Case Overview: Case Study #3: Drooping of Face

A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.

Demographic Data

Patient Initials: Mrs. R. S.

Age: 33years

Sex: Female

Race: Caucasian

Source: Patient

SUBJECTIVE DATA

Chief Complaint (CC): Right-sided facial droop

History of Present Illness (HPI): the patient is a 33-year-old who presented at the ED unit complaining of right-sided facial droop that was associated a two-day history of diminished taste, an ipsilateral facial numbness, and a moderate frontal-occipital pulsating headache. Assignment 1: Case Study Assignment: Assessing Neurological Symptoms. She reported having similar headaches four weeks before the presentation. She had additional symptoms of dull and severe chest pains.

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Medications: none

Allergies: none

Past Medical History (PMH):  up to date with all immunizations, she has a history of insomnia. She denied any history of a chronic underlying medical history such as diabetes mellitus, hypertension, cancer, stroke, allergies, seizure disorders, or MI.

Past Surgical History (PSH): no history of major or minor surgical history

OB/GYN History: LMP 01/24/2021

Menstrual History:

• Menarche: 13 years old
• LMP: 01/24/2021
• Menstrual Pattern: a 30-day cycle
• Duration of flow: 4-5 days
• Flow amount: day 1 and 5-light flow, and day 2-3 moderate flows
• Experiences mild to moderate cramping during menses
• No intermenstrual bleeding
• Menopause: not applicable

Contraceptive Use:

• Current Satisfaction Method: presently, the patient does not use implants, injectable contraceptives, orals, or IUD or injectable contraceptive.
• Past methods, complications, and discontinuation reasons: reported no complications with past contraceptive use. She however explains that she stopped using Mirena IUD in 2019 after her husband opted to undergo a vasectomy. Assignment 1: Case Study Assignment: Assessing Neurological Symptoms.

Cervical and Vaginal Cytology:

1. Most recent Pap: March of 2020
2. Abnormal pap smears history: None

Infections:

1. None

Sexual History:

1. The patient is in a monogamous relationship and identifies herself as a heterosexual
2. No reports of past or current sexual assault.
3. No libido changes. She reports having sexual intercourse 3 – 4 times weekly involving vaginal, and oral sex.

Obstetric History

1. 2 children all term pregnancies- vaginal deliveries
2. Iron deficiency anemia during last pregnancy

Personal/Social History:  currently enrolled in a Master’s Program for Business Administration.  The patient is employed full-time as a manager in a private organization for the last 8 years. She has been married for 10years in a monogamous marriage. She lives in Minneapolis with her husband and two children. She is a Baptist and regularly attends church. She heads the women’s fellowship and volunteers in the children’s ministry twice a month at a local food bank program. She holds social gatherings monthly and weekly date nights. She denied tobacco smoking, she is a social drinker and takes 4-5 units of alcohol monthly especially during social gatherings. She denies recreational and illicit drug use

Family History: She has two siblings; a younger sister who is asthmatic and an elder brother who is alive and healthy. Both parents are also alive and healthy with no history of a chronic underlying familial illness.

Review of Systems (ROS)

Constitutional: the patient appears independently in the office, she denies unintentional weight loss or gain, denies fevers, chills, sore throat, night sweats.

HEENT: patient admits to feeling dizzy, associated with a pulsating intermittent frontal-occipital headache, and loss of taste. She however denied having changes in vision, loss of vision, blurred vision, trauma to the head, she does not use corrective lenses. She denies pain, or ringing in the ears, and hearing loss, and denied abnormal ear discharge.  Assignment 1: Case Study Assignment: Assessing Neurological Symptoms.Denied sores and ulcerations in the gums, tongue, and cheeks, denied difficulty swallowing, closing, or opening jaws, denied hoarseness. She also denied swelling or lumps in the neck, and pain with movement.

Cardiovascular: has moderate dull chest pains, denied palpitations, denied swelling of the upper and lower extremities and facial swelling, and denied inability to take part in sports/physical activity, and history of murmurs.

