Bell's palsy physical examination: Difference between revisions

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==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with [[Bell's palsy CT|Bell's palsy]] usually appear normal. [[Physical examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually remarkable for: unintended eye closure with an effort to smile, incomplete closure and the of the eye when patient attempts to close the eyes, inability to puff the cheek in affected side and impaired or absent [[taste]] in affected side, reduced [[Hearing|hearing acuity]], [[Tenderness]] upon palpation of the [[ear]], facial tenderness in distribution of [[facial nerve]] and asymmetric smile. [[Facial nerve]] reflexes may be impaired, including: impaired [[orbicularis oculi]] and impaired [[corneal reflex]].
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
Observe for asymmetry
 
during the interview; pay close attention
 
to blinking, the nasolabial folds, and the corners of the mouth
 
General examination
 
, otoscopy, palpation for masses near the neck
 
and face, and examination of the skin
 
Assess motor function,
 
asking the patient to:
 
Raise both eyebrows
 
Close both eyes tightly
 
Smile
 
Puff out the cheeks
 
Purse the lips
 
Show both upper and lower teeth (grimace)
 
Assess special sensory function,
 
if clinically indicated
 
Sensation of the face and ear
 
Taste sensation of anterior two-thirds of the tongue
 
Assess reflexes
 
Orbicularis reflex: tap the glabella and observe asymmetry in blink
 
pattern
 
Bell phenomenon: observe upward movement of eyes
 
during forced eye-closure


==Physical Examination==
==Physical Examination==
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with [[Bell's palsy (patient information)|Bell's palsy]] usually appear normal.


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
*[[Vital signs]] in patients with Bell's palsy are usually normal.
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
* Skin examination of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
OR
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises
 
