Patient with deviation of mouth to the right side and unable to close left eye.

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.



CASE:

A 50 Yr old female, a housewife from miryalaguda came in to the opd with chief complaints of deviation of mouth to right side on Saturday evening, later on Monday she noticed unable to close left eye.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 days back then she developed deviation of mouth to right side on Saturday evening associated with drooling of saliva from the left side. later on Monday ( 4 days back) she noticed that she was unable to close her left eye associated with watering from eyes is seen.

C/o dry cough, cold and sore throat 3 days back which were resolved later on without use of any medications. 

No c/o weakness of U.L and L.L

No c/o blurring of vision.

No c/o tinnitus.

No c/o giddiness/fever.


HISTORY OF PAST ILLNESS:

Patient had a h/o of deviation of mouth to right side with drooling of saliva, 2 years back which was resolved by the use of dexamethazone. 

Not a k/c/o HTM/ T2DM / CVA / CAD / Epilepsy / Asthma.

No surgical h/o. 


PERSONAL HISTORY:

Diet: Non-vegetarian. 

Appetite: normal. 

Bowel movements: regular. 

Bladder filler: normal. 

Sleep: adequate. 

Addictions: none. 


FAMILY AND ALLERGIC H/O: none. 


GENERAL EXAMINATION:

Pt is C/C/C with GCS 15/15 and moderate build and moderate nourishment. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema. 

VITALS:

  • BP : 120/90 MMHG.
  • PR : 96 BPM.
  • TEMP: afebrile.
  • RR : 16 cpm.
  • SPO2 : 97% AT RA.
  • GRBS : 123 MG%

SYSTEMATIC EXAMNATION:

CVS: 

  • S1 and S2 heard. 
  • No murmurs. 

RS : 

  • Bilateral air entry present. 
  • No added sounds. 

Per Abdomen: 

  • Obese abdomen,
  • No tenderness,
  • No local rise of temperature, 
  • No palpable masses, 
  • Hernial orifices are clear, 
  • No free fluid, 
  • No organomegaly, 
  • Bowel sounds heard. 

CNS:

  • Pt is conscious, coherent and cooperative and well orientated to name, place and person with GSC of 15/15.
  • Higher mental functions intact ( memory and orientation). 
  • No signs of meningeal irritation. 
  • Deviation of mouth to right side with drooling of saliva.
  • Unable to close left eyelid due to Naso labial fold loss.
  • Cranial nerve examination:  Facial nerve

 MOTOR SYSTEM:

                                                       Right.                 Left

Frowning:                                         +                        +

Closure of eyelibs:                           +                         +

Naso labial folds:                              +                         - 

Whistling:                                          +                        - 

Clenching of teeth:                           +                         - 


 SENSORY SYSTEM:

Anterior 2/3rd of tongue:                   +                       +

REST ALL CRANIAL NERVES ARE INTACT. 

  • REFLEXES:

                                                                    Right                      Left 

                           Biceps                                 +                             +

                           Triceps                                +                             +

                           Supinator                            +                              +

                           Knee                                   +                              +

                           Ankle                                  +                              +

                          Plantar                            flexor                       flexor

  • CERBEBRAL SIGNS: normal.
  • GAIT: normal


PROVISIONAL DIAGNOSIS: 

       UNILATERAL LMN TYPE OF BELL'S PALSY


INVESTIGATIONS:

  • HEMOGRAM:
      1. Hb: 12.8 gm/dl
      2. Total count: 8,100 cells/Cummins
      3. Neutrophils: 85 %
      4. Lymphocytes: 13%
      5. Monocytes: 01%
      6. Basophils: 00
      7. PCV : 42.3 vol%
      8. MCV: 80.9 fl
      9. MCH: 24.5 pg
      10. MCHC: 30.3 %
      11. RDW-CV: 17.2%
      12. RDW-SD: 51.2 fl
      13. RBC COUNT: 5.23 mil/cu.mm
      14. PLATELET COUNT: 2.12 lakhs/cu.mm.

  • CUE:
      1. Colour:  Pale yellow
      2. Appearance: Hazy
      3. Reaction: Acidic
      4. SP. Gravity: 1.010
      5. PUS CELLS: 4-6
      6. EPITHELIAL CELLS: 3-6
      7. RED BLOOD CELLS: 8-10

  • LFT:
      1. Total bilirubin: 0.80 mg/dl
      2. Direct bilirubin: 0.20 mg/dl
      3. SGOT (AST) : 30 IU/L
      4. SGPT (ALT) : 26 IU/L
      5. ALP  : 173 IU/L
      6. Total protein: 7.8 gm/dl
      7. Albumin : 3.8 gm/dl
      8. A/G ratio: 0.98