Respiratory: the patient denied shortness of breath, and difficulty breathing without or with activity. Denied coughing and wheezing. She denied exposure to influenza A and TB, Her last annual flu immunization was on 10/2020. She denied a history of current or chronic respiratory disease or exposure to second-hand smoke at work or home.

Gastrointestinal: she denied vomiting, nausea, diarrhea, constipation, abdominal pain apart from menstrual cramping, she described her stool as light-brown-brown and soft, she denied black or tarry stools, and blood in stool.

Genitourinary: the patient denied pain or burning on urination, frequency, and urgency. She also denied lower back pain or flank pain. Her urine is yellow, no blood-stains, or foul odor. No vaginal sores. Her last LMP was on 01/24/2021.

Musculoskeletal: patient

Psychiatric: the patient admitted to new-onset emotional disturbances after the onset of symptoms of a right-sided facial droop, denied feeling blue or sad, increased tiredness, auditory and visual hallucinations, and thoughts of self-harm and suicidal ideations

Gynecological: patient denies vaginal sores, her last LMP was on 01/24/2021, normal, 30-day30-day cycle, she denied intermenstrual bleeding, admits to abdominal cramping during menses, denies having excess vaginal discharge, green-colored or yellow-colored vaginal discharge, denied a foul-smelling vaginal discharge, vaginal itching, STI exposure. She is married in a monogamous relationship and does not engage in high-risk sexual behavior.

Endocrine: she denied excess thirst, micturition, cracked skin, denied changes in weight, excess growth, or loss of hair.

Neurologic: the patient reports a moderate headache (pulsatile) frontal-occipital, she also reports dizziness, but denies memory loss, seizures, tingling

Hematologic/lymphatic: the patient denied both familial and self-anemia, denied spontaneous bleeding or bruising, prolonged healing from bruising or cuts.

Allergic/immunologic: denied medical, environmental, and food allergies.

OBJECTIVE DATA

General: a middle-aged Caucasian female well-groomed, somnolent, and AOX4 spheres. Assignment 1: Case Study Assignment: Assessing Neurological Symptoms.

Vital Signs-Temp 97.1, RR-18, BP-162/93, Weight-147 pounds, Height-5’7, PR-

HEET: Head: normocephalic with no bruising, lesions, and masses. Clean hair with no scalp scaling, non-tender on palpation and percussion of the maxillary and frontal sinuses. Eyes: PERRLA, no exudates, eyelid lesions, or crusting. No enophthalmos, exophthalmos, or periorbital edema. Her vision- is 20/20 RE, 20/20 LE. Her retina is intact bilaterally, with no evidence for bilateral intraocular bleeding or cataracts. Ears:  intact hearing is intact, no ear discharge, swelling, or redness on the inner and outer structures of the ear. The bilateral assessment of the tympanic membrane revealed that the tympanic membrane was shiny, gray, and intact. Nose/Mouth/Throat: intact, pink, and moist mucus membranes, no evidence of bruising, bleeding, and swelling of the turbinates. The nares have fine hairs with no deviation from the sputum. No sores, wounds, or exudates on the tongue, cheeks, and tongue. The membranes of the oral mucosa are moist, pink, and intact. She has no halitosis or dental caries. She has natural teeth, no pain with chewing, and no pain on the jawline with palpation and percussion. Neck/Lymph: supple, no lymphadenopathy, edema, or tenderness on palpation of both axillae. There is no pain with hyperflexion, hyperextension, or rotation from left to right. There is no jugular distension or carotid bruit.

Cardiovascular/Peripheral Vascular:  the patient has normal heart sounds, S1 and S2 heard, no gallops, murmurs, or rubs. Heart rate is 75BPM regular, +2 brachial, radial, pedal, and femoral pulses, normal HR elevation with activity, and baseline return with rest, normal color for ethnicity, no upper or lower limb and facial edema.

