What management is recommended for a patient with resolved facial weakness and normal orthostatic blood pressure readings?

Management of Resolved Facial Weakness with Normal Orthostatic Blood Pressure

For a patient with resolved facial weakness and normal orthostatic blood pressure readings, clinical observation with follow-up in three months is the appropriate management strategy, as implemented in this case.

Assessment of Resolved Facial Weakness

When evaluating a patient with resolved facial weakness, it's important to distinguish between Bell's palsy and other potential causes:

Bell's Palsy Considerations

• Bell's palsy is defined as an acute unilateral facial nerve paresis or paralysis of unknown cause that develops rapidly (within 72 hours) 1
• More than two-thirds of patients with typical Bell's palsy have complete spontaneous recovery 1, 2
• In patients with resolved symptoms, no additional intervention is typically required beyond monitoring

Stroke Evaluation

• Facial weakness can be a symptom of stroke, but the absence of other neurological findings and complete resolution of symptoms makes this less likely
• The normal neurological assessment in this case is reassuring
• The National Institutes of Health Stroke Scale (NIHSS) includes facial movement assessment, with scores ranging from 0 (normal) to 3 (complete unilateral palsy) 3

Monitoring Recommendations

Follow-up Schedule

• The three-month follow-up interval chosen for this patient is appropriate
• This timeframe allows for:
  • Detection of any symptom recurrence
  • Assessment of complete recovery
  • Identification of any residual deficits

What to Monitor During Follow-up

• Facial symmetry and movement
• Any new neurological symptoms
• Blood pressure readings
• Development of ocular symptoms (if facial weakness recurs)

When Additional Evaluation Is Warranted

Additional evaluation should be considered if:

1. New or worsening neurological findings develop
2. Facial weakness recurs or persists beyond 3 months
3. Other cranial nerve deficits emerge
4. Ocular symptoms develop

Potential Additional Testing (if symptoms recur)

• Electrodiagnostic testing may be considered if complete facial paralysis occurs 3
• MRI imaging should be considered in patients with:
  • Recurrent episodes
  • Other cranial neuropathies
  • Neurologic changes
  • No improvement after 4-6 weeks 3, 1

Specialist Referrals

If symptoms recur or new findings emerge, consider referrals to:

• Neurologist for new or worsening neurologic findings 1
• Ophthalmologist for any ocular symptoms 1
• Facial nerve specialist for incomplete recovery after 3 months 1

Conclusion on Current Management

The current management approach for this 77-year-old male with resolved facial weakness and normal orthostatic blood pressure is appropriate. With normal neurological findings and resolution of symptoms, observation with scheduled follow-up in three months represents the standard of care based on current guidelines.