Case 14: A Woman With Bilateral Bell's Palsy

Michael S. Rafii, MD, PhD Preceptor: Carlos A. Pardo, MD


October 31, 2006

Presenting Complaint

A 44-year-old, right-handed black woman presents with right-sided facial droop after noting left-sided facial droop 1 month earlier. The left facial droop is still resolving.


The patient has been aware of a right facial droop for the past 3 days and reports having had a mild left-sided facial droop last month, which was diagnosed as idiopathic Bell's palsy. She denies headache, focal weakness, paresthesias, or vertigo, but complains of right foot and right knee pain, both worsened by weight bearing for the past 2 months. Her joints feel stiff in the morning, and she noted a fever of 100 degrees F when she took her temperature at home. She has taken ibuprofen, which led to some improvement.

She reports increased fatigue, but denies weight loss or night sweats. She passed a kidney stone 2 months ago. Most recently, she has noticed feeling nauseated, and everything she eats tastes like butter. She also states that things "sound louder" in the right ear.

Past Medical History: No medical or significant childhood illnesses

Medications: Ibuprofen 600 mg as needed

Allergies: Erythromycin

Family History: Breast cancer, hypertension, diabetes mellitus

Social History: Receptionist at law firm; no pets; no recent travel; no use of tobacco, alcohol, or illicit substances

Physical Examination

Weight: 128 pounds; pulse: 76 beats/min; blood pressure: 126/70 mm Hg; respiratory rate:18/min
HEENT: No icterus, no ptosis, normal tympanic membrane, oropharynx clear, mucous membranes moist
Lungs: clear
Cardiac: regular rhythm
Abdomen: soft, bowel sounds present
No rash, edema
Mild joint tenderness upon palpation

Basic Lab Values

Complete blood count (CBC): hemoglobin 11.6, hematocrit 35.1, white blood cell count 4.9K
Chemistries: sodium 137, chloride 101; blood urea nitrogen 12, K 4.1, CO2 21, creatinine 0.7, calcium 10.6
Liver function normal
Albumin: 4.1
Urinalysis: 1.020/dip - negative
beta-Human chorionic gonadotropin - negative
Thyroid-stimulating hormone - 0.841
Lyme antibody - negative
Erythrocyte sedimentation rate (ESR) - 6; rheumatoid factor 5.6 (normal level < 14); antinuclear antibody - negative


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