Transcript BELLS_PALSY

BELL’S
PALSY
Internal Medicine
By Svetlana Gorbounov
PA-S
April, 2006
03/20/06
Patient ID: 28 y/o male
CC: follow up Bell’s palsy.
History of Present Illness
 Right face numbness and tingling with:
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progressing right ear and right
retroauricular pain, 8/10
inability to close right eye, it’s dryness
taste disturbance x 2 days
HPI (continued)
 ED dx: Bell's palsy
 Tx: Prednisone 20 mg tid,
Zovirax 400 mg x 5 /day
 States: often hiking in the forest for the past month.
 Denies:
tick bite, skin rashes, facial swelling,
hx of herpes, HIV, DM, TB,
resent cold, previous hx of facial palsy,
family hx of facial palsy
Past Medical History
 Childhood diseases:
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chicken pox x 4. No chronic medical
conditions.
 Surgeries: none
 Hospitalizations: none
Family History
 Father 55 y/o - HTN, allergic rhinitis.
 Mother 45 y/o W&A.
 Siblings: 2 brothers and 2 sisters, all
W&A.
 Children 3 and 7 y/o, both W&A.
Social History
 Married x 8 years, good relationship,
monogamous.
 Works as sales representative. Reports
high stress level lately.
 Denies tobacco or recreational drugs
 Admits occasional glass of wine.
 Hiking for exercise
Allergies:
 NKDA.
Medications:
 Prednisone:
20 mg tid x days 1-3
20 mg bid days 4-5
20 mg qd days 6-8
10mg qd days 9-10
 Zovirax 400 mg x 5/d - 7 days.
Review of System
 General. Denies weight change, fatigue,
fever, chills.
 Skin: Denies skin lesions or rashes.
 HEENT. Right retroauricular and ear pain
3/10, no facial pain. No tinnitus, hyperacusis,
hearing loss, or vertigo. No change of vision.
No changes in the left side of face.
Review of System (Continued)
 Negative : neck
respiratory
cardiovascular
gastrointestinal
genitourinary
endocrine
Review of System (Continued)
 Neurologic. Positive for:
- right sided facial numbness
- drooling of the right side
- incomplete closure of right eye
 Musculoskeletal. Negative for:
- muscle weakness in extremities
Physical Exam
 General. Well appearing obese male, in NAD.
 VS. BP 120/80, P 75, T 99.1, WT 270, HT 5’11”,
BMI 37.7
 Skin. Good color, no lesions or rashes.
 HEENT. TM intact bilaterally. No lesions in ear
canals bilaterally. PERLA, 4 mm bilaterally. EOM
intact, no nystagmus. Nose and oropharynx clear.
Parotid gland not enlarged, non-tender
 Neck, Lungs, Heart, GI - unremarkable.
Physical Exam (Continued)
 Neurologic.
Alert and oriented x3
Face asymmetry:
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Widened right palpebral fissure
Flattened right nasolabial fold
Sagging right eyebrow
Drooping of the right corner of
the mouth
Physical Exam (Continued)
Facial nerve exam:
 forehead wrinkling L>R.
 voluntary right eyebrow rise almost absent.
 unable to close right eye completely
Physical Exam (Continued)
Facial nerve assessment:
 smile is lateralized to the left
 puffing cheeks asymmetric, L>R.
Physical Exam (Continued)
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CN II-VI, VIII-XII intact.
No sensory deficit bilaterally
DTR 2+ equal
Good muscle tone thruought, strength
5/5 bilaterally
 In office LAB: blood sugar 213 random.
 Differencial diagnosis:
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Bell’s palsy
Rumsay Hunt syndrome
Zoster sine herpete.
Lyme disease
Stroke
HIV
Volume occupying lesion
Systemic diseases
Impression
 Bell’s palsy
 Hyperglucosemia
 Obesity
Plan
 Prednisone 20 mg tid x 2 days then
20 mg bid x 3 days then
20 mg qd x 3 days then
10 mg qd x 2 days
 Zovirax 400 mg x 5/d - 6 days
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Artificial tear drops prn in OD
Plan
(continue)
 Labs: CBC with diff, chem. 12, HbA1C,
lipid panel, TSH, free T4, Lyme IgM/IgG titers
 F/U in 10 days or sooner if symptoms worsen
 Consider discussion on wt reduction
F/U visit 03/29/06
 CC: f/u Bell’s palsy
 Subjective: Dx of Bell’s palsy 10 days ago
Right facial muscle weakness and taste alteration
diminished.
Able to close right eye completely.
No OD soreness or dryness.
No retroauricular pain or earache.
D/c prednisone on 03/28/06 and zovirax on 03/25/06.
Objective
 Skin: clear, no rashes or lesions.
 Neurologic:
Face asymmetry less prominent
Can slightly elevate right eyebrow
Right forehead wrinkling is absent
Smile is slightly asymmetric, slightly drawn to the left
OD closure complete, tight closure absent
Puffing chicks L>R. CN II-VI and VIII-XII intact
 Labs:
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CBC – WNL
Chem 12, HbA1C, lipid panel, TSH with FT4 –
WNL
Lyme titers negative
 Impression:
Bell’s palsy, improvement.
Obesity.
Plan
 Self massage of the face.
 Facial muscle exercises using passive range
of motion as well as actively closing eyes and
smiling.
 Weight reduction: diet, exercise.
 F/u in 2 months or sooner if symptoms of face
palsy reoccur.
Keep in mind
• Lyme disease
• HIV
• Cat scratch in
children
• Volume occupying
lesion
• Systemic diseases