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Case Presentation

by Michael Armstrong

Chief Complaint
My

face is numb on the right side, my vision is blurry, and I cant close my right eye.

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.

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.

Past Medical History


Hypothyroidism Sarciodosis

Medications
Synthroid

Allergies
NKDA NKFA

Vital Signs
BP

166/102 HR 84 RR 16 Temp 98.0 Ht 68 inches Wt 204 lbs

Physical Exam
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.

Physical Exam
Thorax: Symmetrical w/ equal expansion, breath sounds vesicular and CTA b/l. CVA: Normal S1,S2 w/ no murmurs, rubs, or gallops. No JVD. EXT: No edema. Good pulses x 4 extrem.

Neurological

Mental Status: Alert and oriented Cranial Nerves: I VI intact VII rt. side sens/mtr deficit VIII XII intact Motor: Strength 5/5 throughout. Gait normal. Sensory: Romberg neg., pinprick, light touch, position, vibration, and stereognosis intact. Reflexes: Bi, tri, sup, abd, knee, ankle, & pl 2+

R/O Bells Palsy


CT

of the head Lyme titers

Differential Diagnosis
TIA Ramsay

Hunt Syndrome Acoustic Neuromas Heerfordts Syndrome Melkersson-Rosenthal Syndrome

Bells Palsy
Described

by Sir Charles Bell in the 19th century. Idiopathic form of facial paralysis resulting from inflammation of the facial nerve.

Epidemiology
40,000

to 50,000 Americans annually. May occur at any age. 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.

Pathophysiology
Etiology

unknown Some research leans towards herpes virus as a cause Sarcoidosis and Lymes Disease also potential causes

Signs and Symptoms


Unilateral facial paralysis Inability to close the eye Absence of the nasolabial fold May be loss of taste on anterior tongue

Pain behind the ear Tearing Drooling Hyperacusis Sag of the eyebrow

Diagnosis
Based

on clinical findings Imaging studies used to rule out other pathology Lyme titers, PCR testing may indicate cause

Treatment
Corticosteroids Analgesics Lubricating

(efficacy not proven)

eye drops Taping eye closed at night Massage of the weakened muscles

Prognosis
Generally

very good Most patients get significantly better in about 2 weeks even without treatment 80-85% recover completely within 3 months 10% have permanent disfigurement or other long term sequelae

References
National Institute of Neurological Disorders and Stroke (online) National Institute of Dental and Craniofacial Research (online) Merck Manual (online) Harrisons Principals of Internal Medicine