Bell's Palsy Patient Intake Form

Patient Intake Record

Case Report

Patient's Name: Perez, B

Gender: Female

Date of Birth: 06/XX/1985

Occupation: Registered Nurse

Marital Status: Single

Private

Phone [HIDDEN] Private

Chief Complaint: Bell's palsy

History of Present Illness:

The patient states she first felt numbness on her tongue 10 days ago. When she woke up in the morning and was cleaning her teeth, the water was dripping from her mouth. Her right eye was not able to close completely, and she felt numbness on the right side of her face.

Medical History:

The patient consulted with her doctor who confirmed the diagnosis as Bell's palsy; her doctor prescribed prednisone for 14 days. The patient came to see me on 8/29/2013. The patient states she has pain and numbness on the right side of her face, drooling, loss of the ability to taste, and her right eye cannot fully open or close and has excessive tearing.

Personal History:

Menstrual History: She is taking birth control pills.

LMP: N/A

Obstetrical History: None

Smoking/Addiction/Alcohol History: None

Family History: Her mother had Bell's palsy.

Current Medications and Herbs: She is taking Prednisone (Corticosteroids, Anti-inflammatory).

Review of Systems:

Energy: Tired

Sleep: Ok

Mood: Since she is a nurse and continues to work with this condition, it causes her emotional distress because of its characteristic drooping appearance around the eye and mouth, thus adversely effecting self-esteem and work experience.

Appetite/Thirst: Normal appetite. No thirst.

Digestion: Good

Bowels: 1/day, little loose.

Urine: o.k.

(O) Examination

HEENT: Pain and paralysis on right side of face.

Drooling mouth and loss of ability to taste.

Eye cannot fully close on the right side of the face; also excessive tearing.

Neurological: Not able to control her facial muscles.

Musculoskeletal: Shoulder pain; more on right side.

Skin/Lymphatic: None

Cardiovascular: Ok

Respiratory: Ok

Abdominal: None

Limbs/Extremities: Cold feet.

Vital Signs:

Temperature: 97.7

Blood Pressure: 125/78

Heart Rate: 64

Respiration:

Lab Tests, Imaging, EKG, etc.:

Not Available

Pulses:

Left:

1 Wiry

2. Wiry

3. Deep

Right:

1 Slippery

2. Slippery

3. Deep

Tongue: Pink

Coat: white fur

Complexion: Slightly dusky under eyes.

(A) Diagnoses of Diseases and Patterns

Pattern/Syndrome Differentiation Analysis:

The patient is a young, and healthy female nurse, besides the Bell's palsy. She works in rotating shifts and needs to work through the night (12-hours shifts) at the childbirth center. This rotating shift is similar to changing time zones several times a month, without time to adapt or recover; the patient states she did not have enough rest before going to work.

According to T. Deng [1], a lifestyle of consuming incorrect foods, overwork, stress, and indulgence where Qi is consumed without replenishment builds the vacuity pattern. External wind takes advantage of this vacuity to enter her body and attack the sinews and vessels in that area of her face. This results in Qi and blood stagnation causing the inability of flesh to relax or contract. Because the patient was overworked, her Qi weakened [2].

The Qi deficiency can cause a failure in transportation, leading to dampness that further failed to transform and caused turbid phlegm stagnation within the body. External wind invading the collaterals disturbed internal phlegm, which travelled through the face causing stagnation in the channels. Qi and blood failed to nourish the channels, leading to facial discomfort on the affected side, with an inability to close the eye. The right side nasolabial fold flattened. The eye and mouth deviated towards the healthy side. The chronic nature of the patient's illness injured Qi and blood. Qi leads blood; Qi deficiency caused weak movement of blood. The channels, therefore, failed to receive nourishment from Qi and blood, leading to the deviation of the mouth and eye and dull facial expression.

Research Findings:

In traditional Chinese medicine, Bell's palsy can be referred to in several interrelated ways.

The first term is Zh-n Zhong F-ng, or "true wind stroke," which is used to describe a pattern associated with externally contracted wind.

Another is Lei Zhong F-ng [3], or "wind-like stroke," which refers to a pattern of internal wind.

Although Bell's palsy is not the same as a stroke, the symptoms and presentation are similar.

Both patterns include deviation of the eyes and mouth, one-sided symptoms, difficulty speaking and drooling. Obviously, Bell's palsy is not a cerebral vascular accident and there will not be sudden clouding collapse (loss of consciousness).

In Chapter 5 of Essentials from the Golden Cabinet, Zhang Zhong-jing [4] discusses several manifestations of Zhong F-ng. The overarching theory is that external evil wind invades and lodges in the body and is not discharged. He then differentiates patterns according the depth to which the wind penetrates.