  • RFT:
      1. Sr. Creatinine: 1.1 mg/dl
      2. Sr. Urea : 33 mg/dl
      3. Sr. Sodium: 138 mEq/L
      4. Sr. Potassium: 4.5 mEq/L
      5. Sr. Chloride: 106 mEq/L

  • RBS: 171 mg/dl.
  • ECG: 


  • Thyroid profile:
      1. T3: 0.91 ng/ml
      2. T4: 13.61 micro g/dl
      3. TSH: 0.97 micro g/dl
  • FBS: 160 mg/dl
  • PLBS: 259 mg/dl
  • HBA1c: 7.0 %

TREATMENT GIVEN:

- DAY 0 

     VITALS:  

     TEMP - AFEBRILE,

     BP- 120/90 MMHG,

     PR- 90 BPM,

     RR- 16 CPM,

     GRBS- 123 MG/DL,

     SPO2 - 96%.

TREATMENT GIVEN:

1. TAB. PREDNISOLONE 40MG PO BD

2. TAB. VALCYCLOVIR 1GM PO TID

3. TAB. PANTOP 40MG PO OD

4. INJ. OPTINEURON 1AMP IN 100ML/ NS/ IV/OD  


- DAY 1 

VITALS:

   TEMP - AFEBRILE,

   BP - 110/70MMHG,

   PR- 75BPM,

   RR - 16 CPM 

TREATMENT GIVEN:

1. TAB. PREDNISOLONE 40MG PO BD.

2. TAB. VALCYCLOVIR 1GM PO TID.

3. INJ. OPTINEURON 1AMP IN 100ML/ NS/ IV/OD.


- DAY 2 

VITALS: 

TEMP - AFEBRILE,

 BP - 120/80MMHG,

 PR- 90BPM,

 RR - 18 CPM.

 TREATMENT GIVEN

1. TAB. PREDNISOLONE 40MG PO BD.

2. TAB. VALCYCLOVIR 1GM PO TID.

3. INJ. OPTINEURON 1AMP IN 100ML/ NS/ IV/OD.

4. TAB. PAN 40MG  PO OD.




DISCHARGE SUMMARY:

Discharge Date: 14/08/2021 

Ward:GM 

Unit:4

Name of Treating Faculty

  • DR.PRAKASH (INTERN), 
  • DR.LAKSHMAN (INTERN), 
  • DR.SUPRAJA (INTERN), 
  • DR.AKSHARA (INTERN), 
  • DR.SOWMYA (INTERN),
  • DR.PAWAN KUMAR (INTERN),
  • DR.SASHIKALA (PG 1), 
  • DR.VINAY(PG 1), 
  • DR.AASHITHA (PG 2), 
  • DR. VAISHNAVI( PG 2), 
  • DR. USHA (PG 2),
  • DR.HAREEN (SR), 
  • DR.ARJUN (AP), 
  • DR.RAKESH BISWAS (HOD)

Diagnosis :UNILATERAL LMN TYPE OF BELLS PALSY

Case History and Clinical Findings

A 50 YR OLD FEMALE, A HOUSEWIFE FROM MIRYALAGUDA CAME IN TO THE OPD WITH CHIEF COMPLAINTS OF DEVIATION OF MOUTH TO RIGHT SIDE ON SATURDAY EVENING, LATER ON MONDAY SHE NOTICED UNABLE TO CLOSE LEFT EYE.

HISTORY OF PRESENTING ILLNESS:PATIENT WAS APPARENTLY ASYMPTOMATIC 6 DAYS BACK THEN SHE DEVELOPED DEVIATION OF MOUTH TO RIGHT SIDE ON SATURDAY EVENING ASSOCIATED WITH DROOLING OF SALIVA FROM THE LEFT SIDE. LATER ON MONDAY ( 4 DAYS BACK) SHE NOTICED THAT SHE WAS UNABLE TO CLOSE HER LEFT EYE ASSOCIATED WITH WATERING FROM EYES IS SEEN.C/O DRY COUGH, COLD AND SORE THROAT 3 DAYS BACK WHICH WERE RESOLVED LATER ON WITHOUT USE OF ANY MEDICATIONS.NO C/O WEAKNESS OF U.L AND L.LNO C/O BLURRING OF VISION.NO C/O TINNITUS.NO C/O GIDDINESS/FEVER.

HISTORY OF PAST ILLNESS:

  • PT HAD A H/O OF DEVIATION OF MOUTH TO RIGHT SIDE WITH DROOLING OF SALIVA, 2 YEARS BACK USED DEXAMETHAZONE.
  • NOT A K/C/O HTM/ T2DM / CVA / CAD / EPILEPSY / ASTHMA.
  • NO SURGICAL H/O.

PERSONAL HISTORY:

  • DIET: NON-VEGETARIAN.
  • APPETITE: NORMAL.
  • BOWEL MOVEMENTS: REGULAR.
  • BLADDER FILLER: NORMAL.
  • SLEEP: ADEQUATE.
  • ADDICTIONS: NONE.

