Professional Documents
Culture Documents
2/6/19
Ted Tanner, MD MPH MA
At Urgent Care
• Mom reports, “He can’t close his left eye and the left side of his face is
droopy. That polio-like virus is at his school.”
• T. 36.9, HR 75, BP 107/52, RR 26, SpO2 97
• Ht. 129.5cm Wt. 28.4 kg, BMI 16.93
HPI
• 9-year-old male with 1 day of inability to close left eye and facial
asymmetry with smiling.
• Patient also reports slight blurry vision when watching TV or playing
video games.
• Mom reports he had a mild URI-type illness for a few days about 1.5
weeks ago.
• He denies headache, photophobia, phonophobia, upper or lower
extremity numbness or weakness, and gait instability.
• ROS: As reviewed in the HPI.
• PMHx: Eczema, constipation, non-celiac gluten sensitivity, born
term, no surgeries or hospitalizations
• Meds: None
• Allergies: NKDA
• Family HX: non-contributory
• Social: 4th grade, lives with mom and younger brother. Sees dad a
few times a month. No tobacco exposure.
• Immunizations: UTD, no flu shot this year
• Constitutional: alert, interactive, non-toxic
• HEAD: normocephalic, atraumatic. No visible forehead wrinkles with attempted
elevation of left eyebrow
• NECK: supple without meningismus, no LAD, FROM
• EYES: left eye ptosis, EOMI, conjunctivae clear, PEERLA
• EARS: TMs clear. No redness or swelling.
• NOSE: No rhinorrhea
• MOUTH: moist mucus membranes, no lesions. When smiling, the patient is unable
to raise the left side of his mouth, disappearance on nasolabial fold
• RESP: CTAB
• CV: RRR, no murmurs, Normal cap refill, good pulses
• GI: Abdomen soft, NT, ND, no organomegaly
• MSK: No joint swelling or pain. FROM in upper and lower.
• SKIN: no rashes or lesions
• NEURO: Normal mental status. Normal strength, and tone in the extremities. Facial
weakness noted on the left side. Unable to close left eye fully or raise the left
eyebrow.
Thoughts?
Eye Care
artificial tears during day and
ophthalmic ointment + patching at night
Congenital facial palsies = poor
Prognosis
Idiopathic or infectious = great
Prognosis most favorable if some recovery is
Clinical incomplete lesions tend to recover
seen within the first 21 days from onset