SOURCE OF INFORMATION: History provided by the patient, reliable.
CHIEF COMPLAINT: Facial weakness.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who comes to the ER complaining of weakness to the right side of her face. She dates the onset of present illness to a day or so ago when she noted pain behind her right ear and also some abnormalities of taste. She has also noted difficulty in closing her right eye completely. She denies any recent URI symptoms, any pain in her ear canals, ringing in her ear, or sores in her mouth. She has had no headache, weakness of either arm or leg, numbness or tingling of the body, problem with walking or balance. She has no history of hypertension, no diabetes. She does not smoke cigarettes. At this time, she denies numbness to the face. She has no history of stroke or TIA. No sudden loss of vision in either eye.
MEDICATIONS: Currently include Actonel and alprazolam on a p.r.n. basis.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: The patient is married. She does not smoke.
REVIEW OF SYSTEMS:
GENERAL: No fever.
NEUROLOGIC: See HPI.
ENT: See HPI.
EYES: No blurred or double vision. No eye pain or foreign body sensation.
RESPIRATORY: No shortness of breath.
CARDIAC: No chest pain or syncope.
GASTROINTESTINAL: No nausea.
GENITOURINARY: No dysuria.
MUSCULOSKELETAL: No joint pain.
ENDOCRINE: No polyuria, polydipsia, polyphagia.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: She is well developed, well nourished, alert, and cooperative, in no acute distress.
VITAL SIGNS: Blood pressure 124/72, pulse 86, respirations 16, temperature 98.4, O2 sat 99% on room air.
SKIN: Warm and dry. No rash.
HEENT: Eyes: Pupils are 3 mm, nonreactive to light. EOM is intact without diplopia. No conjunctival injection. The patient is able to completely close her right eye without power. Fundi: No hemorrhage is seen. ENT: The nares and TMs are clear. Oropharynx: No mucosal lesions. Tongue is midline. Palate elevates symmetrical.
NECK: Supple. Carotids 2+ without bruits.
CHEST: Breath sounds equal bilaterally.
HEART: Regular rate and rhythm. No murmur, gallop, or rub. Peripheral pulses intact. No cyanosis.
ABDOMEN: Soft, nontender.
EXTREMITIES: Full range of motion. Distal neurovascular intact.
NEUROLOGIC: Alert and oriented x3. There is weakness of the right peripheral seventh nerve with flattening of the nasolabial fold and slight decrease on that side with smile on grimace. The patient is able to wrinkle her forehead on the right, though it appears to be slightly less than the left. Sensation is intact to light touch on both sides of the face. Strength 5/5 peripherally. No pronator drift. Tone normal. DTRs 2+/4 throughout. No clonus or Babinski. Gait normal.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING:
The patient appears to have Bell’s palsy. No clear etiology is suggested at this time given the incomplete nature of the findings. Her prognosis should be good. There is also a window of opportunity for pharmacologic management with acyclovir for possible herpes etiology and also prednisone. We prescribed valacyclovir 1 g t.i.d. for 7 days and prednisone 60 mg daily for 7 days. We also prescribed liquid tears and tear ointment for use at bedtime with a patching of the eye. Follow up for recheck in two days. A 12 lead EKG shows sinus rhythm at 68 beats per minute with PR interval of 156 milliseconds, restoration 78 milliseconds, QRS axis +98 consistent with rightward axis. There are no acute ST-T wave changes.
CLINICAL IMPRESSION: No evidence of dysrhythmia or ischemia or injury in this patient who presents with acute neurologic abnormality.
DIAGNOSIS: Bell’s palsy.
CONDITION ON DISCHARGE: Stable.