FAMILY AND ALLERGIC H/O: NONE.

GENERAL EXAMINATION:

  • PATIENT IS CONSCIOUS,COHERENT,COOPERSTIVE WITH GCS 15/15 AND MODERATE BUILD AND MODERATE NOURISHMENT.
  • NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA.

VITALS:

  • BP : 120/90 MMHG.
  • PR : 96 BPM.
  • TEMP: AFEBRILE.
  • RR : 16 CPM.
  • SPO2 : 97% AT RA.
  • GRBS : 123 MG%        
SYSTEMATIC EXAMNATION:

  • CVS: 
  1. S1 AND S2 HEARD. 
  2. NO MURMURS.

  • RS : 
  1. BILATERAL AIR ENTRY PRESENT. 
  2. NO ADDED SOUNDS.

  • PER ABDOMEN: 
  1. OBESE ABDOMEN, 
  2. NON-TENDER, 
  3. NO LOCAL RISE OF TEMPERATURE,
  4. NO PALPABLE MASSES, 
  5. HERNIAL ORIFICES ARE CLEAR, 
  6. NO FREE FLUID, 
  7. NO ORGANOMEGALY FOUND,
  8. BOWEL SOUNDS HEARD.

  • CNS:- 
  1. PT IS CONSCIOUS, COHERENT AND COOPERATIVE AND WELL ORIENTATED TO NAME, PLACE AND PERSON WITH GSC 15/15.
  2. HIGHER MENTAL FUNCTIONS INTACT ( MEMORY AND ORIENTATION)
  3. NO SIGNS OF MENINGEAL IRRITATION.
  4. DEVIATION OF MOUTH TO RIGHT SIDE WITH DROOLING OF SALIVA.
  5. UNABLE TO CLOSE LEFT EYELID DUE TO NASO LABIAL FOLD LOSS.
  6. CRANIAL NERVE EXAMINATION: FACIAL NERVE    

   MOTOR SYSTEM:

RIGHT                  LEFT 

                             FROWNING:                                          +                            + 

                             CLOSURE OF EYELIBS:                       +                           + 

                             NASO LABIAL FOLDS:                        +                            - 

                             WHISTLING:                                          +                            -

                              CLENCHING OF TEETH:                     +                           -


             SENSORY SYSTEM:

                              ANTERIOR 2/3RD OF TONGUE:         +.                           +

      REST ALL CRANIAL NERVES ARE INTACT.

  • REFLEXES: 

RIGHT                                        LEFT

 

BICEPS                                                            +                                                    + 

TRICEPS                                                          +                                                    + 

SUPINATOR                                                   +                                                     + 

KNEE                                                               +                                                    + 

ANKLE                                                            +                                                    + 

PLANTAR                                                  FLEXOR                                     FLEXOR


  • CERBEBRAL SIGNS: NORMAL 
  • GAIT: NORMAL

Investigations:

Treatment Given(Enter only Generic Name)

- DAY 0 

  VITALS 

  • TEMP - AFEBRILE 
  • BP- 120/90 MMHG 
  • PR- 90 BPM 
  • RR- 16 CPM
  • GRBS- 123 MG/DL 
  • SPO2 - 96%

TREATMENT:

1. TAB. PREDNISOLONE 40MG PO BD,

2. TAB. VALCYCLOVIR 1GM PO TID

3. TAB. PANTOP 40MG PO OD

4. INJ. OPTINEURON 1AMP IN 100ML/ NS/ IV/OD


- DAY 1 

VITALS 

  • TEMP - AFEBRILE 
  • BP - 110/70MMHG 
  • PR- 75BPM 
  • RR - 16 CPM 
TREATMENT GIVEN

1. TAB. PREDNISOLONE 40MG PO BD

2. TAB. VALCYCLOVIR 1GM PO TID

3. INJ. OPTINEURON 1AMP IN 100ML/ NS/ IV/OD


- DAY 2 

VITALS 

  • TEMP - AFEBRILE 
  • BP - 120/80MMHG 
  • PR- 90BPM 
  • RR - 18 CPM 
TREATMENT GIVEN:

1. TAB. PREDNISOLONE 40MG PO BD.

2. TAB. VALCYCLOVIR 1GM PO TID.

3. INJ. OPTINEURON 1AMP IN 100ML/ NS/ IV/OD.

4. TAB PAN 40 MG PO OD.

Advice at Discharge

1. TAB. PREDNISOLONE 40MG PO BD FOR 2 DAYS . THEN 40MG PO OD FOR 3 DAYS.

2. TAB. VALCYCLOVIR 1GM PO TID FOR 5DAYS.

3. TAB. MVT PO OD FOR 15 DAYS.


Follow Up: REVIEW NEXT THRUSDAY TO GENERAL MEDICNE OP OR REVIEW SOS.

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