SOAP Note
Subjective:
The patient is a 50-year-old male presenting with a left-sided facial drop and left-sided neck pain. Symptoms began 6 days ago with a weird sensation of his face deviating to one side. He did not seek immediate medical attention but became concerned when he noticed changes in his speech and difficulty drinking water.
Objective:
Physical assessment reveals a minimal left-sided facial droop. Laboratory results show:
- CBC: unremarkable
- CMP: glucose 167, chloride 110, creatinine 0.48, BUN/creatinine 27.1
- Troponin 0.01
- PROTIME 13.8, INR 1.0
- CTA head and CTA neck: negative
- MRI: no acute intracranial findings, chronic appearing changes in the white matter of both cerebral hemispheres
Assessment:
Differential diagnosis for the patient's symptoms is categorized as follows:
- Single Most Likely Diagnosis
- Bell's Palsy: A condition that causes a temporary weakness or paralysis of the muscles in one side of the face. It is the most likely diagnosis given the patient's symptoms of facial droop and the absence of other alarming signs or findings on imaging studies.
- Other Likely Diagnoses
- Stroke or Transient Ischemic Attack (TIA): Although the CTA head and neck were negative, and the MRI did not show acute intracranial findings, a stroke or TIA cannot be completely ruled out without a thorough evaluation, including a detailed neurological examination and possibly further imaging or tests.
- Multiple Sclerosis: The chronic changes in the white matter seen on the MRI could suggest a condition like multiple sclerosis, especially if the patient has had previous episodes of neurological symptoms.
- Do Not Miss Diagnoses
- Lyme Disease: Can cause facial palsy and should be considered, especially if the patient has been exposed to ticks or has a history of travel to endemic areas.
- Cancer (e.g., Parotid or Brain Tumors): Although less likely, tumors affecting the facial nerve or brain could cause similar symptoms and should not be missed.
- Sarcoidosis: A systemic disease that can affect the nervous system and cause facial palsy among other symptoms.
- Rare Diagnoses
- Melkersson-Rosenthal Syndrome: A rare neurological disorder characterized by recurrent, often unilateral, facial paralysis or weakness, along with swelling of the face and lips, and the development of folds and furrows in the tongue (fissured tongue).
- Heerfordt's Syndrome: A variant of sarcoidosis that includes a combination of uveitis, parotid or salivary gland enlargement, chronic fever, and facial palsy.
Plan:
Further evaluation and management should include:
- Detailed neurological examination
- Consideration of electromyography (EMG) or nerve conduction studies (NCS) to assess the facial nerve
- Screening for conditions like Lyme disease or sarcoidosis if clinically indicated
- Follow-up imaging or tests if initial results are inconclusive or if the clinical picture changes
- Referral to a neurologist for further evaluation and management of potential underlying conditions like multiple sclerosis or stroke/TIA.