Date: 02/25/21
Patient Name:  CM
MRN: ####466
CC: Headache, facial weakness x 4 days

HPI: CM is a 27 y/o female with no PMH presenting with 4 days of headache and 1 day of facial weakness. Pt described headache as right-sided, sharp, constant, gradual onset, 8/10. Facial weakness started 1 day prior. Pt noticed that she was having trouble speaking, her right eye was drooping, and front right half of tongue was less sensitive to taste. Pt stated this never happened before and was only slightly relieved with Tylenol. She has experienced headaches but never this painful or persisting for 4 days. Pt denied weakness/loss of sensation in body, numbness, tingling, dizziness, blurry vision, chest pain, sob, fever, chills, nausea, vomiting, recent illness, recent travel.

PMH
Current illnesses: denies
Past Illness: denies
Surgeries: denies
Allergies: NKDA
Medications: OCP
Hospitalizations: denies
Trauma/Injuries: denies

Social History
Education: high school
Work/finances: unemployed
Family & relationships: lives with mother and daughter
Habits/risk factors: denies
Reproductive History: G1 T1 P0 A0 L1

Family History
Father: 46, alive and well
Mother: 45, DM, alive and well
Brother: 22, alive and well

Review of Systems

General: admits to facial weakness. Denies fever, chills, night sweats, fatigue, loss of appetite, recent weight loss/gain.

Head: admits to headache. Denies dizziness, head trauma, unconsciousness, coma, fractures.

Eyes: admits to wearing reading glasses, unknown correction. Denies lacrimation, pruritus, visual disturbances, photophobia. Last eye exam about three years ago, visual acuity 20/30 OU.

Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.

Peripheral vascular system: Denies intermittent claudication, coldness or trophic changes, peripheral edema, color changes, varicose veins.

Hematologic System: denies anemia, easy bruising/bleeding, lymph node enlargement, history of DVT/PE.

Nervous system: admits to facial weakness, decreased sense of taste on anterior tongue. Denies seizures, loss of consciousness, other sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.

Physical Exam

VS: BP: 115/74  HR: 66  RR: 16  O2 sat: 96% RA  Temp: 37.1 C oral

General: A&O to person, place, time. Well groomed, appropriately dressed, in no apparent distress.

Head: normocephalic, atraumatic, non-tender to palpation.

Eyes: symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity 20/30 OU, uncorrected, 20/30 OD, 20/30 OS. Visual fields full OU. PERRLA, EOM’s intact with no nystagmus.

Nose: symmetrical, no masses, lesions, deformities, trauma, discharge. Nares patent bilaterally.

Ears: symmetrical and normal size. No masses, lesions, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TM’s pearly white and intact with light reflex in normal position AU.

Sinuses: non-tender to palpation over bilateral frontal and maxillary sinuses.

Tongue: pink, well-papillated. No masses, lesions, deviations noted.

Thorax and lungs: Respirations unlabored, no use of accessory muscles. Lungs clear to auscultation bilaterally. No adventitious sounds.

Cardiovascular: RRR. S1 and S2 distinct, no S3 or S4, no murmurs. No splitting of S2 or friction rub noted.

Peripheral vascular: extremities normal in color, size, temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis, or edema noted bilaterally. Capillary refill < 2 seconds throughout. No stasis changes or ulcerations noted.

Neurologic: CN’s intact with exception of CN VII which showed deficit in right side of face. Sensation intact. No atrophy, tics, tremors or fasciculations. Gait steady with no ataxia. Coordination by rapid alternating movements and point to point intact bilaterally, no asterixis.

Musculoskeletal: 5/5 strength and FROM in all extremities. No atrophy, weakness, erythema, swelling. Non-tender to palpation.

 

Assessment:

27 y/o female with no PMH presenting with 4 days of severe headache and 1 day of right-sided facial weakness and decreased sense of taste on anterior tongue.

Ddx:
– CVA
– Bell’s Palsy

Plan:

• CBC, BMP
• CT head due to severe headache preceding s/sx
• Tylenol for pain

Pertinent results:

• CT head showed no abnormalities, ruling out CVA
• Physical exam consistent with Bell’s Palsy

Disposition:

• pt discharged with Valacyclovir and PO Prednisone, PCP follow up