75 year old female with C/o unable to close left eye and deviation of mouth towards right side since 15 days

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I have been given this case to solve in an attempt to understand the topic of “ patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

Presenting complaints:

C/o unable to close left eye lid since 15 days

C/o deviation of mouth toward right side since 15 days

C/o tingling sensation of face since 15 days 

C/o foreign sensation in left eye since 15 days

Hopi:

Patient was apparently asymptomatic 15 days back . Then patient suddenly developed tingling sensation of face, sudden in onset, progressive, no aggravating and relieving factors since 15 days. Then patient complained deviation of mouth toward right side, sudden in onset. Patient was unable to close left eye lid, when she began to complain about foreign body sensation in the left eye to her daughter since 15 days. Patient’s daughter noticed that patient is sleeping without closing left eye lid 3-5 days back. Patient is unable to chew on the right side of the mouth.

H/o cataract surgery done in Kims hospital Narketpalli on 11/2/23

N/k/C/o DM, htn, tb, asthma, cad, epilepsy 

Personal history: 

Alcoholic since childhood. Drinks 90 ml whiskey daily. Smokes chute 3/day since childhood

General examination

No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

Vitals

Temperature: 98.6 F

Pr:63

Rr: 14

Bp: 140/90

Spo2: 99%

Systemic examination 

CVS: s1 s2 + , no murmurs

Rs: BAE+ , NVBS

P/a: soft, non tender  

Cns: NFND , HMF +

Reflexes     Right     Left

Biceps        2+           2+

Triceps       2+           2+ 

Supinator   2+           2+ 

Knee          2+           2+

Ankle         2+           2+ 

Pupils: right - reactive, normal size

            Left- non reactive

Investigations 

Diagnosis

Lmn facial nerve palsy (Bell’s palsy)

With ? Marcus Gunn jaw winking syndrome

With s/P cataract surgery (done 35 days back)

Treatment 

1. Wysolone 10mg / po/ bd

2. Lubrex eye drops (2 drops) tid