHOSOCIOECONOMY
•The patient lives in makassar with his wife, son and his mother
•Patient working as a driver and working for 12 hours a day
•He usually sleep with fan directly on his face.
•He has one son and lived with his child , his wife and parents

History of Medicamentosa
From Neurology
• Methyprednisolone 8 mg 4x3 PC
• Omeprazole 20 mg 2x1 PC
• Folavit 2x20mg
• Antasida syrup 3x1 PC
• Mecobalamin 3x500mg
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PHYSICAL EXAMINATION
• GENERAL STATUS
• Consciousness : Composmentis
• Vital Sign :
• BP : 110/80 mmHg
• Pulse : 80 x/minute
• RR : 20 x/minute
• Temp : 36,50C
• Communication : Good
• Nutritional Status : Body Weight : 66 Kg
Body Height : 167 cm
BMI : 23.66 kg/m2 (Normal)
• Internal status : Integumentum, chest, abdomen are WNL
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MUSCULOSKELETAL STATUS
NECK ROM MMT
Flexion F (0-450) 5
Extension F (0-450) 5
Lateral bending F/F (0-450) 5/5
Rotation F/F (0-600) 5/5

TRUNK ROM MMT

Flexion F (0-800) 5

Extension F (0-300) 5
Lateral bending F/F (0-350) 5

Rotation F/F (0-450) 5/5

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SHOULDER ROM MMT

Flexion F/F (0-1800) 5/5

Extension F/F (0-600) 5/5

Abduction F/F (0-1800) 5/5

Adduction F/F (0-450) 5/5

Internal rotation F/F (0-700) 5/5

External rotation F/F (0-900) 5/5

ELBOW ROM MMT

Flexion F/F (0-1500) 5/5

Extension F/F (1500-0) 5/5

Supination F/F (0-900) 5/5

Pronation F/F (0-900) 5/5

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WRIST ROM MMT

Flexion F/F (0-800) 5/5

Extension F/F (0-700) 5/5

Ulnar deviation F/F (0-300) 5/5

Radial deviation F/F (0-200) 5/5

THUMB ROM MMT

Flexion
MCP F/F (0-900) 5/5
IP F/F (0-800) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-700) 5/5
Adduction F/F (700-0) 5/5
Opposition F/F 5/5
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FINGERS ROM MMT
Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5
Opposition F/F 5/5

HIP ROM MMT

Flexion F/F (0-1200) 5/5

Extension F/F (0-300) 5/5

Abduction F/F (0-450) 5/5

Adduction F/F (0-300) 5/5

Internal rotation F/F (0-450) 5/5

External rotation F/F (0-350) 5/5

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KNEE ROM MMT

Flexion F/ 0-135 5/5

Extension F/ 135-0 5/5

ANKLE ROM MMT

Dorsoflexion F/F (0-200) 5/5

Plantarflexion F/F (0-500) 5/5

Inversion F/F (0-350) 5/5

Eversion F/F (0-150) 5/5

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BIG TOE ROM MMT

Flexion
MTP F/F (0-300) 5/5
IP F/F (0-500) 5/5
Extension F/F (0-800) 5/5

TOES ROM MMT

Flexion

MTP F/F (0-250) 5/5

IP F/F (0-250) 5/5

Extension F/F (0-800) 5/5

NEUROLOGICAL STATUS
COORDINATION
Finger to nose : adequate
Heel to shin : adequate
FISIOLOGIS REFLEX
BALANCE
Biceps +2/+2 Static : adequate
Dynamic : adequate
Triceps +2/+2
Patella +2/+2
Achilles +2/+2 SENSORY
Within normal limit

