Patient: Mr.

M/ 64 th/ 11615554/ Retiree/ Pasuruan

Referred from: ENT (OMSK D/S with abcess subperiosteal D + parese NVII D housebrackmann V post incision drainage and
mastoidectomy D (6/5/2024)
Resident: DOE/MIA/AIK
Positive Findings Problem List Diagnosis Planning
Anamnesis: Medical: Clinical diagnosis: PDx :
Chief Complaint : Patient complained about Parese N VII D LMN type Parese N VII D LMN type PTx: collaboration with ENT
asymmetrical face since 1 month ago house brackmann V ec OMSK house brackmann V ec Modality :
History of Present Illness: D/S post mastoidectomy D OMSK D/S post
(24 days) + hearing problem mastoidectomy D (24 • NMES at facial muscle D (m. frontalis
• The patient complained of asymmetrical face since 1 days) + hearing problem D, orbicularis oculi D m. risorius D, m.
month ago. Surgical:- zygomaticus D, m. orbicularis oris D, m
• Patient felt his right face lower than his left side. R1 (M): Functional diagnosis: mentalis D) 70-85 pulses per second,
It gradually becoming worse. R2 (A): on time 10-15 second range, off time
• Patient felt this symptoms after the back of his Impairment
R3 (C): - - Parese N VII LMN type 50 second – 2 minute range,
right ear become swollen. R4 (P):
• Patient had difficulty to close his right eye, and D 2x/week
R5 (S): discomfort to join - Decrease of hearing • LLLT at stylomastoid foramen D and
his right eye became watery. social activity
• Symptoms of hypersalivation, unable to close or D/S nerva branch facialis
R6 (V): - Disability: Exercise :
open mouth were denied. R7 (O):
• Patient complained of his right ear always had - - Facial exercise using mirror
- Parese N VII LMN type D - Facial massage
discharge since 10 years ago. - Decrease of hearing D/S Handicap:
• Patient also complained of hearing problem since 2 -Discomfort to join social - Y taping
years ago but worse on his right ear in the last activity
month.
• No complain of weakness at extremities, no history
of trauma, fever, headache, teeth pain, or any skin
infection
• Patient had similar symptom at her left face in 2022
but already healed

1
Patient: Mr. M/ 64 th/ 11615554/ Retiree/ Pasuruan
Referred from: ENT (OMSK D/S with abcess subperiosteal D + parese NVII D housebrackmann V post incision drainage and
mastoidectomy D (6/5/2024)
Resident: DOE/MIA/AIK
Positive Findings Problem List Diagnosis Planning

2010-2023 PMo:
• Patient likes to clean his ears with cotton bud. Subjective, Facial MMT
• Patient started to experienced symptoms of discharge coming out PEd:
from his right and left ear. - Explain patient condition
• Patient also complained his hearing decreased especially on his - Purpose & benefit of PMR therapy
right ear. - Routine controlled
- Continue exercise program at
home everyday
May 2023 - Warm compress 2-3 times/day for
• Patient complained of swelling on the back of his right ear. His 10 minutes at right face
hearing becoming worse and his face became asymmetrical. - Use eye drop
• Patient was referred to ENT at RS Soedarsono Pasuruan and patient - Eye cover using sunglasses during
was told to surgery day and eye patch during night
• Patient was referred to RSSA and underwent surgery at 6 May 2024 - Massage with circular motion on
• Patient was given hearing aid after surgery. the weak muscle for 10 minutes,
• Patient complaint of asymmetrical face persisted with intensity as patient’s
preference
• Patient was referred to PMR for physiotherapy
Patient: Mr. M/ 64 th/ 11615554/ Retiree/ Pasuruan
Referred from: ENT (OMSK D/S with abcess subperiosteal D + parese NVII D housebrackmann V post incision drainage and
mastoidectomy D (6/5/2024)
Resident: DOE/MIA/AIK
Positive Findings Problem List Diagnosis Planning
History of Past Illness
• no trauma
Comorbidities
• HT (+) 2 years uncontrolled, DM (-), Obesity (-), CVA (-),
malignancy (-)
History of Family Illness:
• There was no history of family illness related to patient's
condition
Medication and rehabilitation :
From PHC: captopril 3x25mg
Rehabilitation program : -
Patient: Mr. M/ 64 th/ 11615554/ Retiree/ Pasuruan
Referred from: ENT (OMSK D/S with abcess subperiosteal D + parese NVII D housebrackmann V post incision drainage and
mastoidectomy D (6/5/2024)
Resident: DOE/MIA/AIK
Positive Findings Problem Diagnosis Planning
List
History of Functional Activity:
• Patient is a retiree. Patient usually help his children and
grandchildren.
• Patient able to do ADL without difficulty.
• Due to his current condition, patient felt discomfort in joining social
activity. Patient need to use hearing aid and patient still unable to
smile properly.

