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BELL’S 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: progressing right ear and right retroauricular pain, 8/10

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BELL’S PALSY

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  1. BELL’S PALSY Internal Medicine By Svetlana Gorbounov PA-S April, 2006

  2. 03/20/06 Patient ID: 28 y/o male CC: follow up Bell’s palsy.

  3. History of Present Illness • Right face numbness and tingling with: • progressing right ear and right retroauricular pain, 8/10 • inability to close right eye, it’s dryness • taste disturbance x 2 days

  4. 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

  5. Past Medical History • Childhood diseases: • chicken pox x 4. No chronic medical conditions. • Surgeries: none • Hospitalizations: none

  6. 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.

  7. 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

  8. 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.

  9. 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.

  10. Review of System (Continued) • Negative : neck respiratory cardiovascular gastrointestinal genitourinary endocrine

  11. 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

  12. 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.

  13. Physical Exam (Continued) • Neurologic. Alert and oriented x3 Face asymmetry: • Widened right palpebral fissure • Flattened right nasolabial fold • Sagging right eyebrow • Drooping of the right corner of the mouth

  14. Physical Exam (Continued) Facial nerve exam: • forehead wrinkling L>R. • voluntary right eyebrow rise almost absent. • unable to close right eye completely

  15. Physical Exam (Continued) Facial nerve assessment: • smile is lateralized to the left • puffing cheeks asymmetric, L>R.

  16. Physical Exam (Continued) • CN II-VI, VIII-XII intact. • No sensory deficit bilaterally • DTR 2+ equal • Good muscle tone thruought, strength 5/5 bilaterally

  17. In office LAB: blood sugar 213 random. • Differencial diagnosis: • Bell’s palsy • Rumsay Hunt syndrome • Zoster sine herpete. • Lyme disease • Stroke • HIV • Volume occupying lesion • Systemic diseases

  18. Impression • Bell’s palsy • Hyperglucosemia • Obesity

  19. 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 • Artificial tear drops prn in OD

  20. 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

  21. 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.

  22. 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

  23. Labs: • CBC –WNL • Chem 12, HbA1C, lipid panel, TSH with FT4 – WNL • Lyme titers negative • Impression: Bell’s palsy, improvement. Obesity.

  24. 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.

  25. Keep in mind • Lyme disease • HIV • Cat scratch in children • Volume occupying lesion • Systemic diseases

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