Differential Diagnosis for 50-year-old Male with Left Sided Facial Drop and Neck Pain
Single Most Likely Diagnosis
- Bell's Palsy: This condition is characterized by a sudden onset of unilateral facial weakness or paralysis, which matches the patient's symptoms of left-sided facial droop. The fact that the symptoms began with a weird sensation of the face deviating to one side and progressed to noticeable facial droop and speech changes is consistent with Bell's Palsy. The absence of other neurological deficits or systemic symptoms also supports this diagnosis.
Other Likely Diagnoses
- Stroke or Transient Ischemic Attack (TIA): Although the CTA head and neck, and MRI did not show acute intracranial findings, it's essential to consider stroke or TIA, especially given the patient's age and presentation with facial weakness. However, the chronic changes in the white matter and the lack of other acute findings make this less likely.
- Lyme Disease: This condition can cause facial palsy, among other symptoms. Given the patient's presentation with facial droop and the fact that Lyme disease can have a varied presentation, it should be considered, especially if the patient has been exposed to ticks.
- Ramsay Hunt Syndrome: This is caused by the varicella-zoster virus and can lead to facial paralysis, ear pain, and vesicles in the ear. Although the patient does not report ear pain or vesicles, this diagnosis should be considered due to the overlap in symptoms.
Do Not Miss Diagnoses
- Cerebral Vasculitis: This is a rare condition that can cause stroke-like symptoms, including facial weakness. It's crucial to consider this diagnosis due to its potential severity and the need for prompt treatment.
- Multiple Sclerosis: Although less likely given the patient's age and presentation, multiple sclerosis can cause a wide range of neurological symptoms, including facial weakness. The chronic changes in the white matter on MRI could be consistent with this diagnosis.
- Tumors (e.g., Acoustic Neuroma): Any mass lesion affecting the facial nerve could cause facial weakness. Although the MRI did not show acute intracranial findings, chronic or slow-growing tumors might not always be immediately apparent.
Rare Diagnoses
- Sarcoidosis: This condition can cause facial weakness among a myriad of other symptoms due to its systemic nature. It's less likely but should be considered if other diagnoses are ruled out.
- Guillain-Barré Syndrome: Although this condition typically presents with ascending paralysis, it can occasionally cause facial weakness. The lack of other neurological deficits makes this diagnosis less likely.
- Mitochondrial Myopathies: These are a group of disorders that affect the mitochondria and can cause a variety of symptoms, including muscle weakness. Facial weakness could be a part of the presentation, but this would be an uncommon diagnosis to consider first.
SOAP Note for Managing in the Emergency Department
Subjective
The patient is a 50-year-old male presenting with a 6-day history of left-sided facial droop and neck pain. He reports the symptoms started with a weird sensation of his face deviating to one side and have progressed to noticeable facial droop and changes in speech.
Objective
- Physical assessment reveals minimal left-sided facial droop.
- CBC is unremarkable.
- CMP shows glucose 167, chloride 110, creatinine 0.48, BUN/creatinine 27.1.
- Troponin 0.01.
- PROTIME 13.8, INR 1.0.
- CTA head and CTA neck are negative.
- MRI reads “no acute intracranial findings. Chronic appearing changes in the white matter of both cerebral hemispheres.”
Assessment
The patient's presentation is most consistent with Bell's Palsy, given the unilateral facial weakness without other neurological deficits. However, other diagnoses, including stroke/TIA, Lyme disease, and Ramsay Hunt Syndrome, should be considered.
Plan
- Bell's Palsy Management: Consider prescribing corticosteroids to reduce inflammation and improve outcomes.
- Further Evaluation:
- Consider Lyme disease testing if exposure history is positive.
- Evaluate for other causes of facial weakness, including Ramsay Hunt Syndrome.
- Neurology consultation for further evaluation and management, especially to consider less common diagnoses.
- Follow-Up: Arrange for follow-up with a neurologist or primary care physician to monitor the patient's condition and adjust the treatment plan as necessary.
- Patient Education: Educate the patient on the signs and symptoms of stroke and the importance of seeking immediate medical attention if these occur.