Case Presentation by Michael Armstrong by Michael Armstrong

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Transcript of Case Presentation by Michael Armstrong by Michael Armstrong

  • Slide 1
  • Case Presentation by Michael Armstrong by Michael Armstrong
  • Slide 2
  • Chief Complaint My face is numb on the right side, my vision is blurry, and I cant close my right eye. My face is numb on the right side, my vision is blurry, and I cant close my right eye.
  • Slide 3
  • History of present illness Patient is a 39 y/o Hispanic female with a 2 day complaint of numbness to the right side of her face following an aching pain in the right posterior auricular space. The numbness has progressed to the point where the patient has blurred vision and can no longer close her right eye. Patient is a 39 y/o Hispanic female with a 2 day complaint of numbness to the right side of her face following an aching pain in the right posterior auricular space. The numbness has progressed to the point where the patient has blurred vision and can no longer close her right eye.
  • Slide 4
  • HPI cont. The patient states her right eye tears a lot and she drools from the right side of her mouth. She also admits to having difficulty eating and drinking even with a straw. She states Motrin has helped with the pain. She denies weakness to her extremities, loss of consciousness, or head trauma. The patient states her right eye tears a lot and she drools from the right side of her mouth. She also admits to having difficulty eating and drinking even with a straw. She states Motrin has helped with the pain. She denies weakness to her extremities, loss of consciousness, or head trauma.
  • Slide 5
  • Past Medical History Hypothyroidism Hypothyroidism Sarciodosis Sarciodosis
  • Slide 6
  • Medications Synthroid Synthroid
  • Slide 7
  • Allergies NKDA NKDA NKFA NKFA
  • Slide 8
  • Vital Signs BP166/102 BP166/102 HR84 HR84 RR16 RR16 Temp98.0 Temp98.0 Ht68 inches Ht68 inches Wt204 lbs Wt204 lbs
  • Slide 9
  • Physical Exam Gen: Pt. A/O x 3 w/ Rt. side facial droop Gen: Pt. A/O x 3 w/ Rt. side facial droop HEENT: NC/AT, PERRLA, + red reflex b/l, EOM intact, ptosis of rt. eye, + light reflex b/l, disc margins sharp, no A-V nicking, TMs and canals clr., good acuity b/l, nares patent, septum midline, MMM&P, pharynx clr., MMM&P, throat supple, trachea midline, no lymphadenopathy. HEENT: NC/AT, PERRLA, + red reflex b/l, EOM intact, ptosis of rt. eye, + light reflex b/l, disc margins sharp, no A-V nicking, TMs and canals clr., good acuity b/l, nares patent, septum midline, MMM&P, pharynx clr., MMM&P, throat supple, trachea midline, no lymphadenopathy.
  • Slide 10
  • Physical Exam Thorax:Symmetrical w/ equal expansion, breath sounds vesicular and CTA b/l. Thorax:Symmetrical w/ equal expansion, breath sounds vesicular and CTA b/l. CVA: Normal S1,S2 w/ no murmurs, rubs, or gallops. No JVD. CVA: Normal S1,S2 w/ no murmurs, rubs, or gallops. No JVD. EXT: No edema. Good pulses x 4 extrem. EXT: No edema. Good pulses x 4 extrem.
  • Slide 11
  • Neurological Mental Status: Alert and oriented Mental Status: Alert and oriented Cranial Nerves: I VI intact VII rt. side sens/mtr deficit VIII XII intact Cranial Nerves: I VI intact VII rt. side sens/mtr deficit VIII XII intact Motor: Strength 5/5 throughout. Gait normal. Motor: Strength 5/5 throughout. Gait normal. Sensory: Romberg neg., pinprick, light touch, position, vibration, and stereognosis intact. Sensory: Romberg neg., pinprick, light touch, position, vibration, and stereognosis intact. Reflexes: Bi, tri, sup, abd, knee, ankle, & pl 2+ Reflexes: Bi, tri, sup, abd, knee, ankle, & pl 2+
  • Slide 12
  • R/O Bells Palsy CT of the head CT of the head Lyme titers Lyme titers
  • Slide 13
  • Differential Diagnosis TIA TIA Ramsay Hunt Syndrome Ramsay Hunt Syndrome Acoustic Neuromas Acoustic Neuromas Heerfordts Syndrome Heerfordts Syndrome Melkersson-Rosenthal Syndrome Melkersson-Rosenthal Syndrome
  • Slide 14
  • Bells Palsy Described by Sir Charles Bell in the 19 th century. Described by Sir Charles Bell in the 19 th century. Idiopathic form of facial paralysis resulting from inflammation of the facial nerve. Idiopathic form of facial paralysis resulting from inflammation of the facial nerve.
  • Slide 15
  • 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 women and those suffering from diabetes, influenza, common cold, or some other upper respiratory ailment. More common amongst pregnant women and those suffering from diabetes, influenza, common cold, or some other upper respiratory ailment. Occurs more often in spring or fall. Occurs more often in spring or fall.
  • Slide 16
  • Pathophysiology Etiology unknown Etiology unknown Some research leans towards herpes virus as a cause Some research leans towards herpes virus as a cause Sarcoidosis and Lymes Disease also potential causes Sarcoidosis and Lymes Disease also potential causes
  • Slide 17
  • Signs and Symptoms Unilateral facial paralysis Unilateral facial paralysis Inability to close the eye Inability to close the eye Absence of the nasolabial fold Absence of the nasolabial fold May be loss of taste on anterior tongue May be loss of taste on anterior tongue Pain behind the ear Tearing Drooling Hyperacusis Sag of the eyebrow
  • Slide 18
  • Diagnosis Based on clinical findings Based on clinical findings Imaging studies used to rule out other pathology Imaging studies used to rule out other pathology Lyme titers, PCR testing may indicate cause Lyme titers, PCR testing may indicate cause
  • Slide 19
  • Treatment Corticosteroids (efficacy not proven) Corticosteroids (efficacy not proven) Analgesics Analgesics Lubricating eye drops Lubricating eye drops Taping eye closed at night Taping eye closed at night Massage of the weakened muscles Massage of the weakened muscles
  • Slide 20
  • Prognosis Generally very good Generally very good Most patients get significantly better in about 2 weeks even without treatment Most patients get significantly better in about 2 weeks even without treatment 80-85% recover completely within 3 months 80-85% recover completely within 3 months 10% have permanent disfigurement or other long term sequelae 10% have permanent disfigurement or other long term sequelae
  • Slide 21
  • References National Institute of Neurological Disorders and Stroke (online) National Institute of Neurological Disorders and Stroke (online) National Institute of Dental and Craniofacial Research (online) National Institute of Dental and Craniofacial Research (online) Merck Manual (online) Merck Manual (online) Harrisons Principals of Internal Medicine Harrisons Principals of Internal Medicine