Assessing Neurological Symptoms
Patient Information:
Initials: JH Age: 33 years old Sex: Female Race: Hispanic
S.
CC: “The right side of my face has been dropping since morning.”
HPI: JH is a 33-year-old Hispanic female who came to the hospital complaining of her right face ‘drooping.’ She claims that the feeling started in the morning on the same day that she came to the hospital. She also complains of excessive tearing and drooling on the whole of her right side. She is however in no pain.
Location: right side of the face
Onset: in the morning
Character: drooping face
Associated signs and symptoms: excessive tearing and drooling on her right side
Timing: In the morning
Exacerbating/ relieving factors: none has been mentioned
Severity: not specified
Current Medications: None
Allergies: No known allergies to drugs, food or any environmental factor.
PMHx: No history given. No surgical history.
Soc Hx: Occupational and major hobbies in addition to family status has not been provided.
Fam Hx: Family history has not been provided.
ROS:
GENERAL: Denies weight loss, chills, fever, fatigue or general weakness.
HEENT: Eyes: Confirms excessive tearing. Denies visual loss, double vision, blurred vision, or yellow sclerae. Ears, Nose, Throat: Denies, hearing loss, congestion, sneezing, sore throat or runny nose.
SKIN: Denies itching or skin rash
CARDIOVASCULAR: Denies chest pain, chest discomfort or chest pressure. No edema or palpitations.
RESPIRATORY: Denies breathing problems, shortness of breath, sputum or cough. No shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies nausea or vomiting, diarrhea or anorexia. Denies abdominal pain or bleeding.
GENITOURINARY: Denies burning on urination, painful urination or excessive urine frequency.
NEUROLOGICAL: Confirms drooping of the right side of the face. Confirms drooling on her right side. Denies headache, syncope, dizziness, ataxia, paralysis. Denies any change in bladder or bowel control.
MUSCULOSKELETAL: Denies muscle or joint pain or stiffness.
HEMATOLOGIC: Denies bleeding, bruises or history of anemia.
LYMPHATICS: Denies enlarged lymph nodes or any history of organomegaly.
PSYCHIATRIC: Denies any history of anxiety, depression or mania.
ENDOCRINOLOGIC: Denies excessive sweating, excessive cold or heat intolerance. Denies polydipsia or polyuria.
ALLERGIES: Denies any history of asthma attacks, eczema, hives, rhinitis or any allergic reactions.
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Physical exam:
GENERAL: The patient is fatigued with general body weakness. Fever & chills are also present. No weight gain or weight loss.
HEAD: Her head is normocephalic and atraumatic with no injury
EENT: Eyes: white sclera, pinkish conjunctiva, no jaundice or pallor. Presence of excessive tearing in the right eye, no movement on the eyebrows, eyelid opening is normal; lower lid is sagging. Ears, Nose, Throat: No hearing problems, sneezing, running nose, sore throat or congestion. The nasolabial fold is absent on the right side. Presence of drooling on her right side, no movement of lips and mouth slightly open on the left side.
SKIN: Normal warm skin with no lesions, itching or dryness.
CARDIOVASCULAR: No murmurs. Heart rhythm and heart rate is normal, with good S1 &S2 sound and no S3 & S4. No signs of peripheral edema.
RESPIRATORY: No breathing problems, respiration is even and unlabored. No cough, sputum or shortness of breath.
GASTROINTESTINAL: soft abdomen with no tenderness on palpation. Presence of bowel sounds in all of the four quadrants.
NEUROLOGICAL: Paralysis of the right facial nerve.
MUSCULOSKELETAL: ROM, no joint pain, back pain or stiffness.
LYMPHATICS: No signs of enlarged lymph nodes.
Diagnostic results: unilateral, single episodes that involve all the nerve branches is an indication of Bell’s palsy. Consequently, studies show that unequal distribution of weakness on different zones of the face on physical examination suggests Bell’s palsy (Eviston et al., 2015). This condition occurs at any age above two years, but most commonly experienced by individuals between the age of 15 to 45 years. It is also important to check for the presence or absence of other associated symptoms such as dry eyes, synkinesis, and pain to be able to rule out other differential diagnoses. From the physical examination, the patient is suspected of having an acute unilateral facial palsy which is a significant indication of Bell’s palsy. Other imaging tests such as needle electromyography (EMG), CT scan, and MRI are necessary for ruling out other conditions with the same symptoms (Wiggins, & Ashok, 2015). Serological test for Borrelia Burgdorferi should also be requested, such that a negative result will indicate bell’s palsy as a possible diagnosis.
