assignment

11

Introduction

M.J., a 22-year-old African American woman, observed in the mirror that the left side of her mouth is slanted when she smiles. She says she's experienced headaches on and off for the last three days. Since she began cleaning her teeth, she's noticed a decline in her sense of taste. For the purpose of gathering additional information about the patient's health and determining a diagnosis, I'll think about what kinds of physical exams and diagnostic testing might be most useful. To support my findings, I'll look at five possible differential diagnoses and use evidence-based practice.

Patient Information: M.J. 22-years-old Female African American

Subjective

CC (chief complaint): Patient states, “I observed in the mirror that the left side of my mouth was slanted when I smile.” She also states, “I have been experiencing headaches on and off for the last three days.” Patient reports a decrease in her taste when she started brushing her teeth.

HPI: The patient is a 22-year-old African American female who developed a left sided slant of her mouth when she looked in the mirror, which began this morning. The patient reports on and off headaches for the last three days. The pain she describes as sharp, pressure continuously. Pain at this moment is a 5 out of a pain scale of 0-10 at best. Worst is a 10/10. Patient reports pain does not get better with over the counter tylenol or ibuprofen. She reports not knowing what triggers the pain or what necessarily makes it any better. Feels like the bright light possibly makes it worst, but she is unable to tell for sure. She is also presenting with loss of taste after brushing her teeth this morning, she is concerned she might be having a mini stroke.

Location: head

Onset: 3 days Before testing

Character: sharp, pressure around the eyes, temples and sometimes allover.

Associated signs and symptoms: nausea, photophobia, phonophobia

Timing: constantly and is not sure what makes it better or worse.

Exacerbating/ relieving factors: she is unsure if light bothers her, takes Tylenol and ibuprofen but not completely sure if it helps.

Severity: pain at this time is 5/10 at worse 10/10 pain scale.

Current Medications: Norvasc 5mg oral once a day, Tylenol 500mg- 1000mg by mouth once a day as needed for pain every 6 hours, Ibuprofen 400-800mg by mouth as needed for pain every 6 hours, multivitamin by mouth daily, Lo/ovral-28 once daily by mouth for birth control.

Allergies: no known medication allergies, no food or environmental allergies noted.

PMHx: History of hypertension controlled. No surgical history. Tdap current (2021), flu vaccine (Oct 2021), COVID vaccine current 1st dose Pfizer on 3/12/2021, 2nd dose Pfizer on 4/12/2021 and booster dose on 10/21/2021

Soc Hx: Patient is a full time student at the University of Florida studying Psychology, works part-time as a cashier in Publix. Lives with two other roommates. Patient has medical insurance through her parents, has reliable transportation and is financially doing well as a student. She loves to read, ride horse, swim, and loves Yoga. She exercises every day. Patient denies any tobacco use including smokeless. Patient denies the use of recreational or IV drug use. Patient maybe has a drink once or twice a month mixed drinks when she goes out to eat with friends. Patient sexually active with one male partner on birth control. Patient denies physical/sexual abuse. Patient has never been pregnant. Patient feels safe in her environment. Patient reports an excellent support system of both mother and father and is very close to her older sister who is a lawyer in town.

Fam Hx:

Mother is 43 and has history of high blood pressure and diabetes. Father is 45 and has history of high blood pressure and arthritis. Sister is 32 and healthy.

Maternal grandmother age 65 has history of high blood pressure, stroke – no residual effects, diabetes type 2.

Maternal grandfather deceased at age 50 – car accident.

Paternal grandmother 68 history of high blood pressure and arthritis.

Paternal grandfather 70 with history of high blood pressure, diabetes, stroke, and arthritis.

Review of System:

General: Patient reports, “I observed in the mirror that the left side of my mouth was slanted when I smile.” She also reports, “I have been experiencing headaches on and off for the last three days.” Patient reports a decrease in her taste when she started brushing her teeth. Patient denies any fever, chills, fatigue or weight loss.

