A CLINICAL PRESENTATIONIntermediate Level Family Clinical

SUNY ITTanjia Hynes FNP-S

Patient Presentation

10 year old female Pt. mother reports that yesterday she noticed that when her

daughter smiled the left corner of her face did not move Mom reports no fevers, rashes, or recent illness Pt. denies headache States that she feels fine but feels like the left side of her face

is not moving Reports no significant pain but states she did have a tingling

feeling the other day that only lasted for a few minutes When mom saw no improvement this morning she was

concerned and brought her to the office Mother and Pt. do not feel like there is any weakness or deficit

in any other part of the body Pt also reports difficulty closing her left eye and feels like it is

very dry

HPI

General: Denies fever, chills, malaise, fatigue Skin: Denies rashes or any changes in her skin, hair. Head: Denies headache at this time but does report slight headache

off and on over the summer Neck: Denies lumps, swollen glands, decreased ROM, pain or stiffness Ear: Denies pain, discharge, ringing in the ears, hearing loss, dizziness Eyes: reports left eye dry, inability to close fully, denies double or

blurred vision, no drainage or trauma to the eye. Right eye no complaints offered

Nose: Denies pain, bloody nose, any changes in smell Mouth: Denies sore throat, change in voice Respiratory: Denies SOB, night sweats, difficulty breathing Cardiovascular: Denies chest pain, palpitations Neurological: reports inability to close left eye fully, left side of mouth

does not move when she smiles. Denies pain difficulty speaking, change in memory. Reports no weakness in any other extremity

ROS

Immunizations up to date

No allergies to medications

No family history of stroke at young age

No surgeries or hospitilizations

Last medical exam 2 months prior for well exam where no vaccinations were administered

PERTINENT PAST MEDICAL HISTORY

OBJECTIVE FINDINGS

General: 10 year old alert, oriented, no physical distress female sitting in upright position on examination table

Vitals: T=98.8 temporal P=82B/P= 110/72 R=20 Height/weight: 50inches/22.7 kg Skin: pink, dry, warm to touch, no rashes, lesions or bruising noted,

no bugs found on pt. Head: normocephalic, no lesions, bumps, or soars noted, no bugs

noted Ears: no pain on palpation of the targus/pinna, no exudate present,

tympanic membranes intact visible pearly in color light reflex visible Eyes: sclera white, no discharge, red reflux present, PERRLA, optic

disc/cup present without signs of hemorrhage. Mouth: uvula midline, tonsils present without swelling or exudate,

gag reflex positive Respiratory: respirations even, lungs clear to auscultation no

accessory muscle use noted, denies tenderness to palpation

Objective

Cardiovascular: S1 S2 normal, no thrills, murmurs present, no JVD,

Musculoskeletal: Ambulates without difficulty, full ROM in all extremities, strength 5+ throughout, denies pain

Neurological: CN I, II, III, IV, V, VI, VIIII, IX, X, XI, XII intact, CN VII-left side of forehead unable to make crease, unable to keep left eye closed against resistance, left side of face unable to puff, left corner of mouth droop when asked to smile, negative romberg and pronator drift, light touch intact, reflexes 2+, plantar intact

Objective Continued

PLAYING DETECTIVESo class what are your thoughts?

How might you proceed in diagnosing this child?

Are there any tests that you might want to order?

Do you want to get this child out of your office sooner than later?

DIFFERENTIAL DIAGNOSIS

Diagnosis symptoms

1) Tumor2) Facial Nerve Injury3) Lyme Disease4) Ramsay Hunt

Syndrome5) Rosenthal-

Melkersson syndrome

6) Stroke7) Bell’s Palsy

1) progressive facial paralysis, a parotid mass, local pain, primary cancer elsewhere in the body, tinnitus, or ipsilateral eighth nerve-type hearing loss

2) Hx of trauma or surgery3) fever, headache, fatigue, arthritis, skin

rash (erythema migrans), hx of tick bites or exposure, or location in an endemic area.

4) Blisters are present on the auricular concha of the pinna.

5) recurrently swollen lips or face and fissured/geographic tongue.

6) Other neurological deficits noted and forehead movement is spared

7) idiopathic unilateral peripheral facial nerve paralysis of sudden onset affecting all branches, with no history or physical evidence of apparent cause

(Madhok & Swan, 2014)

Can this child have a tumor? Does she have progressive fascial paralysis, palpable mass, tinnitus, or

hearing loss? NoCan she have facial nerve injury? Pt denies any trauma to head or faceCan she have Lyme Disease? Denies rash, fever, does not remember being bitten by a tick; However

reports headache off/on over the summer and does live in a county where Lyme disease is prevalent

Can she have Ramsey hunt syndrome? No evidence on physical exam of lesions, blisters, on face, mouth, earsCan she have Rosenthal-Melkersson syndrome? No evidenced of facial swelling, lip, no abnormality with the pt. tongueCould this patient be having a stroke? Any other neurological deficits found elsewhere in the body? NO

So what does our patient have?

What is the right Diagnosis?

After ruling out the other differential diagnosis by HPI and physical assessment,

What does this little girl have?Bell’s Palsy

And what is the most common cause for this in children?

Facial nerve weakness or paralysis

Idiopathic

Usually unilateral

Can be caused by a virus, exposure to cold, facial trauma( usually herpetic in nature)

Manifestation of Lyme disease (Hollier & Hensley, 2011).

Bell’s Palsy

Bell’s Palsy

Assessment Findings Diagnostics

Numbness to affected side

Sagging of eyebrow Mouth drawn to affected

side Partial or total paralysis Excessive or inadequate

tearing One sided loss of taste,

ear pain, cheek pain Loss of nasolabial fold

Lyme titer

CT to r/o stroke

EMG testing

Hollier & Hensley, 2011

early treatment with oral glucocorticoids , prednisone 2mg/kg/day up to 60-80mg daily for 5 days followed by a five-day taper. Should start treatment within 3 days of first symptoms

Artificial tears should be placed in the affected eye during the day with lubricating ointment and patching at night to protect cornea

Antivirals can be utilized in severe cases with a clear etiology: valacyclovir 20 mg/kg three times per day (up to 1000 mg three times daily) for one week

facial nerve palsy due to a specific cause should be treated for that underlying cause

(Clark, 2014)

Treatment in Children

SINCE “Lyme disease has become the most common cause of acute facial nerve palsy among children in areas endemic for this infection” This became our source of action.

(Clark, 2014, para lyme)

Dr. O’Connor said “Bell’s Palsy is Lyme Disease until proven differently”

Facial ParalysisPt was treated with oral prednisone at 2mg/22.7kg/day= 45.4mg/dayPt prescribed 20 mg tablet; 2 tabs daily for 5 days then taper

schedule for 5 daysMother instructed on use of over the counter tears for her affected

eyeLyme Disease

LABS= CBC, and Doxycycline can only be given to a child greater that 8 years of age:

alternative for <8 years would be amoxicillinDosage: 100mg po 2 x daily for 14-21 daysFollow- up appointment in 3 days; referred to neurologist

This week I followed up on this child: Lyme titer results were extremely positive.

What did we do for

Questions

Clark, G.D. (2014). Facial nerve palsy in children. Retrieved from https://online.epocrates.com/noFrame/?ICID=eolepocratesheaderbutton

Hollier, A. & Hensley, R. (2011). Clinical guidelines in primary care: A reference and review book. Lafayette, LA: Advanced Practice Education Associates.

Madhok, V. & Swan, I. (2014). Bell palsy. Retrieved from https://online.epocrates.com/noFrame/?ICID=eolepocratesheaderbutton

REFERENCES