Identification:

• Name: M.R.
• Sex: Male
• Race: Asian
• Nationality: Bengali
• Age: 62
• Marital Status: Married
• Address:
• Religion:

Informant:

• Source of hx: Self
• Competency: Competent

 

Referral Source:  None

CC:  “ I cant move one side of my face” X4 hours

HPI:

62 y/o male with a pmhx of DM presents to the ED with c/o inability to move the right side of his face for the past 4 hours. Patient states that his symptoms started three days ago, when he started to notice he did not have a sense of taste on the right side of his tongue while eating. He then started to feel numbness that started yesterday on the right side of his face, but did not think much of it. This morning, while he was rinsing his mouth, he noticed while spitting water out, water remained in his mouth on the right side and was slowly exiting the mouth because the right side of his lip was mildly opened. He knew that something was wrong at that point and decided to come into the ER. Patient admits to numbness in the right side of his face. Denies dizziness, one sided or generalized weakness, loss of strength, gait problems, sight change, LOC, trauma to the head, recent illness, trouble swallowing, or any other symptoms.

DDx:

• Bell’s Palsy – Classic presentation; not an insidious onset; no body weakness, gait abnormality; dizziness or any other symptoms
• Stoke- one sided facial weakness with numbness; cannot exclude without labs and imaging

Pmhx: DM

 

Past surgical hx:

• No past surgical hx

Medications:

• Metformin 1000 MG tablet PO BID

Allergies:

• No known food, environmental or drug allergies.

Family hx:

• No known Family history

Social Hx:

• Denies using drugs, tobacco, alcohol use, recent travel.

General:

• Denies fever, chills, fatigue, loss or gain of weight, N/V, diaphoresis, loss of appetite and night sweats.

Skin, hair and nails:

• Denies change in texture to skin, hair and nails, excessive dryness, discolorations, pigmentations, sweating, moles/rashes, pruritis, and change in hair distribution.

Eyes:

• Denies visual disturbances, lacrimation, photophobia, itching, corrective lenses, blurriness, and discharge. Denies wearing glasses.

HENNT:

• Denies headaches, vertigo, head trauma
• Denies hearing loss, tinnitus, pain, discharge, wearing hearing aids
• Denies epistaxis, discharge, obstruction, rhinorrhea, stuffiness, sneezing, allergies
• Denies swelling/lumps, stiffness, or decreased ROM
• Denies sore throat, neck pain, hoarseness, bleeding in mouth/throat, sore tongue, mouth ulcers, voice changes or wearing dentures.

Pulmonary:

• Denies cough, wheezing, SOB, pain on inspiration, hemoptysis, orthopnea, cyanosis, PND, clubbing, or any history of asthma.

Cardiovascular:

• Denies CP, HTN, edema, palpitations, irregular heartbeats, syncope, claudication, murmurs, and orthopnea.

 

Gastrointestinal:

• Denies indigestion, intolerance of foods, N/V, diarrhea, jaundice, bleeding (oral or anal), hemorrhoids, constipation any change in BM, dysphagia, pyrosis, flatulence, blenching or burping, rectal bleeding and abdominal pain.

Genitourinary:

• Denies frequency, nocturia, urgency, dysuria, oliguria, lesions, discharge, hematuria, pyuria, dyspareunia, any flank pain.

 

Nervous System:

• Admits to decrease in sensation of the right side of his face
• Denies seizures, headache, LOC, loss of strength, change in cognition, mental status, memory, ataxia, sensory disturbances, syncope, slurring of speech, focal weakness, neck stiffness and tingling.

MSK:

• Denies joint/muscle pain, deformity, swelling, redness, arthritis.

Peripheral Vascular System:

• Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System:

• Denies new or known bruising, bleeding, petechiae, purpura, blood transfusions, lymph node enlargement, hx of DVT/PE and anemia

Endocrine:

• Denies polyphagia, polyuria, polydipsia, intolerance to heat/cold, goiter, excessive sweating or hirsutism.

Psychiatric:

• Denies depression/sadness, suicidal ideation, anxiety, seeing a mental health specialist, memory deficits, OCD, and taking medication for mental illness.

 

Physical

General:

• Thin male, well nourished, in no acute distressed. Acceptable hygiene appears age stated. Is alert and cooperative

Vitals:

• BP: R
  1. Seated 128/88
• R: 17 breaths/min, unlabored
• P: 76 beats/min, regular
• T: 9 degrees F (oral)
• O2 Sat: 98% Room air
• Height 5 feet 7 inches Weight 149 lbs.    BMI: 23.4

Skin:

• Warm and moist, good turgor, nonicteric, no lesions, scars, or tattoos.

Head:

• No scars, bumps, trauma, tenderness to palpation, normocephalic, atraumatic

Hair:

• Average quantity and distribution

Nails:

• No clubbing, cap refill <2 seconds throughout.

