Internal Medicine
By Svetlana Gorbounov
PA-S
April, 2006

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

 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

 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

 Childhood diseases:
 chicken pox x 4. No chronic medical conditions.
 Surgeries: none
 Hospitalizations: none

 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.

 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

:
 NKDA.
:
 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.

 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.

(Continued)
 Negative : neck respiratory cardiovascular gastrointestinal genitourinary endocrine

(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

 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.

(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

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

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

(Continued)
• 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:

Bell’s palsy
 Rumsay Hunt syndrome
 Zoster sine herpete.
 Lyme disease

Stroke
 HIV
 Volume occupying lesion
 Systemic diseases

 Bell’s palsy
 Hyperglucosemia
 Obesity

 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

(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

 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.

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

 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.

• Lyme disease
• HIV
• Cat scratch in children
• Volume occupying lesion
• Systemic diseases