Case Study: Chief Complaint

Chief Complaint
Left-sided facial tingling.

History
Patient is a 56-year-old right-handed white female who presented to her PCP in May complaining of several weeks of tingling sensation on the left side of her face, mainly in the V1 and V2 distributions along with some facial twitching. She thought she may have had a tick bite prior to that and her Lyme titers were checked. They were negative, but her ESR was 47, CRP was 7.2. She did have an MRI, which revealed only one small subcortical T2 and flair white matter lesion in the left frontal region. There was no evidence for inflammation of the VII nerve. Currently, she states that there is always a slightly different sensation on the side of her face, but not as much tingling as before.

This is a very small area and mild twitching. There is no actual facial spasm. There has not been any facial asymmetry or movement problems. No flattening of the nasolabial fold. No problems closing her left eye. No actual pain. No sensation in the mouth. No dysarthria or dysphagia. No other motor, sensory, or cerebellar symptoms. No cognitive symptoms. She was under considerable stress at the time that this started, visiting a friend who had left facial and jaw cancer. He has died and she has been back home. Her stress level is decreasing and she is noticing that along with the decrease in stress, her symptoms are getting better. She has never had any focal cranial nerve

Diabetes.

Hepatitis C.

Hypothyroidism.

Diverticulosis.

Barrett 's esophagus.

Lumbosacral spine surgery.

Cholecystectomy.

Multiple D&Cs.

Allergies
Sulfa.

Medications
Advair, Flonase, Synthroid, vitamin E, vitamin D, Protonix, Xanax, Lunesta.

Physical Examination
Constitutional
Weight 240 pounds. Height 5 '2". Respirations 12. Pulse 69.

General
She is in no obvious distress.

Mental Status
She is oriented x3, alert, cooperative. Good short-term, long-term, and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration.

Cranial Nerves
Fundi were benign. Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation, and movement, although touching the left side of her face did cause the after image of the sensation. Normal auditory acuity and shoulder shrug. Tongue and uvula were midline.

Motor
Was 5/5. No fix or drift all four extremities.

Cerebellar
Revealed finger-to-nose, heel-to-shin, and rapid alternating motion.

Sensory
Was intact to primary modalities.

Gait
Normal. Negative Romberg.

DTRs
2+ throughout. Toes are downgoing.