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The bells palsy standard workup. Clinical criteria. Be convinced it's not a stroke. Screen for eye and ear shingles. Educate and treat. Written in the negative. Copy/pastable template below:

Step 1: Clinical Diagnosis
Working dx of Bells Palsy, evidenced by:
– unilateral facial palsy
– with loss of forehead crease on affected side – this is inconsistent with an UMN lesion such as stroke/mass.
– assoc ptosis and lid lag.
– Symptoms are acute, and have progressed over past 48 hours.

Step 2: Be sure it is not a stroke or UMN lesion.
– Taste intact, tested with ___ (juice / coffee)
– visual fields normal
– PEARL, no RPAD.
– No opthalmoplegia, diplopia, or nystagmus.
– Sensation normal and equal to UL / LL.
– Normal tongue movements. No tongue deviation at rest.
– Ambulant with normal gait.
– Can walk heel to toe.
– No lateralizing weakness

Step 3: Screen for herpes zoster oticus (Ramsay Hunt syndrome)
– No vesicular rash to the ear, including on otoscopy
– patient denies hearing loss
– Hearing is unaffected:
— Hearing in R and L ears are at least equivalent to examiner.
— L ear: Air conduction > Bony conduction (normal)
— R ear: Air conduction > Bony conduction (normal)
— Equal intensity of sound when tuning fork placed in center of head.

Step 4: Exclude herpes zoster opthalmicus (ocular shingles) and eye injury from lid paralysis.
– No significant ectropion or inability to close eye fully.
– No fluorescein uptake on blue light examination.
– Vision grossly normal, able to read small font at arm’s length.

Treatment / Disposition
– Home on Prednisolone 1mg/kg up to 75mg for 5 days. Edu. Handout. Home with GP review and red flag / safety net to represent if develops vision issues / rash / hearing issues.
– Admit if there are any signs of Herpes Zoster Oticus/Opthalmicus, admit under ID for IV antivirals.