Chief complaint: Facial droop X 2 days
HPI:
62 y/o female with PMHx of GERD, HTN, HLD, migraines and a CVA 15 years ago presents to the emergency room today with complaints of left facial weakness and decreased taste in her mouth since yesterday morning, which has then worsened today. She mentions she could not come to the ER yesterday because she was working. Pt. denies headache, shortness of breath, fever, chills, chest pain, dysuria, cough, nausea, dizziness, numbness, tingling, diarrhea, constipation, or vomiting.
Past Medical History
GERD
HTN
Hyperlipidemia
Migraines without an aura
Stroke (circa 2009)
Past surgical history
EGD – QHC in July 2023
Screening Colonoscopy – QHC in June 2023
Medications
Amlodipine 5 mg – 1 tablet taken by mouth daily
Aspirin 81 mg – 1 tablet taken by mouth daily
Omeprazole 20 mg oral tablet – 1 tablet taken by mouth daily
Allergies
– NKDA
– Food allergy: Shellfish
– Denies seasonal allergies
Family history
– Father – DM, MI
– Mother – no known problems
Social History
Habits: denies drinking alcohol, smoking cigarettes, or using illicit substance abuse.
Travel: Pt has not traveled recently
ROS
General – Pt admits to left sided facial weakness. Denies fever, fatigue, and weight loss
Skin, Hair, Nails – denies any change in hair texture, excessive dryness or sweating, discolorations, pigmentations, rashes, or pruritus
Head – denies losing unconsciousness, headache or being lightheaded currently.
Eyes – Pt admits to lacrimation. Denies visual disturbances, blurry vision, fatigue, photophobia, or pruritus.
Nose/sinus – denies obstruction, discharge, or epistaxis.
Ears – denies deafness, pain, discharge, tinnitus, or hearing aids.
Mouth/throat – denies bleeding gums, sore tongue, mouth ulcers, voice changes or denture use.
Neck – denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – denies lumps, nipple discharge, or pain.
Pulmonary system – Denies orthopnea, dyspnea, wheezing, hemoptysis, cyanosis, cough, paroxysmal nocturnal dyspnea.
Cardiovascular system –Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur, chest pain or hypertension.
Gastrointestinal system – Denies vomiting, decreased appetite, pyrosis, flatulence, eructation, flank pain, diarrhea, jaundice, change in bowel habits, constipation, abdominal pain, pelvic pain, rectal bleeding, or dysphagia
Genitourinary system – Denies incontinence, change in urine color, polyuria, dysuria or nocturia
Menstrual/obstetrical –Denies any abnormalities such as vaginal bleeding, vaginal discharge, vaginal itching, or dyspareunia.
Nervous – Pt is complaining left-sided facial weakness. Denies weakness, sensory disturbances, or seizures.
Musculoskeletal system – Denies redness, back pain, arm pain, swelling or arthritis.
Peripheral vascular system – denies intermittent claudication, trophic changes, varicose veins, peripheral edema, or color changes.
Hematologic system – denies easy bruising and bleeding, anemia, lymph node enlargement, blood transfusions, or h/o DVT/PE.
Endocrine system – denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
Psychiatric – Denies helplessness or hopelessness, anxiety, depression, and a history of seeing a mental health professional, lack of interest in usual activities, suicidal ideation, or OCT.
Physical Exam
General: Female in her 60’s is awake, alert, and oriented x 3 and in no acute distress. She is dressed appropriately for the weather and has a good affect and mood.
Vital signs:
– BP: L: 124/84 mm/Hg
– Respiratory rate: 18 breaths/min, unlabored
– Pulse: 77 beats/min, regular
– Temperature: 97.9 degrees F (oral)
– O2 sat: 98% room air
Skin – No bruising was noted on the patient. Good turgor. No tenting. Normal body temperature was noted. Non-icteric
Hair – Average quantity and distribution. No nits or lice were seen; no seborrhea was noted
Nails – No clubbing was seen; cap refill was under 2 seconds. No splinter hemorrhages, lesions, swelling nor any beau’s lines were noted. Atraumatic.
Head – Normocephalic, atraumatic and non-tender to palpation.
Eyes – Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctive pink.
Ears – Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge, bleeding or foreign bodies in external auditory canal AU.
Nose – Symmetrical nares with no masses, lesions, deformities, trauma or discharge. Nares patent bilaterally. Nasal mucosa pink. No discharge noted on anterior rhinoscopy. Septum midline without any lesions, deformities or perforation. No foreign bodies.
Sinuses – Non tender to palpation and percussion over bilateral frontal and maxillary sinuses.
Lips – Pink, moist with no cyanosis or masses noted. Non-tender to palpation.
Oral Mucosa – Pink and well hydrated. No masses, lesions or leukoplakia noted.
Palate – Pink and well hydrated. No masses or lesions noted.
Teeth – Good dentition with a couple of filled cavities noted.
Gingivae – Pink and moist. No hyperplasia or masses.
Tongue – Pink, well papillated. No masses, lesions or deviation noted.
Oropharynx – Well hydrated with no erythema, exudates, masses, or lesions. Tonsils are present with no erythema or exudates. Uvula midline with no lesions noted.
Neck – Trachea midline. No masses, lesions, or scars noted. Supple and non-tender to palpation. Full range of motion. No palpable cervical adenopathy.
Thyroid – Non-tender, no thyromegaly. No palpable nodules nor any bruits noted.
Chest – Symmetrical, no deformities and no trauma noted. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout
Lungs – Symmetrical expansion with respiration. No intercostal retractions, or tenderness. Breath sounds clear to auscultation bilaterally. No rales/wheezes/rhonchi auscultated.
Heart – Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdomen – Non-distended, soft and non-tender. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No palpable masses or organomegaly. No inguinal hernia. No palpable lymphadenopathy. Costovertebral angle nontender.
Mental status exam: Patient is well appearing, has good hygiene and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory and attention intact.
Neurological: Cranial nerve deficit with dysarthria and facial asymmetry (left-sided drooping) noted.
Motor/Cerebellar: Weakness with an incomplete eyebrow lift on the left side of her face and drooping of the angle of the left side of her mouth noted. Also noted was a decreased ability to blink left eye. Full active/passive ROM of all upper and lower extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 of both upper and lower extremities. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, and no asterixis
Reflexes: 2+ throughout, negative Babinski, no clonus appreciated
Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative
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 stasis changes or ulcerations noted. No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy.
DDX
Bell’s Palsy
CVA
Assessment: 62 y/o female with PMHx of GERD, HTN, HLD, migraines and a CVA 15 years ago presents to the emergency room today with complaints of left facial weakness and decreased taste in her mouth since yesterday morning, which has then worsened today. On physical exam left sided weakness was noted with drooping angle on the left side of the mouth, decreased inability to blink left eye, and incomplete left-sided eyebrow lift.
Plan: CT Head without contrast, CBC, CMP, PTT, PT/INR, EKG and Rapid Covid/Flu.
Since Bell’s Palsy is very high on the differential Solu-MEDROL 125 mg injection and a valacyclovir 1000 mg tablet will be given while the patient waits for her CT scan.
Will continue to monitor patient and discussed case with attending.
