Bell's Palsy

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of facial ‍weaknessparalysisdrooping on the ‍rightleft

Onset was ‍gradualsudden



Associated symptoms: *Try using right-click for negatives*

‍facial pain

‍facial numbness

‍drooling

‍change in taste

‍tearing

‍phonophobia

‍tinnitus

‍jaw pain

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍extremity weakness

‍difficulty walking

‍difficulty with speech

‍aphasia

‍fever, up to ‍°, over ‍ ‍hoursdays



Contributing factors:

‍recent viral infection

‍recent tick bite

‍stress

‍lack of sleep

no history of: ‍TIA, ‍stroke, ‍diabetes, ‍hypertension





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: ‍normocephalicatraumatic, scalp ‍normalrashlesion

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Neurologic:

- Mental status: ‍alert, oriented to ‍3 spheres, speech ‍intact

- Cranial nerves: ‍all intact

- Strength: ‍intact 5/5 throughout except for ‍4/5 on ‍rightleft ‍, ‍pronator drift

- Sensation: ‍intact throughoutdecreasedabsent to ‍light touch on ‍

- Reflexes: ‍intact 2+ throughout except for ‍1+ on ‍rightleft ‍, ‍plantar downward

- Cerebellar function: ‍intact, ‍normalimpaired finger-nose, ‍normalimpaired rapid alternating movements, ‍normalimpaired heel-shin, Romberg ‍negative, Dix-Hallpike ‍negative

- Gait: ‍steadyunsteady, ‍intactimpaired tandem gait, ‍intactimpaired heel walk and toe walk





ASSESSMENT:

‍Bell's palsy ‍likelysuspectedpossible

DDx: Bell's palsy, Lyme disease, herpes simplex virus reactivation, otitis media, Ramsay Hunt syndrome (herpes zoster oticus), sarcoidosis, acoustic neuroma, parotid gland tumors, stroke, TIA, HIV, diabetes mellitus, trauma to the facial nerve, multiple sclerosis





PLAN:

Investigations:

- Blood work: ‍CBC, ‍creatinine, ‍electrolytes, ‍glucose, ‍CRP, ‍coagulation profile, ‍Lyme serology

- CT scan of the brain

- MRI of the brain

Treatments:

- Advise that there is no signs of stroke, that condition is benign, and that most cases resolve spontaneously within a few months

- ‍Corticosteroids

- ‍Antivirals

- Eye care: artificial tears during the day, ointment at night, eye patch at night

- Facial exercises

Further care:

- Referral to ENT specialist within 10 days

- Referral to neurologist if central cause not ruled out

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen, if new symptoms develop such as vision changes or severe headache, or if symptoms do not improve with treatment

- Referral to ER if difficulty swallowing, difficulty breathing, or severe headache occurs