A 38-year-old previously well man presents complaining of new onset left-sided facial droop and numbness upon waking this morning. The patient reports drooling, particularly while drinking or eating, and states his coffee tasted “weird” the last couple of days. He denies any recent illnesses, pain, head trauma, fever, headache, extremity weakness, confusion, anxiousness, abnormal speech, and vision changes, and he notes that his left eye is dry because it is difficult to shut it. The patient admits to a history of hypertension, hyperlipidemia, and tobacco use but states compliance with his medications. He was a smoker on the outside, but has not had tobacco in 2 years. He reports using water in his left eye to try to alleviate the dryness with some results. He dropped a Health Services Request form 2 days ago because his symptoms are getting worse, and is being seen in the clinic by you, the Sick Call Nurse.
The patient’s medical history is significant for hypertension (diagnosed 5 years ago and well controlled), hyperlipidemia (compliant on statins for 4 years), and he is obese. His social history is pertinent for tobacco use (20-pack-year history), but has not had tobacco for 2 years during his incarceration.
Penicillin (reaction: hives); no known food allergies.
Hydrochlorothiazide 12.5 mg, 1 tablet PO QD.
Simvastatin, 20 mg, 1 tablet PO QHS
Vitals: T 36.9°C (98.4°F), P 77, R 16, BP 116/76 mmHg, HT 178 cm (70 in.), WT 109.8 kg (242 lbs), BMI 34.7.
General: A&O×4. Nontoxic appearing. Ambulates with steady gait. Speaks in full sentences. Psychiatric: Cooperative.
Head: Normocephalic/atraumatic. +Facial asymmetry. No left forehead creases with raising of eyebrows.
Eyes: Left ptosis. Left mild scleral injection.
PERRL bilaterally. EOM intact bilaterally. Conjunctivae pink bilaterally. Non-tender to palpation bilaterally.
Mouth: Left droop, drooling. Moist mucous membranes.
Lungs: Clear to auscultation bilaterally without adventitious sounds.
Chest: S1, S2 – RRR. No murmurs, rubs, or gallops.
Musculoskeletal: 5/5 equal strengths in all extremities. Sensation grossly intact.
Neurologic: Left-sided facial droop. Cranial nerves III/V/VII decreased. Decreased sharp/dull sensation to left side of face. No (dysphasia) slurred speech. No pronator drift. Cranial nerves II, IV, VI, IX to XII intact.
Correctional Nurse Actions
Conduct Nurse Sick call and document assessment. Noting the abnormal neurologic findings and history, refer for a same-day provider appointment.
Differential Diagnoses for Mr. Grant
Cerebrovascular accident needs to be considered. The patient has a unilateral facial droop, numbness, and acute onset. He has a history of hypertension, smoking, obesity, and hyperlipidemia. A CVA is less likely given lack of slurred speech, pronator drift, unilateral extremity weakness, and confusion.
Bell’s palsy is a likely diagnosis. The patient presents with unilateral facial droop/numbness. He is unable to close his eyelid and wrinkle forehead. There is no arm drift, slurred speech, or extremity weakness.
Intracranial mass is considered because of the neurologic findings on exam and the patient’s smoking history. This diagnosis is less likely given the acute versus gradual/progressive onset and the absence of headache/seizures/gait abnormalities.
Guillain-Barre syndrome is on the differential list because of the patient’s facial droop/numbness. However, this is a less likely diagnosis because Guillain-Barre syndrome usually presents bilaterally and has a ground-to-brain progression of symptoms.
Multiple sclerosis can present with ptosis and facial droop/numbness, but this diagnosis is less likely given that the patient has no additional neurologic symptoms/findings like extremity weakness or history of the same, though the current presentation could present the first episode.
Lyme disease is considered but has low likelihood. The patient has focal neurologic symptoms but no “target” rash, no myalgias/arthralgias, and no reported tick exposures.
Most Likely Diagnosis
Bell’s palsy is the most likely diagnosis given the patient’s unilateral facial droop/numbness/ weakness and his inability to close his eyelid or wrinkle his left forehead. Important, he has no pronator drift, dysphasia, or unilateral extremity weakness, which would make CVA more likely.
Bell palsy is a clinical diagnosis and diagnostic testing is rarely indicated. Diagnostic criteria are as follows: (1) diffuse facial nerve (CN VII) involvement manifested by paralysis/weakness of the facial muscles, with or without loss of taste on the anterior two-thirds of the tongue or altered secretion of the lacrimal and salivary glands, and (2) acute onset and recovery usually within 6 months. Non-contrast CT of the head can assess for intracranial pathology (e.g., stroke) if presentation is unclear or complicated.
Bell’s palsy is an acute peripheral unilateral facial neuropathy likely caused by an inflammation/infection of the facial nerve (CN VII); however, its complete pathophysiology is poorly understood. Most cases are idiopathic in nature, but a herpes simplex–mediated viral inflammatory/immune response is the commonly and widely accepted etiology. Viral infection or reactivation is postulated to lead to nerve demyelination while inflammation and edema are implicated in nerve compression.
Mr. Grant is started on 60 mg prednisone once daily for 7 days in addition to 1,000 mg valacyclovir TID for 7 days.
Mr. Grant was advised to return to the clinic in one week for reevaluation and further management, or sooner if he develops adverse medication effects or if other symptoms arise.
Patient education was conducted regarding the pathophysiology of Bell’s palsy; his prognosis; and potential adverse effects of prednisone. Warning signs/symptoms and return precautions were also explained. Mr. Grant’s questions were answered and he verbalized understanding of all teachings.
The patient did well and recovered completely in 4 weeks.
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