HEENT:

Head: Patient denies head trauma or brain injury. Patient has continuous headache describes as sharp and pressure. Denies seizures or dizziness.

Eyes: Denies vision loss or need for glasses. Patient reports having eyes check every other year.

Ears: Patient denies ear pain or discharge. Patient denies hearing loss or ringing in the ear.

Nose: Patient reports no nasal secretion or stuffy nose. Patient able to smell.

Throat: Patient denies coughing. Patient able to swallow. Patient states she has dental cleanings twice a year and check-ups.

Skin:

Patient denies bruising or rashes.

Patient says she has dry skin and uses lotion

Respiratory:

Patient denies coughing

Patient denies shortness of breath.

Cardiovascular/Peripheral Vascular:

Denies chest pain.

Patient denies heart palpitations.

Denies any swelling or shortness of breath on exertion.

Neurological:

Patient complains of continuous headaches. Patient denies any loss of consciousness.

Patient denies seizures.

Patient denies any numbness/tingling of extremities.

Lymphatics:

Denies any enlarged nodes.

Gastrointestinal:

Denies nausea or vomiting.

Patient denies changes in bowel regimen.

Genitourinary:

Patient reports age of menarche to be 14.

Date of last menstrual periods approximately 5 days ago. Patient denies any burning or hematuria.

Musculoskeletal:

Patient denies any stiffness or back pain. Patient denies limited range of motion

Endocrine:

Patient denies excessive urinating.

Patient denies sweating or temperature intolerance.

Hematologic:

No anemia, bleeding or bruising.

Allergic/immunologic:

Patient denies rhinitis and itching eyes. Patient denies asthma, hives or eczema.

Psychiatric: Patient denies depression/anxiety . Patient denies suicidal/homicidal ideation

Objective.

Physical Exam

Vital signs: BP 117/67 Temporal 98.6 RR 14 and regular HR 78 and regular

Height: 5’7” Weight: 140lb

General: 22-year-old African American female, well-developed, well nourished, She is alert and oriented x’s 3. Patient appears anxious and distressed due to onset of slant on the mouth, continuous headache and decreased taste buds. +Left sided facial droop. + excessive tearing and drooling to the left side.

Neurological: Alert and OrientedX3. Cranial nerve 1-olfactory-able to identify smell of alcohol pad. Cranial nerve 2-optic-vision 20/20 using Snellen. Pupils equal round and reactive to light and accommodation. Cranial nerve 3-oculomotor, Cranial nerve 4-trochlear, cranial nerve 6- abducens- +cardinal gaze, convergence and peripheral vision. No nystagmus. Cranial nerve 5 - trigeminal- Slowed corneal reflex in left eye. -orbicularis oculi reflex in left eye. The orbicularis oculi reflex is tested by gentle finger percussion of the glabella while observing for involuntary blinking with each stimulus (Patel & Levin, 2015). Sensation intact to bilateral face. Jaw deviates to left when mouth opened against resistance. Cranial nerve 7-facial- asymmetrical smile and unable to pucker lips. Drooping left eyelid and +Bells phenomenon. Cranial nerve 8 (vestibulocochlear, acoustic, auditory)- gross hearing intact using whisper test. Hearing greater in left ear using Weber. AC greater than BC bilaterally using Rinne test. Cranial nerve 9 glossopharyngeal, Cranial nerve 10 vagus- uvula midline, +gag response. Cranial nerve 11 spinal accessory- strong resistance bilaterally to opposite head turn and shoulder elevation. Cranial nerve 12 hypoglossal- tongue midline, normal size, no weakness against resistance, no deviation to one side or the other.

Neck: The neck is supple without any masses. No JVD or bruits noted.

Chest/Lungs: Clear to auscultation, non-labored respirations.

Pulses: Heart/Peripheral Vascular: S1/S2 without murmur, rub, or gallop. Bilateral radial +2, Bilateral pedal pulses +2. Capillary refill <3 seconds on extremities. No edema noted.