Psycho-Socio-Economic:
• Patient did not feel worried about his condition and willing to get
better
• Patient is married. His wife is 60 yo, a housewife.
• Patient had 2 children. He lives with 1 st daughter (37 y.o,
housewife) and her family husband and two granddaughter.
• The patient daily needs were fulfilled by his pension money and by
his children
• Economic status: middle-class
• Medical status: BPJS

4
 2 3

2
3

20/20 1
independent 2

2
1

2
1
19
Patient: Mr. M/ 64 th/ 11615554/ Retiree/ Pasuruan
Referred from: ENT (OMSK D/S with abcess subperiosteal D + parese NVII D housebrackmann V post incision drainage and
mastoidectomy D (6/5/2024)
Resident: DOE/MIA/AIK
Positive Findings

Physical exam:
• GCS 456 (Compos Mentis)
• BP : 130/80 mmHg HR : 74x/min, RR : 20x/min, spO2: 98%
• BW = 78 kg, BH = 177 cm BMI : 21.4 (normoweight)
• Ambulation : Independent
• Gait : normal gait
• Chest : heart : S1S2 single, murmur -, gallop –
lung : rh-/-, wh-/-, ves +/+
Chest expansion: 2 – 2 – 2
Breath count test: 20 – 20 – 21
• Abdomen : soefl, hepar and lien unpalpable
• Extremities : warm acral +/+, oedema -/-
• integumen : scar - erythema -

• Reflexes:
Physiological Reflexes: Pathological Reflexes:
- BPR +2/+2 - Babinski -/-
- TPR+2/+2 - Chaddock -/-
- KPR+2/+2 - Hoffman -/-
- APR +2/+2 - Tromner -/-
I (Olfactory)
Cranial Nerve Examination
Smell function (N)
II (Opticus) Visus (normal) visual field (normal) Pupillary reflex (+)
III (Occulomotor) Eye movement Superior (+), Inferior (+), Medial (+),

IV (Trochlear) Eye movement inferonasal (+)

V (Trigeminal) Mastication muscle (+), face sensory (normal), kornea reflex (+/+), mental reflex (+)
VI (Abducens) Eye movement lateral (+)
VII (Facialis) Face expression (Parese LMN Type D), 2/3 anterior tongue (normal), schimmer test (not
tested), hyperacusis (+)

VIII (Vestibulotrochlear) Hearing (decreased), hallpike manuvre (not tested)