A.
Differential Diagnoses:
- Bell’s Palsy: Bell’s palsy is a neurological condition characterized by an acute unilateral palsy of the peripheral facial nerve. The diagnosis of this condition is normally confirmed in patients of whom medical history and physical examination are unremarkable, including deficits that affect all the zones of the face equally, and fully resolve within three days. Bell’s palsy leads to a sudden weakness of the facial muscles temporarily, which makes one side of the face to droop (Eviston et al., 2015). The patient in the assigned case scenario is positive for most of the indicating signs and symptoms of Bell’s palsy making this condition the most appropriate diagnosis.
- Lyme disease: This is a bacterial infection that is transmitted by a vector, infected black-legged tick which is commonly referred to as the deer tick. Prolonged infection causes injury to the neurological system that may present as paralysis on one side of the face, weakness in both limbs, numbness, and impaired movement of muscles (Wormser et al., 2015).
- Facial nerve schwannoma: This is a type of a primary benign intracranial tumor of the vestibular nerve of the myelin-forming calls. The main sign and symptoms of this condition is the slow progression of facial nerve paralysis which causes drooping of the face, which the patient in this case study is positive for (Slattery, 2014). Additional symptoms include hearing loss, vestibular symptoms, pain, and tinnitus.
- Idiopathic orofacial granulomatosis (Melkersson-Rosenthal syndrome): This condition is characterized by insidious and slowly progressive paralysis of the facial nerve. The parotid mass is usually palpable upon physical examination (Miest et al., 2017).
- Cerebrovascular accident (CVA): This condition is commonly known as stroke, and it is caused by blockage or rupture of blood vessels supplying blood to the brain. It is characterized by numbness and paralysis in the face which the patients positive for, among other symptoms (Karliński, Gluszkiewicz, & Członkowska, 2015). These symptoms include difficulty in walking, loss of balance and coordination, dizziness, blurred or darkened vision, a sudden headache that is accompanied by nausea and vomiting and difficulty in speaking.
References
Eviston, T. J., Krishnan, A. V., Croxson, G. R., Kennedy, P. G. E., & Hadlock, T. (December 01, 2015). Bell’s palsy: Aetiology, clinical features, and multidisciplinary care. Journal of Neurology, Neurosurgery, and Psychiatry, 86(12), 1356-1361.
In Slattery, W. H. (2014). The facial nerve. New York, NY: Thieme.
In Wiggins, R. H., & In Ashok, S. (2015). Head and neck imaging. Philadelphia, PA: Elsevier.
Karliński, M., Gluszkiewicz, M., & Członkowska, A. (January 01, 2015). The accuracy of prehospital diagnosis of acute cerebrovascular accidents: an observational study. Archives of Medical Science, 11(3), 530-535.
Miest, R. Y., Bruce, A. J., Comfere, N. I., Hadjicharalambous, E., Endly, D., Lohse, C. M., & Rogers, R. S. (January 01, 2017). A Diagnostic Approach to Recurrent Orofacial Swelling: A Retrospective Study of 104 Patients. Mayo Clinic Proceedings, 92(7), 1053-1060.
Wormser, G. P., Weitzner, E., McKenna, D., Nadelman, R. B., Scavarda, C., & Nowakowski, J. (January 01, 2015). Long-term assessment of fatigue in patients with culture-confirmed Lyme disease. The American Journal of Medicine, 128(2), 181-4.
Patient Information:
B.B., 22 years old, African America female
S.
CC (chief complaint): “Facial drooping”
HPI: The client is a 22-year-old African American female who visited the facility with complaints of facial drooping. The patient reports that she noticed facial drooping while looking at herself in the mirror. She noted that the left side of her mouth is slanted when she smiles. She also reported some headaches off and on for a few days. The patient’s sense of taste has decreased. She felt the decrease when brushing her teeth.
Current Medications: The patient denied any current use of medications.
Allergies: The patient reports that she is allergic to penicillin. She develops a cough and wheezing when she takes penicillin-containing medications. She also reported a history of seasonal allergies.