Musculoskeletal: Bilateral grips equal and bilateral. Full ROM present in all extremities. +weakness to left side of forehead muscles.

Skin: Warm, dry and intact. No lesions or rash present.

Diagnostic results:

Lumbar puncture is useful, and the classic finding is elevated protein with normal cell count (albuminocytologic dissociation) to assist in diagnosing Guillain-Barré syndrome (BMJ Best Practice & Jacob, 2022). This can also test for Lyme disease.

CBC with differential can determine if there is an infectious process.

MRI and brain biopsy are used to confirm diagnosis of GBM (Lee et al., 2017).

The House-Brackmann Facial Nerve Grading System is a tool to help identify the degree of facial nerve weakness (Warner et al., 2022).

A. Differential Diagnosis:

Bell’s Palsy - Acute, ipsilateral facial muscle weakness is the primary symptom of bell palsy, which is caused by an idiopathic disease of the peripheral nerves that affects the facial nerve (also known as cranial nerve VII). To rule out other causes of unilateral facial paralysis, doctors look for signs and symptoms that mimic Bell palsy, such as a central nervous system lesion (such as a stroke or demyelinating disease), parotid gland tumor, the Lyme disease, Ramsay Hunt syndrome, granulomatous disease, acute otitis media, cholesteatoma, diabetes,

trauma and Guillain-Barre syndrome. Between 30% and 60% of patients with facial palsy have such underlying Many of these illnesses can be distinguished from Bell palsy by their related characteristics. A neurologist should be consulted if a patient's facial palsy does not improve after three weeks (Warner et al., 2022). This is a diagnosis of exclusion that is most frequently made in clinical settings. In most cases, Bell's palsy goes away on its own, although therapy with corticosteroids can significantly enhance the patient's chances of making a full recovery from nerve damage (NIH, 2022). There is no diagnostic test to make this a diagnosis. This patient fits the diagnosis.

Lyme Disease – Multiple organ systems are frequently affected by Lyme disease, which is caused by an active infection with any of many pathogenic components of the Borrelia burgdorferi sensu lato complex (Bbsl). In the United States, it is the most frequent vector-borne infection. Chronic and late manifestations of an active infection with B. burgdorferi have been documented. These include conditions such as carditis, meningitis, cranial nerve palsy, radiculopathy, arthritis, reversible peripheral neuropathies, reversible chronic encephalopathy, polyneuropathy, Leukoencephalitis, cognitive and psychiatric symptoms, as well as fatigue, headache, hearing loss, tinnitus, and fibromyalgia Importantly, some investigations confirmed subjective data that lacked comparable physical exam findings by using objective measures of pathology (Shor et al., 2019). This is a probable diagnosis

Ramsay Hunt Syndrome – A late consequence of varicella-zoster virus infection, Ramsay Hunt syndrome, or herpes zoster oticus, causes inflammation of the geniculate ganglion of cranial nerve VII. An ipsilateral facial paralysis, pain in the neck, and small vesicles around the ear and auditory canal are the characteristic symptoms of Ramsay Hunt, a clinical diagnosis. Long-term problems are more likely if a diagnosis is missed or delayed. However, therapy aims to shorten the sickness' overall length while also providing analgesia and guarding against the potential problems that might arise. This exercise focuses on the Interprofessional team's role in the diagnosis and treatment of Ramsay Hunt syndrome (Crouch et al., 2022). This diagnosis can be possible but without knowing exactly is she was exposed to either varicella-zoster virus or herpes zoster oticus it is difficult to make this a diagnosis.

