By: Siti Nurulismah

Name: Madam LDP Age: 35 years old Gender: Female Religion: Buddha Ethic: Chinese Status: Married Address: Selayang Occupation: Housewife

Madam LDP, a 35 years old Chinese Malaysian lady presented with right sided facial asymmetry on the same day of visit to the clinic.

She was previously well then her family noticed that the right side of her face didnt seem to move as much as the left. The right corner of her mouth appeared to droop and associated with drooling of saliva. Thus, she was unable to eat and drink properly. She also complained of inability to close her right eye. She noticed it upon waking from sleep. Her right eye would not close all the way and associated with tearing.

There was also acute onset, persistent dull aching pain around the right ear for one day prior to facial asymmetry. This was the first time she experienced this condition. There was no history of trauma. No fever, no loss of weight and no loss of appetite.

Normal in particular; There was no hearing loss, no tinnitus, no vertigo, no dry mouth, no remarkable changes in taste sensation, No limb weakness, no numbness or tingling sensation No loss of vision, no diplopia or no eye pain. No symptoms of URTI No polyphagia, polydipsia or polyuria

There was no known long term illness e.g. hypertension, diabetes mellitus or heart problem. But, she did have chicken pox during childhood She was not taking any drugs or traditional medication, never been admitted to hospital and never undergone any surgeries. The also known history of any ear, nose and throat problems or surgeries relating to these. There was also no known allergy

Her last normal menstrual period was at 21st November 2011. Her menses were regular with 8 days duration

68 years old

65 years old

40 years old

She is the only child in her family Her father has heart problem, diabetes mellitus and hypertension while her mother has diabetes mellitus She had no child and her husband is hypertensive. No other family members that having similar complaint with her and no family history of malignancy.

She was a housewife She lived in a double story house at Selayang with her husband She was never smoked and consumed alcohol occasionally Her husband also never smoked

Generally She is conscious and alert. She is not in pain and not in respiratory distress There is no abnormal involuntary movement There is right sided facial asymmetry noted Anthropometry Weight : 50 kg Height : 157 cm BMI : 20.3 kg/m2 (ideal)

Pulse volume Respiratory rate Blood pressure Temperature

: 80 bpm, regular rhythm, normal : 16 bpm : 115/80 mmHg : 37C

Impression: all within normal range

Madam LDP is oriented to time, place and person All the cranial nerves are intact except for cranial nerve VII CN VII: left side is intact. Right side she cant raise her eyebrow, cant close eye tightly, cant puff out her cheek, cant grin and showed her teeth properly. However, the sensory is intact Motor: normal muscle bulk, tone and power for all limbs Sensory: intact for all dermatomes Reflexes: normal for all limbs Coordination: normal

Inspection: There is right side facial asymmetry

Loss of wrinkle on right forehead Droop of right eyebrow Loss of her right nasolabial fold Drooping of right angle of mouth

There is no obvious mass, scar, rash or enlarged thyroid gland Palpation:

Trachea at midline Lymph nodes are not palpable Salivary gland examination: no tenderness or swelling Thyroid examination: symmetry, not enlarged and no tenderness

Inspection Both pinna have normal size, shape and position. No vesicles, redness or scars with normal pre and post auricular appearance. Both external ear canals are clear and there is minimal brown cerumen. Apart from that, there is no erythema, vesicles or discharge Palpation There is mild tenderness at right mastoid. Otoscopy Cone light reflex present anteroinferiorly, the tympanic membranes are pearly gray in appearance. No retraction and no perforation. Tuning fork tests Rinnes test: positive on both ears. AC>BC Weber test: centralized

The nares are patent. Nasal mucosa is pink, moist and there is no excessive discharge for both right and left nostrils.

There is no scar, erythematous rash or lesions at the lips and in the mouth Teeth are all present, straight and in a good pair Gums are pink and intact The palate and uvula move in the midline The tongue is thick and reveals slow lateral movement There are no swelling of the parotid glands There are no jaws tenderness upon bilateral palpation

CVS, RS and abdomen examinations are normal.

Madam LDP, a 35 years old Chinese lady presented with right sided facial asymmetry on the same day of visit to the clinic that associated with tearing at right eye and preceded by pain around the right ear. Physical examination revealed lower motor neuron lesion signs at the right side of her face and mild tenderness at right mastoid but other ear examinations are normal.

Right sided Bells Palsy