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Bell's Palsy

HISTORY:
Facial  on the  for  
Onset: 














Other elements:

EXAM:
General appearance: 
Vital signs: , BP , HR , RR , SpO2  %, Temp °
Head: 
Ears: -R: , -L: 
Neck: 
Heart: , 
Lungs: , 
Neurologic:
- Mental status: , oriented in , speech 
- Cranial nerves: 
- Strength: upper extremities -R /5 , -L /5 
lower extremities -R /5 , -L /5 
- Sensation: upper extremities -R , -L , 
lower extremities -R , -L 
- Reflexes: triceps -R , -L , biceps -R , -L , brachioradialis -R , -L 
patellar -R , -L , achilles -R , -L , plantar -R , -L 
- Cerebellar function: , finger-nose , rapid alternating movements , heel-knee , Romberg , Dix-Hallpike , 
- Gait: , tandem walking , heel and toe walking 

ASSESSMENT:
 
DDx: 

PLAN:
- Blood work: , , , , , , 
- CT scan of the brain
- MRI of the brain
- Advise that there is no signs of stroke, that condition is benign, and that most cases resolve spontaneously within a few months
- 
- 
- Eye care: artificial tears during the day, ointment at night, eye patch at night
- Facial exercises
- Referral to ENT specialist within 10 days
- Referral to neurologist if central cause not ruled out
- Follow-up in  
- Return if symptoms worsen, if new symptoms develop such as vision changes or severe headache, or if symptoms do not improve with treatment
- Go to ER if difficulty swallowing, difficulty breathing, or severe headache occurs