Melkersson-Rosenthal Syndrome – One or both lips swell up (cheilitis granulomatosa) and the tongue becomes fissural in Melkersson-Rosenthal syndrome, a rare neurological condition. MRS usually begins in adolescent or youth. After the first onset, this condition may recur on and off. Edema can persist, worsen, and eventually become permanent after repeated outbreaks that can last anywhere from a few days to several years. MRS has an unclear etiology, however it may be caused by a hereditary disease. Because the typical triad is rarely observed in its entirety, it is challenging to diagnose this illness. Orofacial edema is the most frequent and early sign of MRS. Fissured tongue and facial paralysis occur in roughly 30 per cent of those affected (Torabi et al., n.d.). This patient's medical history does not include any incidents of recurrent facial palsy, orofacial edema, or a fissured tongue. As a result, it is possible to disregard this diagnosis for the time being.

Guillain-Barré syndrome – Acute inflammatory neuropathy characterizes Guillain-Barré syndrome (GBS). Patients with this condition have trouble with movement, lack of deep tendon reflexes, paresthesias, and an elevated level of albumin in the cerebrospinal fluid (CSF), all of which are clinically defined (albuminocytologic dissociation). The most prevalent kind of polyradiculoneuropathy is acute inflammatory demyelinating polyradiculopathy. Facial paralysis is a frequent symptom of GBS; however it is not always bilateral or symmetrical (BMJ Best Practice & Jacob, 2022). This patient does not present with bilateral facial palsy; therefore this diagnosis would have to be ruled out.

Glioblastoma Multiform / Cerebellar Pointe Angle Glioblastoma- Regardless of the site of origin, tumors in the CPA present with sign and symptoms resulting from compression of fifth, seventh, and eighth cranial nerves and lateral aspect of pons and cerebellar peduncle. One in every twenty intracranial tumors is a glioblastoma multiform (GBM), the most common primary brain tumor in adults. Most cases of GBM are found in the supratentorial area, which includes the hemispheres of the brain, most often the cerebral cortex. At adults, primary infratentorial GBM is rare, especially in the cerebellopontine angle (CPA). There have been a few documented occurrences of GBM in CPA. It is more common for intra axial GBM to originate from the cerebellar hemisphere or the brainstem and then spread into the CPA. We have only found a single example of an extra axial GBM that started in the eighth cranial nerve's root entrance zone (Lee et al., 2017).

References

BMJ Best Practice & Jacob, S. (2022, June 29). Guillain-barre syndrome - symptoms, diagnosis and treatment. Retrieved July 28, 2022, from https://bestpractice.bmj.com/topics/en- us/176

Crouch, A. E., Hohman, M. H., & Andaloro, C. (2022). Ramsay hunt syndrome. National Library of Medicine: StatPearls. Retrieved July 28, 2022, from https://doi.org/10.1007/springerreference_42346

Lee, J.-H., Kim, J., & Kwon, T.-H. (2017). Primary glioblastoma of the cerebellopontine angle : Case report and review of the literature. Journal of Korean Neurosurgical Society, 60(3), 380–384. Retrieved July 28, 2022, from https://doi.org/10.3340/jkns.2015.0303.006

NIH. (2022, July 25). Bell's palsy fact sheet. National institute of neurological disorders and stroke. Retrieved July 28, 2022, from https://www.ninds.nih.gov/bells-palsy-fact-sheet

Shor, S., Green, C., Szantyr, B., Phillips, S., Liegner, K., Burrascano, J., Bransfield, R., & Maloney, E. L. (2019). Chronic lyme disease: An evidence-based definition by the ilads working group. Antibiotics, 8(4), 269. Retrieved July 28, 2022, from https://doi.org/10.3390/antibiotics8040269

Torabi, M., Afshar, M. K., & Barati, H. (n.d.). Melkersson-rosenthal syndrome: A case report of the classic triad. Journal of Dentistry, (Online First). Retrieved July 28, 2022, from https://doi.org/10.30476/dentjods.2019.77804.

Warner, M. J., Hutchison, J., & Varacallo, M. (2022). Bell palsy. Specialty Imaging: Temporomandibular Joint, 734–737. Retrieved July 28, 2022, from https://doi.org/10.1016/b978-0-323-37704-1.50155-8