Bells Palsy MDM and DCI

Assessment & Plan Elements
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[text] presents with [checkbox value="right|left"] facial droop. Weakness involves the entire hemiface and does not spare the forehead. There is no associated extremity weakness or slurred speech. Pt's clinical and physical exam features are most consistent with Bell's Palsy. There is no evidence for stroke, trauma, infection or other serious disorders. Plan is to treat the patient symptomatically and expectantly with close follow up. (note:protect eyes with patch and lubrication. Rx with steroids and acyclovir) See DCI.


Take the medication prescribed as directed.
Take Motrin and/or Norco for pain.
Lubricate your affected eye 4 times an hour to prevent drying and irritation. Patch your eye closed at night.
Follow up with your PMD in 3-5 days for a recheck.
Return to the ER for worsened or expanding weakness, slurred speech, mental status changes or any other concerns.

[checkbox name="Bells Treatment" value="Acyclovir 5x/d x 10 days. |Prednisone 40 mg po daily x 5 days. |Natural Drops - 1 gtt every 15 min while awake"]
presents with facial droop. Weakness involves the entire hemiface and does not spare the forehead. There is no associated extremity weakness or slurred speech. Pt's clinical and physical exam features are most consistent with Bell's Palsy. There is no evidence for stroke, trauma, infection or other serious disorders. Plan is to treat the patient symptomatically and expectantly with close follow up. (note:protect eyes with patch and lubrication. Rx with steroids and acyclovir) See DCI.


Take the medication prescribed as directed.
Take Motrin and/or Norco for pain.
Lubricate your affected eye 4 times an hour to prevent drying and irritation. Patch your eye closed at night.
Follow up with your PMD in 3-5 days for a recheck.
Return to the ER for worsened or expanding weakness, slurred speech, mental status changes or any other concerns.

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