PATOLOGIS REFLEX

Hoffman Tromner Negatif/Negatif Spasticity: -/-

Babinski Negatif/Negatif
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NEUROLOGICAL EXAMINATION
N. Cranialis I –XII:
N. Cranialis I : Within normal limit
N. Cranialis II : Within normal limit
N. Cranialis III : Within normal limit
N. Cranialis IV : Within normal limit
N. Cranialis VI : Within normal limit
N. Cranialis VII : Parese N. VII (D) peripheral type
N. Cranialis VIII : Within normal limit
N. Cranialis IX : Within normal limit
N. Cranialis X : Within normal limit
N. Cranialis XI : Within normal limit
N. Cranialis XII : Within normal limit
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MMT MUSCLE INERVATED BY N. VII

• M. Occipitofrontalis Trace/Good
• M. Corrugator Supercilii Poor / Good
• M. Orbicularis Oculi Poor / Good
• M. Procerus Poor/ Good
• M. levator labii superioris alaeque nasi Poor / Good
• M. Buccinator Poor / Good
• M. Risorius Poor / Good
• M. Orbicularis Oris Poor /Good
• M. Zygomaticus Mayor Poor /Good
• M. Mentalis Poor /Good
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OCCIPITOFRONTALIS
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M. corrugator supercilii
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M. orbicularis oculi
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M. procerus
M. nasalis
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M. levator labii superioris alaeque nasi

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M. buccinator
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M. zygomaticus major et minor

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M. risorius
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M. risorius, m. depressor labii inferioris

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M. levator labii superioris M. depressor labii inferioris

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M. orbicularis oris
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M. depressor anguli oris

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M. mentalis
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SPECIAL SENSORY & PARASYMPATHETIC N. VII

 Schirmer’s Test : 5 mm/6 mm
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 Stapedial Reflex : no hiperakusis

 Taste Sensory : normal
 BARTHEL
INDEX

Score Interpretation
91-100 Independent
61-90 Mild
dependency
41-60 Moderate
Dependency
21-40 Severe
Dependency
0-20 Total
dependency

100
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PROBLEM LIST
Body Function :
• B730 Muscle power function : weakness of the right facial
muscle

Body Structure :
• S198 Structure of the nervous system other specified :
parese of N.VII sinistra periferal type
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PROBLEM LIST
• Activity Limitation :
D560 Drinking
D520 Caring for body part : water leakage from his mouth when
gurgling

• Participation Restriction :
D920 Recreation and leisure : cannot participate his family on a
vacation

• Environmental :
E580 Health services, systems and policies : use BPJS insurance
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CLINICAL DIAGNOSIS
Bell’s Palsy D
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PROGNOSIS
• AD VITAM : BONAM
• AD SANATIONAM : DUBIA AD BONAM
• AD FUNGSIONAM : BONAM
GOALS
• Short Goals:
• Increase MMT at the muscle
• Prevent dry eyes
• Can drinking without leakage from one side of the mouth
• Able to close his eye normaly

• Long Goals:
• Better quality vocational
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PLANNING
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• Medical : methyl prednisolone 8mg 3X4 , omeprazole

2x1, folavit 1x400mg, antasida syrup 3x1 sdt,
mecobalamin 3x500mg

• Rehabilitation Medicine
Goal
1. Reduce further complication
2. Increasing facial muscle power
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PMx : Clinical, MMT, ROM

PDx :
• Explain patient condition for Bell’s Palsy
• Using Y plaster
• Warm compress and gentle massage
• Protect her eye from exposure using sunglasses
• Baloon blowing practice
• Continue the exercise at home
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o Male 24 yo, reffered from Neurology Outpatient Clinic

with Bell’s Palsy Dextra. The patient complained his
face skewed to the left, left eye can’t close properly,
dificult to gurgling.
o From physical examination we found decrease of MMT
for left facial muscles innervated by cranial nerve VII S.
o We diagnosed the patient with Bell’s Palsy Dextra
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o Our planning therapy consist of Warm Compress facial

muscle continue with fascial massage, strengthening
muscle exercise of fasial muscle in front of the mirror.
o We educate the patient to give warm compress on the
Left face at home, strenghthening exercise on the right
facial muscle in front of mirror, us eyeglasses at day
and Using artificial eye drops, Continue exercise at
home, and use inverted Y tape.
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Thank You
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