PMHx: The client reports that she was hospitalized when she was 18 years old because of meningitis. She denied any history of surgeries. She also denied any other history of chronic illnesses.
Soc & Substance Hx: The patient is a university student. She is majoring in business and finance. She reports that she takes alcohol occasionally. She does not smoke or use illegal substances. She is the only child in her family. The patient lives with her parents in a rented apartment. The patient spends her leisure time with her friends, reading, or visiting new places. She wears a seat belt when driving and a helmet when riding a bicycle. The client denies being in any relationship. Their home has smoke detectors.
Fam Hx:
Her mother has asthma, diabetes, and hypertension
Her father smokes, has hypertension, and is obese
Her grandfather has heart disease
Her grandmother has dementia
Surgical Hx: The client denied any history of surgical procedures
Mental Hx: Diagnosis and treatment. Current concerns: The client reports that she has never been diagnosed or started treatment for mental health problems such as major depression or anxiety.
Reproductive Hx: The client reports that her menarche started when she was 13 years old. She has a regular menstrual cycle that occurs after every 28-32 days and lasts 4-5 days. She denies any problems with her menstrual cycle. The client has never been pregnant. She has a history of contraceptive use. She denies being in any relationship currently. The client reports that she prefers sexual relationships with men. She engages in vaginal sex. She denies a history of sexually transmitted infections. The patient denies urgency, frequency, or dysuria.
ROS:
GENERAL: The client is dressed appropriately for the occasion. She denies fever, weight loss, or chills. There is evident facial drooling on the left side.
HEENT: Eyes: The client does not wear corrective lenses. She reports left eye dryness due to the facial drooping problem. She cannot close the left eyelid. She denies eye pain, drainage, or blurred vision. Ears, Nose, Throat: She denies changes in hearing, sneezing, nasal congestion, or a sore throat.
SKIN: She denies itchiness, skin rash, or abnormal findings on her self-breast examination.
CARDIOVASCULAR: The client reports no experiences of chest pain, discomfort, or palpitations
RESPIRATORY: The client denies any experiences of cough, difficulty breathing, wheezing, or sputum production
GASTROINTESTINAL: The client reports a decreased sensation of taste. She denies nausea, vomiting, diarrhea, or abdominal pain
NEUROLOGICAL: The client reports left-side facial drooping. She denies syncope, loss of consciousness, changes in her bladder and bowel control, loss of balance, or difficulty coordinating movements
MUSCULOSKELETAL: The client denies muscle or joint pain, inflammation, stiffness, or decreased range of motions
HEMATOLOGIC: The client denies easy bruising or a history of anemia.
LYMPHATICS: The client reports that she has no history of lymph node surgical removal. She denies lymphadenopathy.
PSYCHIATRIC: The client denies a history of mental health disorders such as depression and anxiety
ENDOCRINOLOGIC: The client denies experiencing heat or cold intolerance. She also denies diabetes-related symptoms such as polyuria, polyphagia, or polydipsia.
GENITOURINARY: The client denies urinary leakage, dysuria, urinary frequency or urgency
ALLERGIES: MA is allergic to penicillin and has seasonal allergies
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Physical exam:
Vitals: BP 108/70, P 72, T 99.1, RR 20, SPO2 98%
Respiratory system: There is no wheezing, cough, sputum production, dyspnea, or respiratory distress
Cardiovascular system: Presence of S1 and S2 heart sounds. Absence of S3 and S4 heart sounds and peripheral edema
Skin: There is left-sided facial drooping. There is increased pain sensitivity when the affected side is touched.
Neurological: There is left-sided facial drooping. There is increased pain sensitivity to touch on the affected side. The client is unable to close the left eyelid. There is no syncope, decreased level of consciousness, or balance and gait problems
Diagnostic results: Nerve conduction test and electromyography should be performed to determine nerve involvement and its severity. The studies will also provide insights into the prognosis of the client’s problem. A complete blood count should also be performed to rule out causes such as viruses. A blood test for Lyme disease should also be conducted. Ophthalmic examination should be performed to determine eyelid position, orbicularis strength, and lagophthalmos (Singh & Deshmukh, 2022). The additional laboratory investigations that should be done include a syphilis screen, erythrocyte sedimentation rate, and C-reactive protein tests.
A.