<gallery widths="150px">
 
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</gallery>
 
===HEENT===
===HEENT===
* [[Nystagmus]] is not a feature of bell's palsy and it could help to differentiate Bell's palsy from [[Ramsay-Hunt syndrome|Ramsay Hunt syndrome]](witch may have [[nystagmus]])   
* Unintended eye closure with an effort to smile<ref name="pmid20879064">{{cite journal| author=Kim J, Lee HR, Jeong JH, Lee WS| title=Features of facial asymmetry following incomplete recovery from facial paralysis. | journal=Yonsei Med J | year= 2010 | volume= 51 | issue= 6 | pages= 943-8 | pmid=20879064 | doi=10.3349/ymj.2010.51.6.943 | pmc=2995977 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20879064  }} </ref>
* Extra-ocular movements are normal
* Incomplete closure and the of the eye when patient attempts to close the eyes<ref name="pmid17956069">{{cite journal| author=Tiemstra JD, Khatkhate N| title=Bell's palsy: diagnosis and management. | journal=Am Fam Physician | year= 2007 | volume= 76 | issue= 7 | pages= 997-1002 | pmid=17956069 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17956069  }} </ref>
* Facial tenderness
* Inability to puff the cheek in affected side<ref name="pmid25685117">{{cite journal| author=Ng SY, Chu MH| title=Treatment of Bell's Palsy Using Monochromatic Infrared Energy: A Report of 2 Cases. | journal=J Chiropr Med | year= 2014 | volume= 13 | issue= 2 | pages= 96-103 | pmid=25685117 | doi=10.1016/j.jcm.2014.06.010 | pmc=4322014 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25685117  }} </ref>
*Pupils examination is usually normal.
* Impaired or absent [[taste]] in affected side<ref name="pmid1443087">{{cite journal| author=Merren MD| title=Case 1: Bell's palsy and persistent loss of taste. Case 2: Bell's palsy, dramatic recovery with high dose steroid therapy. | journal=Am J Otol | year= 1992 | volume= 13 | issue= 5 | pages= 488 | pmid=1443087 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1443087  }} </ref>
*Ophthalmoscopic exam is usually normal.
* [[Facial nerve]] reflexes may be impaired, including:
** Impaired [[orbicularis oculi]] (blink) reflex (gentle finger percussion of the [[glabella]] while observing for involuntary [[blinking]] with each stimulus. The [[efferent]] response of this reflex is carried  by  the  [[facial  nerve]]) <ref name="pmid4722478">{{cite journal| author=Marinacci AA| title=Orbicularis oculi (blink) reflex in Bell's palsy. | journal=Bull Los Angeles Neurol Soc | year= 1973 | volume= 38 | issue= 3 | pages= 126-37 | pmid=4722478 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4722478 }} </ref>
** Impaired [[corneal reflex]] <ref name="pmid20386632">{{cite journal| author=Sanders RD| title=The Trigeminal (V) and Facial (VII) Cranial Nerves: Head and Face Sensation and Movement. | journal=Psychiatry (Edgmont) | year= 2010 | volume= 7 | issue= 1 | pages= 13-6 | pmid=20386632 | doi= | pmc=2848459 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20386632  }} </ref>
* [[Tenderness]] upon palpation of the [[ear]] may be present.<ref name="pmid19932939">{{cite journal| author=Han DG| title=Pain around the ear in Bell's palsy is referred pain of facial nerve origin: the role of nervi nervorum. | journal=Med Hypotheses | year= 2010 | volume= 74 | issue= 2 | pages= 235-6 | pmid=19932939 | doi=10.1016/j.mehy.2009.06.027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19932939  }} </ref>
*[[Facial-nerve palsy|Facial tenderness]] in distribution of [[facial nerve]]<ref name="pmid25544960">{{cite journal| author=De Seta D, Mancini P, Minni A, Prosperini L, De Seta E, Attanasio G et al.| title=Bell's palsy: symptoms preceding and accompanying the facial paresis. | journal=ScientificWorldJournal | year= 2014 | volume= 2014 | issue=  | pages= 801971 | pmid=25544960 | doi=10.1155/2014/801971 | pmc=4270115 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25544960  }} </ref>
* [[Hearing|Hearing acuity]] may be reduced(because of impairment of the function of [[Stapedius|stapedius muscle]]).<ref name="pmid8444335">{{cite journal| author=Margolis RH| title=Detection of hearing impairment with the acoustic stapedius reflex. | journal=Ear Hear | year= 1993 | volume= 14 | issue= 1 | pages= 3-10 | pmid=8444335 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8444335  }} </ref>
* [[Hearing|Hearing acuity]] may be reduced(because of impairment of the function of [[Stapedius|stapedius muscle]]).<ref name="pmid8444335">{{cite journal| author=Margolis RH| title=Detection of hearing impairment with the acoustic stapedius reflex. | journal=Ear Hear | year= 1993 | volume= 14 | issue= 1 | pages= 3-10 | pmid=8444335 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8444335  }} </ref>
* [[Wrinkle|Wrinkling]] of the [[forehead]] when raising the [[eyebrows]] is asymmetric or absent on the affected side.<ref name="pmid21747074">{{cite journal| author=Sajadi MM, Sajadi MR, Tabatabaie SM| title=The history of facial palsy and spasm: Hippocrates to Razi. | journal=Neurology | year= 2011 | volume= 77 | issue= 2 | pages= 174-8 | pmid=21747074 | doi=10.1212/WNL.0b013e3182242d23 | pmc=3140075 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21747074  }} </ref>
* Asymmetric smile<ref name="pmid20879064">{{cite journal| author=Kim J, Lee HR, Jeong JH, Lee WS| title=Features of facial asymmetry following incomplete recovery from facial paralysis. | journal=Yonsei Med J | year= 2010 | volume= 51 | issue= 6 | pages= 943-8 | pmid=20879064 | doi=10.3349/ymj.2010.51.6.943 | pmc=2995977 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20879064  }} </ref>
* [[Nystagmus]] is not a feature of bell's palsy and it could help to differentiate [[Bell's palsy (patient information)|Bell's palsy]] from [[Ramsay-Hunt syndrome|Ramsay Hunt syndrome]](witch may have [[nystagmus]])
* Extra-ocular movements are normal.
*[[Weber test]] is usually normal.
*[[Weber test]] is usually normal.
*[[Rinne test]] is usually normal.
*[[Rinne test]] is usually normal.
* [[Ear canal]] is usually normal.
* [[Ear canal]] is usually normal.
* [[Tenderness]] upon palpation of the [[ear]] may be present.<ref name="pmid19932939">{{cite journal| author=Han DG| title=Pain around the ear in Bell's palsy is referred pain of facial nerve origin: the role of nervi nervorum. | journal=Med Hypotheses | year= 2010 | volume= 74 | issue= 2 | pages= 235-6 | pmid=19932939 | doi=10.1016/j.mehy.2009.06.027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19932939  }} </ref>
*[[Ophthalmic artery|Ophthalmoscopic]] exam is usually normal.
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
* [[Pupil|Pupils]] examination is usually normal.