Respiratory/Chest/Breast: symmetrical chest wall, left and right breast has the same size, her nipples protrude outwards, has a dark areola with intact skin, no palpable masses or lumps, no discharge from the nipples,  or tenderness with rotation.  The lungs are bilaterally clear, the breathing is normal and rhythmic with no accessory muscles use. On auscultation, there are no abnormal breath sounds (crackles, wheezing, rhonchi, or rales). No clubbing.

Neurologic: the patient is A0X4, follows commands, recalls past three days events, her speech and coordination were slow. She had a right facial droop. Had an intact depth of perception, deep tendon reflexes were intact.

Musculoskeletal: no edema, can distinguish touch, had a normal color for her ethnicity and her lower and upper muscle extremities had developed symmetrically. She had a full range of motion (FROM) on all joints. Her left strength was 5/5, right-3/5 RUE, and 4/5 RLE with slow coordination.

Diagnostic Tests

Head CT Scan: this radiologic test is important to help in excluding a likely intracerebral hemorrhage, an epidural and subdural hematoma. Assignment 1: Case Study Assignment: Assessing Neurological Symptoms.

MRI Scan: to detect possible hemorrhages and infarctions in the brain

Random/Rapid Blood glucose (RBG): an RBG   is essential to help in ruling out hyper or hypoglycemia that can subsequently result in stroke symptoms.

CBC (Complete Blood Count): a CBC is important in identifying and detecting blood disorders such as anemias, clotting problems, bleeding disorders, and cancers.

Lipid panel: a lipid panel can demonstrate the patient’s risk of thrombosis or coronary heart disease.

ASSESSMENT

Differential Diagnoses

• Ischemic Stroke-this is a medical emergency that usually has a sudden onset and results from focal cerebral ischemia. Therefore, it requires urgent medical attention. Additional symptoms of ischemic stroke include weakness of the side that is affected, and difficulties in managing secretions such as saliva (Randolph, 2016).
• Transient Ischemic Attack (TIA)-TIA has a sudden onset with neurologic deficits with no permanent deficits. It also has stroke-like symptoms that may last within 20-30 minutes before resolving on its own completely (Amarenco, 2020).  A TIA can occur several times daily or only 2-3 times over several years.
• Bell’s Palsy- is idiopathic, unilateral, and of sudden onset and affects cranial nerve VII. Patients may experience pain that begins behind the ear followed by facial paresis that only lasts within 48-72 hours (Warner, Hutchison & Varacallo, 2020). The side that is affected is usually expressionless, flat, and unable to grimace or blink. Salivation and the lacrimal gland can also be impaired.
• Guillain-Barre Syndrome- GBS has a rapid and acute onset and is progressive but with a self-limited inflammatory polyneuropathy.Assignment 1: Case Study Assignment: Assessing Neurological Symptoms.  Inflammatory polyneuropathy Is often caused by mild sensory loss and muscular weakness. Additional signs include; symmetric weakness and flaccid weakness that starts in the lower limbs and progresses to the upper limbs (Willison, Jacobs & van Doorn, 2016). Patients also have weakness of the oropharyngeal and facial muscle weakness that causes drooping and inability to control secretions such as saliva.
• Myasthenia Gravis – it occurs commonly in young women and involves episodic weakness of muscles. The most common symptoms that patients present with are diplopia, ptosis, and muscle weakness that causes weaknesses of the lower and upper limbs (Farmakidis et al., 2018). Patients experience hyper salivation and lacrimation with cholinergic crises.

References

Amarenco, P. (2020). Transient ischemic attack. New England Journal of Medicine, 382(20), 1933-1941.

Farmakidis, C., Pasnoor, M., Dimachkie, M. M., & Barohn, R. J. (2018). Treatment of myasthenia gravis. Neurologic clinics, 36(2), 311-337.

Randolph, S. A. (2016). Ischemic stroke. Workplace health & safety, 64(9), 444-444.

Warner M.J, Hutchison J., & Varacallo M. (2020). Bell Palsy. StatPearls Publishing; 2020 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482290/

Willison, H. J., Jacobs, B. C., & van Doorn, P. A. (2016). Guillain-barre syndrome. The Lancet, 388(10045), 717-727.