IX (Hypoglosus), X (Vagus) 1/3 posterior tongue sensory (N), voice quality (normal), uvula, pharnx arcus (normal), gag
reflex (normal), swallowing test (dry swallowing, TOR-BSST normal)
XI (Asesorius) Trapezius, sternocleidomastoideus muscle (normal)
XII (Glossopharingeal) Tongue movement (normal)
Patient: Mrs. M/ 58 th/ 11576803/ Housewife/ Pasuruan
Referred from: neurologist (Bell’s Palsy + OA genu S)
Resident: PUT/RIT/AIK
Positive Findings
Local Status :
Bell’s sign (+)
Excessive tears (+)
Fasciculation (-)
House-brackman grading : V
At rest : Asymmetry
Forehead. : Barely any movement
Eye : incomplete closure
Mouth : slight movement
Motoric Cn. VII
M. FRONTALIS
REST
ZERO (0)/ NORMAL
M. CORRUGATOR SUPERCILI M. ORBICULARIS OCULI
POOR(2)/ NORMAL
POOR (2) / NORMAL
Motoric Cn. VII
M. NASALIS M. LEVATOR ANGULARIS SUPERIOR ORIS
ZERO (0)/ NORMAL ZERO (0)/ NORMAL
Motoric Cn. VII
M. ORBICULARIS ORIS M. ZYGOMATICUS MAJOR
POOR (0) / NORMAL ZERO (0) / NORMAL
Motoric Cn. VII
M. RISORIUS M. BUCCINATOR
ZERO (0)/ NORMAL POOR (2)/ NORMAL
Motoric Cn. VII
M. DEPRESSOR LABII INFERIOR M. MENTALIS
ZERO (0)/ NORMAL POOR (2)/ NORMAL
ICF DIAGNOSIS PATIENT CONDITION
Functional Diagnosis Parese N VII D LMN type house brackmann V ec OMSK D/S post
mastoidectomy D (24 days) + hearing problem

Body Function
B730 Muscle Power Functions Weakness on the right face
B270 Hearing function Hearing function

Body Structure
S710 Structure of head and neck region Parese N VII LMN type
OMSK D/S post mastoidectomy D

Activity and Participation

D910 Community life Discomfort to do social activity

Environment
E1101 Drugs Patient’s consume medication
E310 Immediate family His family supports him
E580 Health services, systems, and policies BPJS
Personal Factor Male, 64 y.o, retiree, Javanese, Muslim
Diagnosis
Clinical Diagnosis Parese N VII D LMN type house brackmann V
ec OMSK D/S post mastoidectomy D (24
days) + hearing problem
Topical Diagnosis Facialis Nerve D susp. At level Parotis Gland

Etiological OMSK D/S post mastoidectomy D (24 days)

Prognosis

Ad Vitam : Bonam

Ad Sanationam : Dubia ad Bonam

Ad Functionam : Dubia ad Bonam

 Goals

Mid Term Long Term

Prevent further Complications Able to join social activity with comfort
Improve MMT facial muscle
Patient: Mr. M/ 64 th/ 11615554/ Retiree/ Pasuruan
Referred from: ENT (OMSK D/S with abcess subperiosteal D + parese NVII D housebrackmann V post incision drainage and mastoidectomy D (6/5/2024)
Resident: DOE/MIA/AIK

Problems Causes Goal Planning Time Setting

• Discomfort to join • Parase N. VII • Improve facial PDx : - improve muscle strength
social activity D LMN type muscle strength Modality : within 1-3 months
• Reduce facial • Able to join • NMES at motor point facial muscle at m. frontalis D, m. corrugator supercili D,
muscle social activity m. zygomaticus major D, m. risorius D, m. orbicularis oris D, m. nasalis D, m.
strength D with comfort mentalis D, 70-85 pulses per second, on time 10-15 second range, off time
50 second – 2 minute range, 2x/week
• LLLT at stylomastoid foramen area and facialis nerve branch frequency 4
KHz duration 1 minute, gridding method

Exercise :
• Facial exercise with mirror
• Facial massage
• Y taping

Pmo: subjective, MMT

PEd:
- Continue exercise at home
- Using eyeglasses and artificial tears
- Warm compress 2-3 times/day for 10 minutes at affected side
- Massage with circular motion on the weak muscle for 10 minutes
- Continue facial exercise at home (in front of mirror)