What are the next appropriate steps in management

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Reference no: EM133998620

Assignment

Chief Complaint

"Facial numbness."

History of Present Illness

A 38-year-old previously well man presents complaining of new onset left-sided facial droop and numbness upon waking this morning. The patient reports drooling, particularly while drinking or eating, and states his morning coffee tasted "weird." He denies any sick contacts, recent illnesses, history of the same, pain, head trauma, fever, headache, extremity weakness, confusion, anxiousness, abnormal speech, and vision changes, although he notes that his left eye is dry because it is difficult to shut it. The patient admits to a history of hypertension, hyperlipidemia, and tobacco use but states compliance with his medications as well as recent attempts at tobacco cessation (reducing from 0.5 pack per day to approximately 5 cigarettes per day). He reports use of over-the-counter lubricating drops for his left eye to alleviate the dryness. He denies any other therapy. He attempted to make an appointment with his regular PCP but is unable to be seen there until next month, so he presents now to the urgent care clinic affiliated with the PCP's practice.

Review of Systems

The patient's ROS is positive for unilateral facial muscle weakness, facial numbness, an inability to close the left eyelid, dry eye, drooling, and taste changes. ROS is negative for fever, pain, trauma, headache, vision changes, confusion, anxiousness, extremity weakness/numbness/tingling, seizures, and dysphasia.

Relevant History

The patient's medical history is significant for hypertension (diagnosed 15 years ago and well controlled), hyperlipidemia (compliant on statins for 10 years), and obesity. His social history is pertinent for tobacco use (20-pack-year history). The family history is noncontributory.

Allergies

Penicillin (reaction: hives); no known food allergies.

Medications

Hydrochlorothiazide 12.5 mg, 1 tablet PO QD.
Simvastatin, 20 mg, 1 tablet PO QHS.

Physical Examination

Vitals: T 36.9°C (98.4°F), P 77, R 16, BP 116/76 mmHg, HT 178 cm (70 in.), WT 109.8 kg (242 lbs), BMI 34.7.
General: A&O×4. Nontoxic appearing. Ambulates with steady gait. Speaks in full sentences.
Psychiatric: Cooperative.
Head: Normocephalic/atraumatic. +Facial asymmetry. No left forehead creases with raising of eyebrows.
Eyes: Left ptosis. Left mild scleral injection. PERRL bilaterally. EOM intact bilaterally. Conjunctivae pink bilaterally. Non-tender to palpation bilaterally.
Mouth: Left droop, drooling. Moist mucous membranes.
Neck: FROM.
Chest: RRR. No murmurs, rubs, or gallops.
Lungs: Clear to auscultation bilaterally. Unlabored respiration.
Musculoskeletal: 5/5 equal strengths in all extremities. Sensation grossly intact.
Neurologic: Left-sided facial droop. Cranial nerves III/V/VII decreased. Decreased sharp/dull sensation to left side of face. No (dysphasia) slurred speech. No pronator drift. Cranial nerves II, IV, VI, IX to XII intact.

Clinical Discussion Questions

I. What are the differential diagnoses?
II. What is the most likely diagnosis? Why? Get the instant assignment help.
III. Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well.
IV. What are the next appropriate steps in management?

Reference no: EM133998620

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