Post on 18-Dec-2015
Case Presentation
by Michael Armstrongby Michael Armstrong
Chief Complaint
My face is numb on the right side, my My face is numb on the right side, my vision is blurry, and I can’t close my vision is blurry, and I can’t close my right eye.right eye.
History of present illness
Patient is a 39 y/o Hispanic female Patient is a 39 y/o Hispanic female with a 2 day complaint of numbness to with a 2 day complaint of numbness to the right side of her face following an the right side of her face following an aching pain in the right posterior aching pain in the right posterior auricular space. The numbness has auricular space. The numbness has progressed to the point where the progressed to the point where the patient has blurred vision and can no patient has blurred vision and can no longer close her right eye.longer close her right eye.
HPI cont.
The patient states her right eye tears a The patient states her right eye tears a lot and she drools from the right side of lot and she drools from the right side of her mouth. She also admits to having her mouth. She also admits to having difficulty eating and drinking even difficulty eating and drinking even with a straw. She states Motrin has with a straw. She states Motrin has helped with the pain. She denies helped with the pain. She denies weakness to her extremities, loss of weakness to her extremities, loss of consciousness, or head trauma.consciousness, or head trauma.
Past Medical History HypothyroidismHypothyroidism SarciodosisSarciodosis
Medications SynthroidSynthroid
Allergies NKDANKDA NKFANKFA
Vital Signs BPBP 166/102166/102 HRHR 8484 RRRR 1616 TempTemp 98.098.0 HtHt 68 inches68 inches WtWt 204 lbs204 lbs
Physical Exam Gen: Pt. A/O x 3 w/ Rt. side facial droopGen: Pt. A/O x 3 w/ Rt. side facial droop HEENT: NC/AT, PERRLA, + red reflex b/l, HEENT: NC/AT, PERRLA, + red reflex b/l,
EOM intact, ptosis of rt. eye, + light reflex EOM intact, ptosis of rt. eye, + light reflex b/l, disc margins sharp, no A-V nicking, b/l, disc margins sharp, no A-V nicking, TM’s and canals clr., good acuity b/l, nares TM’s and canals clr., good acuity b/l, nares patent, septum midline, MMM&P, pharynx patent, septum midline, MMM&P, pharynx clr., MMM&P, throat supple, trachea clr., MMM&P, throat supple, trachea midline, no lymphadenopathy. midline, no lymphadenopathy.
Physical Exam Thorax:Thorax: Symmetrical w/ equal Symmetrical w/ equal
expansion, breath sounds vesicular and expansion, breath sounds vesicular and CTA b/l.CTA b/l.
CVA: Normal S1,S2 w/ no murmurs, rubs, CVA: Normal S1,S2 w/ no murmurs, rubs, or gallops. No JVD.or gallops. No JVD.
EXT: No edema. Good pulses x 4 extrem.EXT: No edema. Good pulses x 4 extrem.
Neurological Mental Status: Alert and orientedMental Status: Alert and oriented Cranial Nerves: I – VI intactCranial Nerves: I – VI intact
VII rt. side sens/mtr deficitVII rt. side sens/mtr deficit VIII – XII intact VIII – XII intact
Motor: Strength 5/5 throughout. Gait normal.Motor: Strength 5/5 throughout. Gait normal. Sensory: Romberg neg., pinprick, light touch, Sensory: Romberg neg., pinprick, light touch,
position, vibration, and stereognosis intact.position, vibration, and stereognosis intact. Reflexes: Bi, tri, sup, abd, knee, ankle, & pl 2+ Reflexes: Bi, tri, sup, abd, knee, ankle, & pl 2+
R/O Bell’s Palsy CT of the headCT of the head Lyme titersLyme titers
Differential Diagnosis TIATIA Ramsay Hunt SyndromeRamsay Hunt Syndrome Acoustic NeuromasAcoustic Neuromas Heerfordt’s SyndromeHeerfordt’s Syndrome Melkersson-Rosenthal SyndromeMelkersson-Rosenthal Syndrome
Bell’s Palsy Described by Sir Charles Bell in the Described by Sir Charles Bell in the
1919thth century. century. Idiopathic form of facial paralysis Idiopathic form of facial paralysis
resulting from inflammation of the resulting from inflammation of the facial nerve.facial nerve.
Epidemiology 40,000 to 50,000 Americans annually.40,000 to 50,000 Americans annually. May occur at any age.May occur at any age. More common amongst pregnant More common amongst pregnant
women and those suffering from women and those suffering from diabetes, influenza, common cold, or diabetes, influenza, common cold, or some other upper respiratory ailment.some other upper respiratory ailment.
Occurs more often in spring or fall.Occurs more often in spring or fall.
Pathophysiology Etiology unknownEtiology unknown Some research leans towards herpes Some research leans towards herpes
virus as a causevirus as a cause Sarcoidosis and Lymes Disease also Sarcoidosis and Lymes Disease also
potential causespotential causes
Signs and Symptoms Unilateral facial Unilateral facial
paralysisparalysis Inability to close Inability to close
the eyethe eye Absence of the Absence of the
nasolabial foldnasolabial fold May be loss of taste May be loss of taste
on anterior tongueon anterior tongue
Pain behind the earPain behind the ear TearingTearing DroolingDrooling HyperacusisHyperacusis Sag of the eyebrowSag of the eyebrow
Diagnosis Based on clinical findingsBased on clinical findings Imaging studies used to rule out other Imaging studies used to rule out other
pathologypathology Lyme titers, PCR testing may indicate Lyme titers, PCR testing may indicate
causecause
Treatment Corticosteroids (efficacy not proven)Corticosteroids (efficacy not proven) AnalgesicsAnalgesics Lubricating eye dropsLubricating eye drops Taping eye closed at nightTaping eye closed at night Massage of the weakened musclesMassage of the weakened muscles
Prognosis Generally very goodGenerally very good Most patients get significantly better in Most patients get significantly better in
about 2 weeks even without treatmentabout 2 weeks even without treatment 80-85% recover completely within 3 80-85% recover completely within 3
monthsmonths 10% have permanent disfigurement or 10% have permanent disfigurement or
other long term sequelaeother long term sequelae
References National Institute of Neurological Disorders National Institute of Neurological Disorders
and Stroke (online)and Stroke (online) National Institute of Dental and National Institute of Dental and
Craniofacial Research (online)Craniofacial Research (online) Merck Manual (online)Merck Manual (online) Harrison’s Principals of Internal MedicineHarrison’s Principals of Internal Medicine