Primary and Differential Diagnoses
Bell’s palsy: Bell’s palsy is the client’s primary diagnosis. Bell’s palsy is a condition that develops from the inflammation of cranial nerve VII. Bell’s palsy is characterized by symptoms that include partial or total unilateral paralysis, facial droop, drooling, asymmetric smile, and poor eyelid closure. Other symptoms that patients might experience include a loss of taste, jaw pain, sensitivity to sound on the affected side, and headache (Singh & Deshmukh, 2022; Zhang et al., 2020). The client in the case study has these symptoms, hence, Bell’s palsy is her primary diagnosis.
Stroke: Stroke is one of the differential diagnoses that should be considered. Stroke is a neurological disorder that develops from inadequate blood supply to the brain. It develops from causes associated with either bleeding to the brain or occlusion of the blood supply. Patients experience symptoms such as paralysis, difficulty speaking, unilateral numbness, headache, and difficulty walking among others (Murphy & Werring, 2020; Powers, 2020). Stroke is the least likely diagnosis because of the absence of symptoms such as difficulty speaking and walking in the client.
Cerebellopontine angle tumor: Cerebellopontine angle tumor is the other diagnosis that should be considered for the patient. The tumor affects the housing of cranial nerves V, VI, VII, and VII and blood vessels, including the anterior inferior cerebellar artery (Lak & Khan, 2023). Patients experience symptoms such as tinnitus, hearing loss, headaches, vertigo, gait dysfunction, and facial drooping, which are not evident in the case study.
Lyme disease: Lyme disease is the other differential to be considered for the patient. Lyme disease is a tick-borne condition that is associated with symptoms, including headache, fever, fatigue, and skin rash. It can also be associated with numbness, facial palsy, and visual disturbances (Coburn et al., 2021; Mead, 2022). Lyme disease is the least likely cause of the client’s problem because of the absence of fever, fatigue, and skin rashes.
Different diagnostic and laboratory investigations such as nerve conduction tests and Lyme antibody tests should be performed. The patient should be educated on the importance of using artificial tears, chewing on the unaffected side, engaging in facial exercises, treatment adherence, and covering the affected eye to prevent trauma. The patient should also be educated on the importance of wearing glasses or goggles to prevent dust or dirt from the affected eye. She should also be encouraged to maintain oral hygiene to prevent tooth infections. She should also be educated on the importance of remaining adequately hydrated and avoiding alcohol-containing products, which will dry her oral mucosa (Mustafa & Suleiman, 2020; Singh & Deshmukh, 2022). I agree with the preceptor’s diagnosis since the client’s complaints do not show an underlying pathology such as stroke or malignancy. I learned about the importance of a comprehensive neurological exam to rule out potential diagnoses of Bell’s palsy. I will investigate the impact of Bell’s palsy on the client’s functioning and quality of life should I experience a similar case in the future.
References
Coburn, J., Garcia, B., Hu, L. T., Jewett, M. W., Kraiczy, P., Norris, S. J., & Skare, J. (2021). Lyme Disease Pathogenesis. Current Issues in Molecular Biology, 42(1), Article 1. https://doi.org/10.21775/cimb.042.473
Lak, A. M., & Khan, Y. S. (2023). Cerebellopontine Angle Cancer. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559116/
Mead, P. (2022). Epidemiology of Lyme Disease. Infectious Disease Clinics, 36(3), 495–521. https://doi.org/10.1016/j.idc.2022.03.004
Murphy, S. JX., & Werring, D. J. (2020). Stroke: Causes and clinical features. Medicine, 48(9), 561–566. https://doi.org/10.1016/j.mpmed.2020.06.002
Mustafa, A. H. K., & Suleiman, A. M. (2020). Bell’s Palsy: A Prospective Study. International Journal of Dentistry, 2020, e2160256. https://doi.org/10.1155/2020/2160256
Powers, W. J. (2020). Acute Ischemic Stroke. New England Journal of Medicine, 383(3), 252–260. https://doi.org/10.1056/NEJMcp1917030
Singh, A., & Deshmukh, P. (2022). Bell’s Palsy: A Review. Cureus. https://doi.org/10.7759/cureus.30186
Zhang, W., Xu, L., Luo, T., Wu, F., Zhao, B., & Li, X. (2020). The etiology of Bell’s palsy: A review. Journal of Neurology, 267(7), 1896–1905. https://doi.org/10.1007/s00415-019-09282-4