Eyes:

• symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white, no icterus; conjunctiva & cornea clear. Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU). Visual fields full OU. PERRLA.  EOMs full with no nystagmus. Funduscopic exam refused.

Ears:

• Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears.  No discharge / foreign bodies in external auditory canals AU.   TM’s pearly white / intact with light reflex in normal position AU.  Auditory acuity intact to whispered voice AU.

 

Nose:

• Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions / deformities / injection / perforation.   No evidence of foreign bodies.

Sinuses:

• Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Lips:

• Pink, moist; no evidence of cyanosis or lesions.

Mucosa:            

• Pink; well hydrated. No masses; lesions noted.  No evidence of leukoplakia.

Palate:

• Pink; well hydrated.   Palate intact with no lesions; masses; scars.

Teeth:

• Decent dentition / no obvious dental caries noted.

Gingivae:

• Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge.

Tongue:

• Pink; well papillated; no masses, lesions or deviation noted.

Oropharynx:

• Well hydrated; no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils absent, no hx of removal.  Uvula pink, no edema, lesions

Neck:

• Good ROM. Trachea midline. No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. No stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid:

• Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest:

• Symmetrical, no deformities, no evidence trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted.  Lat to AP diameter 2:1.   Non-tender to palpation.

Lungs:

• Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical.   Tactile fremitus intact throughout.  No adventitious sounds. No rales, Rochi, or wheezing heard.

Heart:  

• Carotid pulses are 2+ bilaterally without bruits. RRR; S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Abdomen:

• Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations.BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of hepatomegaly or splenomegaly. No masses noted.   No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Peripheral Vascular:

• The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

Mental Status:

• Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves:

• I – Intact no anosmia.
• II- VA 20/20 bilaterally. Visual fields by confrontation full. Funduscopic exam refused
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good. Corneal reflex not tested.
• VII- Facial movements asymmetrical with right sided weakness
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

 

Motor/Cerebellar:

• Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone throughout. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative.

Sensory:

• Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally.

Meningeal Signs:

• No nuchal rigidity noted. Brudzinski sign negative. Kernig’s sign negative.

MSK LE:

• No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

MSK UE:

• No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

Labs and Imaging:

• CBC – WNL
• BMP- WNL
• Finger Stick- 102
• CT head non-contrast- No signs of ischemic or hemorrhagic stroke
• Bell’s Palsy – Classic presentation; not an insidious onset; no body weakness, gait abnormality; dizziness or any other symptoms
• Stoke- one sided facial weakness with numbness; cannot exclude without labs and imaging
• TIA- even though labs and imaging are normal, patient could have been having TIA’s for the past three days, with heightening of symptoms this morning
• Tick Paralysis- sense of weakness, without a fever, sensory exam is normal, however, patient has no difficulty walking or breathing, so unlikely
• Cranial nerve inflammation or compression secondary to tumor or lesion- One side numbness and weakness with normal labs, however, CT head would be positive for a mass

Assessment:

62 y/o male with a pmhx of DM presents with complain of right sided facial weakness and numbness X 4 hours. All clinical findings indicate Bell’s palsy.

Plan:

Bell’s palsy:

• Polyvinyl Alcohol 1.4% Administer 1-2 drops to both eyes 3-4 times daily as needed for dry eyes
• Prednisone 20 MG tablet- Take 1 tablet a day 3 times a day for 7 days
• Val acyclovir 1000 MG tablet- Take 1 tablet by mouth 12 hours for 7 days

Diabetes:

• Continues Metformin 1000 MG tablet by mouth 2 times a day

Patient Education:

• Inform the patient that they did the right thing by coming into the emergency room.
• Bell ’s palsy is a condition where there is a temporary paralysis of the facial muscles, it usually affects one side of the face. It normally occurs after a viral infection, so it is thought to be viral, that is why anti-viral medication is administered. Steroids will also be given to help reduce any inflammation that has been caused by the virus and will help shorten time to full recovery. If it is possible, using an eye patch while sleeping at night, to help protect the eye, might be a good idea, but it is important not to tape the patch on, because the patch can scratch your eye and cause damage. It is important to keep your eyes moist, especially at night, to prevent permanent eye damage, so using the artificial tears that were prescribed would be more beneficial at night, considering that it could make your vision blurry during the day. As mentioned before, the effect of Bell’s palsy is only temporary, most of the time, and weakness of the face should decrease, with full function within 2-12 weeks. There is a small possibility that the effects of Bell’s palsy may be permanent and also a small chance of reoccurrence, but it is highly unlikely.
• Educate patient that if similar symptoms occur to promptly come to the emergency room right away, especially if they are associated with one-sided body weakness, dizziness, vision changes, abnormal walking, or anything else.
• Tell Patient to follow up with their PCP in one week to check for signs of recovery

Feedback:

As stated in the comments

Grade:A-