contoh assessment bells palsy

Subjective Information

Name : Mdm.N Age : 52 years old Sex : Female Race : Malay Occupation : teacher MRN : 424424 D.O.A : 10.4.14 D.O.AX : 12.4.14 @ 10am DR. Diagnosis : Rt. Facial palsy DR. MX : Refer to physiotherapy

1.Chief complaint • Pt c/o numbness and discomfort at Rt. Side of face and tongue• Pt c/o difficulty to close her Rt. Eyes and mouth since 2/7 ago

2.Current Hx :• pt. woke up at 5am in the morning to prepare for her work when she

realize he Rt. Side of face dropped and uneven• She then went to PSH with her husband on 10.4.14 @ 7.00am for further

medical attention3.Past Hx :• Pt. suffers massive headache on and off since 10 years ago• The pain became regular lately since 3/7ago • She went to local clinic at larkin for medical attention but no

improvement in her headache

Medical hx◦ Migrain since 10years ago◦ °DM, °HPT, °Asthma

Family hx-NIL

5.Social Hx : Nature of work : prolong walking, standing and sitting Marital status : Married and has 3 children Smoking/alcohol : NIL Type of house : single storey terrace houce Transportation : car (auto) Hobby/sport : pt is not active in sport

6.Medication Hx : Pain killer

7.Investigation

CT scan done on 10.4.14 @10.00am-conclusion : no significant abnormality

Pain Scale

On rest

Rt Lt Lt Lt

Muscle weakness

6.Type of Pain : Numbness of Rt. Side of face

7.Aggravating Factor : Lying on Rt.side

8.Ease factor : Lying on Lt.side

9.Irritability high

Objective Information

1.General Observation A mesomorph size Malay woman come to physiotherapy department

independently No gait abnormality Depressed facial expression Pt is cooperative

2.Local Observation Asymmetrical face on Rt.side °Redness, °scar, °swelling

3.On Palpation Warmness noted at Rt. Side of face

Muscle Action Remarks (Rt.) Remarks(Lt.)

Frontalis Raise eyebrow 2/5 5/5

Obicularis oculi Close eye 2/5 5/5

Proceus Frawn 3/5 5/5

Zygomatic minor

Smile 3/5 5/5

Zygomatic major

Smile(with seen teeth)

3/5 5/5

Buccinator Blowing 2/5 5/5

Obicularis oris Close mouth 2/5 5/5

Mentalis Wrinkle chin 1/5 5/5

Reduced muscle power on Rt. Side of facial d/t muscle weakness

Test Rt Lt

Hot and cold Intact Intact

Light touch Intact Intact

Sharp and blunt Intact Intact

No sensory deficit

7.Problem Listing Asymmetrical face (dropped on Rt. Side) d/t muscle weakness Reduced muscle strength d/t underlying condition

8. Short term goalTo improve facial muscle power within 1 monthsTo reeducate and gain functional movement of facial muscle within 6

months

9. Long term goalTo maximize ADL functionTo improve confidence levelTo prevent secondary complication eg. Eyes and mouth infection

Plan of Treatment Faradic current

◦ To reeducate muscle movement Kabat rehab technique (pnf)

◦ to approach functional muscle movement Cryotherapy

◦ To reduce swelling and reduce pain

Intervention • cryotherapy• Pt in Lt. side lying, cryocuff on Rt.facial area, 20minutes• Faradic stimulation• Pt in Lt.side lying, faradic stimulation at pt.’s Rt. Muscle group, 20minutes

Evaluation◦ Pt claimed better after treatment◦ Pt was able to perform all activities that had given

Review◦ Kiv facial mmt for next ass.◦ Kiv ADL assessment for next ass.

Home advices◦ Do not lie on affected side◦ Massage facial upwards when washing face◦ Blow strwas or balloons◦ Use eye patch or wet cotton on affected eyes

during sleep