1. BELL’S PALSY
Internal Medicine
By Svetlana Gorbounov
PA-S
April, 2006

2. CC: follow up Bell’s palsy.
03/20/06
Patient ID: 28 y/o male
CC: follow up Bell’s palsy.

3. History of Present Illness
Right face numbness and tingling with:
progressing right ear and right retroauricular pain, 8/10
inability to close right eye, it’s dryness
taste disturbance x 2 days

4. HPI (continued) ED dx: Bell's palsy Tx: Prednisone 20 mg tid,
Zovirax 400 mg x 5 /day
States: often hiking in the forest for the past month.
Denies: tick bite, skin rashes, facial swelling,
hx of herpes, HIV, DM, TB,
resent cold, previous hx of facial palsy,
family hx of facial palsy

5. Past Medical History Childhood diseases: Surgeries: none
chicken pox x 4. No chronic medical conditions.
Surgeries: none
Hospitalizations: none

6. Family History Father 55 y/o - HTN, allergic rhinitis.
Mother 45 y/o W&A.
Siblings: 2 brothers and 2 sisters, all W&A.
Children 3 and 7 y/o, both W&A.

7. Social History Married x 8 years, good relationship, monogamous.
Works as sales representative. Reports high stress level lately.
Denies tobacco or recreational drugs
Admits occasional glass of wine.
Hiking for exercise

8. Allergies: NKDA. Medications: Prednisone: 20 mg tid x days 1-3
20 mg bid days 4-5
20 mg qd days 6-8
10mg qd days 9-10
Zovirax 400 mg x 5/d - 7 days.

9. Review of System
General. Denies weight change, fatigue, fever, chills.
Skin: Denies skin lesions or rashes.
HEENT. Right retroauricular and ear pain 3/10, no facial pain. No tinnitus, hyperacusis, hearing loss, or vertigo. No change of vision. No changes in the left side of face.

10. Review of System (Continued)
Negative : neck
respiratory
cardiovascular
gastrointestinal
genitourinary
endocrine

11. Review of System (Continued)
Neurologic. Positive for:
- right sided facial numbness
- drooling of the right side
- incomplete closure of right eye
Musculoskeletal. Negative for:
- muscle weakness in extremities

12. Physical Exam General. Well appearing obese male, in NAD.
VS. BP 120/80, P 75, T 99.1, WT 270, HT 5’11”, BMI 37.7
Skin. Good color, no lesions or rashes.
HEENT. TM intact bilaterally. No lesions in ear canals bilaterally. PERLA, 4 mm bilaterally. EOM intact, no nystagmus. Nose and oropharynx clear.
Parotid gland not enlarged, non-tender
Neck, Lungs, Heart, GI - unremarkable.

13. Physical Exam (Continued)
Neurologic.
Alert and oriented x3
Face asymmetry:
Widened right palpebral fissure
Flattened right nasolabial fold
Sagging right eyebrow
Drooping of the right corner of the mouth

14. Physical Exam (Continued)
Facial nerve exam:
forehead wrinkling L>R.
voluntary right eyebrow rise almost absent.
unable to close right eye completely

15. Physical Exam (Continued)
Facial nerve assessment:
smile is lateralized to the left
puffing cheeks asymmetric, L>R.

16. Physical Exam (Continued)
CN II-VI, VIII-XII intact.
No sensory deficit bilaterally
DTR 2+ equal
Good muscle tone thruought, strength 5/5 bilaterally

17. In office LAB: blood sugar 213 random. Differencial diagnosis:
Bell’s palsy
Rumsay Hunt syndrome
Zoster sine herpete.
Lyme disease
Stroke
HIV
Volume occupying lesion
Systemic diseases

18. Impression
Bell’s palsy
Hyperglucosemia
Obesity

19. Plan Prednisone 20 mg tid x 2 days then 20 mg bid x 3 days then
20 mg qd x 3 days then
10 mg qd x 2 days
Zovirax 400 mg x 5/d - 6 days
Artificial tear drops prn in OD

20. Plan (continue) Labs: CBC with diff, chem. 12, HbA1C,
lipid panel, TSH, free T4, Lyme IgM/IgG titers
F/U in 10 days or sooner if symptoms worsen
Consider discussion on wt reduction

21. F/U visit 03/29/06
CC: f/u Bell’s palsy
Subjective: Dx of Bell’s palsy 10 days ago
Right facial muscle weakness and taste alteration diminished.
Able to close right eye completely.
No OD soreness or dryness.
No retroauricular pain or earache.
D/c prednisone on 03/28/06 and zovirax on 03/25/06.

22. Objective Skin: clear, no rashes or lesions. Neurologic:
Face asymmetry less prominent
Can slightly elevate right eyebrow
Right forehead wrinkling is absent
Smile is slightly asymmetric, slightly drawn to the left
OD closure complete, tight closure absent
Puffing chicks L>R. CN II-VI and VIII-XII intact

23. Labs: Impression: CBC – WNL
Chem 12, HbA1C, lipid panel, TSH with FT4 – WNL
Lyme titers negative
Impression:
Bell’s palsy, improvement.
Obesity.

24. Plan Self massage of the face.
Facial muscle exercises using passive range of motion as well as actively closing eyes and smiling.
Weight reduction: diet, exercise.
F/u in 2 months or sooner if symptoms of face palsy reoccur.

25. Keep in mind Lyme disease HIV Cat scratch in children
Volume occupying lesion
Systemic diseases