Neurological: No headaches. Negative for syncope or dizziness. No change in memory or thinking patterns and no problems with coordination. No falls or seizure history. Allergic/Immunologic: Seasonal allergic rhinitis. Objective Physical Exam: Vita/l signs: B/P - 110/65, P - 75, T – 97.8, RR - 20, Wt - 165 lbs, Ht - 5’8”, BMI – 25.1. General: Alert and oriented x4, no distress noted. HEENT: Head without tenderness, no head trauma, denies headache. Eyes appear symmetrical, facial creases and nasolabial fold absent on right side, right eyelid not closing. Saliva pooling in the right side of the mouth, facial sensations intact. Neck without masses and tenderness. Neck: No JVD present. No pain, rigidity, trauma, or injury. Trachea is midline. Normal range of motion. Cardiovascular/Peripheral Vascular: Heart rate is regular with good S1, S2; S3 auscultated, no murmur heard. +2 bilateral pedal pulses and +2 radial.
Neurological: Cranial nerve VII grossly impaired, balanced gait. Awake, alert, and oriented to situation, person, place, and time. Diagnostic tests : Lyme antibody, Rapid plasma reagin (RPR), Brain MRI, Head CT. Assessment Differential Diagnosis: 1. Bell’s Palsy 2. Lyme disease 3. Cerebrovascular Accident 4. Intracranial mass/lesion 5. Neurosyphilis Justification of Diagnostic Tests and Differential Diagnosis Diagnostics measures to reach a diagnosis include Lyme antibody, Rapid plasma reagin (RPR), Brain MRI, Head CT. Positive RPR will show the presence of syphilis, while Lyme antibody will reveal presence of Lyme disease. A head CT or MRI will reveal the presence of an intracranial mass or lesion (Schoenfeld & Andrikopoulou, 2012). Bell’s Palsy is the most probable diagnosis for this patient. Symptoms of bells palsy vary among individuals but include sudden weakness on one side of the face, drooping eyelid or corner of the mouth, drooling, inability to close the eye or mouth, altered taste, and excessive tearing in the eye (NINDS, 2018).
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- Summer '15
- Headaches, Headache, Bell's palsy