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
* Neck [[examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
OR
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]
 
===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
*[[Pulmonary examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
OR
* Asymmetric chest expansion / Decreased chest expansion
*Lungs are hypo/hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
 
===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
*[[Cardiovascular|Cardiovascular examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
 
===Abdomen===
===Abdomen===
Abdominal examination of patients with [disease name] is usually normal.
*[[Abdominal examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
 
OR
*[[Abdominal distention]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
*[[Baba Raghav Das Medical College|Back examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
*[[Genitourinary organs|Genitourinary examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 
===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
*Patient is usually oriented to persons, place, and time.
OR
* [[Glasgow coma scale]] is usually 15.
*Patient is usually oriented to persons, place, and time
* [[Plantar reflex|Babinski reflex]] is usually normal.
* Altered mental status
* [[Muscle rigidity]] is usually normal.
* Glasgow coma scale is ___ / 15
*Upper and lower extremity [[Tone (linguistics)|tone]] is usually normal.
* Clonus may be present
*[[Sensation]] in the upper and lower extremity is usually normal.
* Hyperreflexia / hyporeflexia / areflexia
*[[Straight leg raise|Straight leg raise test]] is usually normal.
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
*[[Gait]] is usually normal.
* Muscle rigidity
*[[Finger agnosia|Finger-to-nose test]] is usually normal.
* Proximal/distal muscle weakness unilaterally/bilaterally
*[[Palmar|Palm]] [[Tapas Acupressure Technique|tapping test]] is usually normal.
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
*[[Extremities|Extremities examination]] of patients with [[Bell's palsy (patient information)|Bell's palsy]] is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 14:52, 9 April 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

Patients with Bell's palsy usually appear normal. Physical examination of patients with Bell's palsy is usually remarkable for: unintended eye closure with an effort to smile, incomplete closure and the of the eye when patient attempts to close the eyes, inability to puff the cheek in affected side and impaired or absent taste in affected side, reduced hearing acuity, Tenderness upon palpation of the ear, facial tenderness in distribution of facial nerve and asymmetric smile. Facial nerve reflexes may be impaired, including: impaired orbicularis oculi and impaired corneal reflex.

Physical Examination

Appearance of the Patient

Vital Signs

  • Vital signs in patients with Bell's palsy are usually normal.

Skin

  • Skin examination of patients with Bell's palsy is usually normal.

HEENT

Neck

Lungs

Heart

Abdomen

Back

Genitourinary

Neuromuscular

Extremities

References

  1. ↑ 1.0 1.1 Kim J, Lee HR, Jeong JH, Lee WS (2010). "Features of facial asymmetry following incomplete recovery from facial paralysis". Yonsei Med J. 51 (6): 943–8. doi:10.3349/ymj.2010.51.6.943. PMC 2995977. PMID 20879064.
  2. ↑ Tiemstra JD, Khatkhate N (2007). "Bell's palsy: diagnosis and management". Am Fam Physician. 76 (7): 997–1002. PMID 17956069.
  3. ↑ Ng SY, Chu MH (2014). "Treatment of Bell's Palsy Using Monochromatic Infrared Energy: A Report of 2 Cases". J Chiropr Med. 13 (2): 96–103. doi:10.1016/j.jcm.2014.06.010. PMC 4322014. PMID 25685117.
  4. ↑ Merren MD (1992). "Case 1: Bell's palsy and persistent loss of taste. Case 2: Bell's palsy, dramatic recovery with high dose steroid therapy". Am J Otol. 13 (5): 488. PMID 1443087.
  5. ↑ Marinacci AA (1973). "Orbicularis oculi (blink) reflex in Bell's palsy". Bull Los Angeles Neurol Soc. 38 (3): 126–37. PMID 4722478.
  6. ↑ Sanders RD (2010). "The Trigeminal (V) and Facial (VII) Cranial Nerves: Head and Face Sensation and Movement". Psychiatry (Edgmont). 7 (1): 13–6. PMC 2848459. PMID 20386632.
  7. ↑ Han DG (2010). "Pain around the ear in Bell's palsy is referred pain of facial nerve origin: the role of nervi nervorum". Med Hypotheses. 74 (2): 235–6. doi:10.1016/j.mehy.2009.06.027. PMID 19932939.
  8. ↑ De Seta D, Mancini P, Minni A, Prosperini L, De Seta E, Attanasio G; et al. (2014). "Bell's palsy: symptoms preceding and accompanying the facial paresis". ScientificWorldJournal. 2014: 801971. doi:10.1155/2014/801971. PMC 4270115. PMID 25544960.
  9. ↑ Margolis RH (1993). "Detection of hearing impairment with the acoustic stapedius reflex". Ear Hear. 14 (1): 3–10. PMID 8444335.
  10. ↑ Sajadi MM, Sajadi MR, Tabatabaie SM (2011). "The history of facial palsy and spasm: Hippocrates to Razi". Neurology. 77 (2): 174–8. doi:10.1212/WNL.0b013e3182242d23. PMC 3140075. PMID 21747074.

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