Rotation 2, Family Medicine
Street Smalls, Jamaica
Visit Date: 02/12/2019
Patient: Ms. H
Race: African American
Informant: Pt himself, reliable.
CC: “drooping eyelid” x1 day
HPI: 42 y/o Female /c no sig PMHx presenting to clinic c/o droopy Left eyelid and cheek x1 day. Patients reports numbness sensation started upon waking up this morning. Patient admits to difficulty with left eye closure and left sided facial weakness, with slight right deviation of labia throughout the day. Patient admits URI x2weeks ago. Denies recent travel, h/a, dizziness, abnormal taste, confusion, loss of balance, vision changes, double vision-associated neurological symptoms, neck pain.
PSH: Appendectomy 2000, Hysterectomy 2017
- Up to date
- Flu shot 2018
- Mother: Alive 70s, OA
- Father: Deceased 60s from Stroke, hx of HTN
- Caffeine/coffee x1 a day
- Denies drugs, smoking/tobacco/illicit drug use
- Alcohol: socially, 1-2 drinks per week
- Marital Status: In a relationship, Sexually active with boyfriend do not use protection
- Exercise/Diet: Works out x3 a week, eats x3 meals a day
- Occupation: Home health aid
General: Denies recent weight loss/gain, loss of appetite, weakness/fatigue, fever, night sweats, chills
Skin/Hair: Denies discoloration, moles/rashes, pruritus, changes in hair distribution, excessive dryness/sweating, change in hair/skin texture, lacerations
Head: Admits to Left-Sided facial droop. Denies h/a, vertigo, lightheadedness
Eyes: Decreased lacrimation in Left eye. Unable to close left eye. Denies photophobia, pruritus, blurring, diplopia, other visual disturbances. Last eye exam 2018
Ears: Denies hearing loss, pain, discharge and tinnitus
Noses/sinuses: Denies discharge, epistaxis, obstruction, congestion
Mouth/throat: Denies hoarseness, lesions, bleeding gums, sore tongue, sore throat, mouth ulcers, use of dentures
Neck: Denies localized swelling/lumps, stiffness or decreased ROM
Breast: Denies lumps, nipple discharge, pain
Respiratory: Denies SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND, choking, chest tightness, stridor
Cardiac: Denies chest pain, palpitations, irregular heartbeat, syncope, heart murmurs, DOE
GI: Denies appetite changes, indigestion, nausea, constipation, vomiting, pyrosis, flatulence, diarrhea, jaundice, bloating, anal bleeding and rectal pain.
GU: Denies frequency, polyuria, urgency, dysuria, nocturia, oliguria, incontinence, flank pain, changes in frequency, hesitancy, dribbling
MSK: Denies arthralgias, swelling, tenderness, edema, arthritis, muscle/joint pain or back pain
Peripheral Vascular: Denies intermittent claudication, trophic changes, peripheral edema, varicose veins
Heme: Denies anemia, easy bruising or bleeding, lymph node enlargement
Endo: Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, goiter, hirsutism
Nervous: Admits to numbness, sensation change in left side face. Denies h/a, LOC, sensory disturbances, ataxia, change in cognitions, loss of strength, seizures
Psych: Denies little interest or pleasure in doings things. No feelings of depression or hopelessness
General Appearance: Alert and oriented x3. Appears documented age. Small build. Good hygiene and grooming. Posture, gait normal. Patient in no acute distress.
Temp: 97.8 F
HR: 65 bpm, RRR
BP: sitting 135/84 Right arm
BMI: 25.19 kg/m^2
RR: 17 breaths per min, unlabored
O2 Sat: 98
Pain Scale 2
Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars tattoos, lacerations
Hair: Average quantity and distribution
Nails: Cap refill <2 secs throughout. No clubbing
HEENT: Left upper lid mild droop and minimal symmetry along left side of mouth
Head: NC-AT, no specific facies, non-tender to palpation throughout.
Eyes: Left upper lid mild droop and minimal symmetry along left side of mouth. Incomplete closure of Left eye. Normal sensory to light touch to skin. PEERLA. EOMI
Ears: Symmetrical. No evidence of trauma, lesions, discharge bilaterally. TM pearly white intact /c cone of light normal position bilaterally.
Nose: Symmetrical with no masses, lesions, deformities, trauma, discharge, no FOB.
Throat: No erythema, exudates, uvula midline.
Neck: No lymphadenopathy, no thryomegaly.
Heart: RRR, Normal S1, S2. No murmurs heard. PMI in 5th ICS midclavicular .No heaves, thrills noted
Lungs: Clear to percussion and auscultation bilaterally. No crackles, rhonchi, rales. No use of accessory muscles noted.
Breasts: Not assessed
Abdomen: Symmetrical, soft, ND/NT, BS present in all 4 quadrants. No bruits. Tympany to percussion throughout. Neg CVAT bilaterally
GU: Not assessed
Rectal: Not assessed
Peripheral Vascular: Pulses normal, no cyanosis no edema.
MSK: Not assessed
Neuro: No dysarthria, dysphonia or aphasia noted
- I-Intact, no anosmia
- II- VA 20/20 bilateral. Visual fields by confrontation full. Fundoscopic + red light reflex. OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages, or papilledema noted
- III, IV, VI- PERLA, EOMI, intact w/o nystagmus
- V- Left facial droop, strength 4/5. Corneal reflex loss in Left. Mastication normal
- VII- Facial movements asymmetrical and slight weakness
- VIII- Not assessed
- IX-X-XIII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
- XI- Not assessed
Normal reflexes. No sensory deficits intact to light touch, sharp, dull, . Speech and coordination appropriate. Finger to nose test normal. Palm tapping test normal. Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. No pronator drift. Gait normal with no ataxia
- -ischemia, hemorrhage
- -extremities on affected side often involved
- Guillain Barre Syndrome
- affect both facial nerves, bilateral
- Otitis media
- + facial palsy, – gradual onset w/ accompanying ear pain
- – fever
- – conductive hearing loss
- Lyme disease
- – history of tick exposure, rash, or arthralgias
- Ramsay Hunt syndrome
- -pronounced prodrome of pain, vesicular eruption in ear canal or pharynx
- Bells Palsy
- + unilateral, acute onset, facial droop
- +hx of viral illness prior
Assessment & Plan
42 y/o F w/ no sig Pmhx c/o of “droopy eyelid” x1. Pt reports numbness sensation x1 day. Patient presents with left eye droop, difficulty closing Left eyelid, asymmetrical facial movements and slight left sided weakness 4/5. Pt admits to URI x2 weeks ago. findings most consisted with Bells Palsy
- Start Valacyclovir HCL Tablet, 1GM Tab Oral QD for 10 days
- Start PredniSONE Tablet, 20mg 2 Tabs for 5days, then 1 tab for 2 days, then ½ mg for 3 days, Oral QD 10 days
Patient informed about disease process, therapeutic intervention and the anticipated course of the illness. Bell’s Palsy is a facial palsy, a weakness of the muscles of the face. Health maintenance education for treatment of Bells Palsy is predominantly supportive. Steroids prednisone and antivirals valacyclovir are recommended treatments. Physical therapy including facial exercises shown to result in faster, more complete recovered. Due to incomplete eye closure in patients suffering from Bell’s Palsy, ye care is imperative. The affected eye should be taped shut in unable to close completely at night if the patient experiencing difficulty. Artificial tears can be administered 2 drops TID, for daytime and night to lubricate eye protecting the cornea. An eye patch may also be applied for further eye protection. 80-90% of cases will resolved within few weeks, follow-up in 2 weeks. If symptoms worse or additional symptoms begin RTO or go to ED.