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Monday, June 8, 2020

MDM - Bell's Palsy

[##]-year-old [male/female] presents with complaint of [right-sided/left-sided] facial asymmetry with history and exam consistent with Bell's palsy.

Initial considerations in this patient included Bell's palsy, cerebrovascular accident CVA), transient ischemic attack (TIA), trigeminal neuralgia, intracranial mass or hemorrhage, tick paralysis and the Lyme disease, and other infectious and toxicologic etiologies among others.

Patient presented with [## hours/days] of facial asymmetry without other associated neurologic deficits.  Patient noted to have complete [right-sided/left-sided] facial droop and weakness in the distribution of the facial nerve (cranial nerve VII), specifically including inability to raise the eyebrow or wrinkle her forehead on the affected side.  Patient reported associated [alteration in taste/hyperacusis/subjective facial numbness with no objective findings on exam/retroauricular pain].  Patient noted to have otherwise unremarkable neurologic exam.  Patient [reported/denied] prior similar episodes in the past.  Patient denied any preceding trauma.  Doubt significant intracranial process at this time with no indication for acute imaging.

Given onset of symptoms [within the past 72 hours/greater than 72 from time of presentation] we discussed plan for discharge [with/without] Prednisone.  We also discussed plan for discharge with [Valacyclovir/Acyclovir] despite limited evidence of benefit with no significant associated harm.  We also discussed covering the eye overnight and provided patient with lubricating eye-drops on discharge.  We discussed return precautions and recommended follow up with primary care provider in [time frame], and the patient demonstrated understanding and agreement.

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