What is the best course of action for a 29-year-old with hypertension and a history of gestational diabetes presenting with facial numbness, crooked smile, altered sense of taste, and inability to close one eye or wrinkle the forehead?

Acute Bell's Palsy Management

This patient has acute Bell's palsy (idiopathic facial nerve palsy), and the best course of action is to initiate corticosteroids immediately, ideally within 72 hours of symptom onset, combined with eye protection measures to prevent corneal injury.

Clinical Presentation Analysis

The clinical picture is classic for Bell's palsy:

• Unilateral complete facial weakness affecting all branches of the facial nerve (inability to close eye, wrinkle forehead, raise eyebrow) distinguishes this from a central lesion
• Altered taste sensation indicates involvement of the chorda tympani nerve
• Acute onset (4 hours) with periauricular pain is typical
• Mouth deviation to the unaffected (left) side due to unopposed muscle action

The inability to wrinkle the forehead on the affected side confirms a peripheral facial nerve lesion rather than a central stroke, which would spare forehead function due to bilateral cortical innervation of the upper facial muscles.

Immediate Management Priority

Eye Protection (Critical First Step)

The inability to fully close the right eye creates an ophthalmologic emergency requiring immediate intervention:

• Artificial tears should be applied frequently during the day (every 1-2 hours while awake)
• Lubricating ointment at night with eye taping or moisture chamber
• Protective eyewear during the day to prevent corneal abrasion and exposure keratopathy
• Urgent ophthalmology referral if any signs of corneal injury develop

Corticosteroid Therapy (Primary Treatment)

Prednisolone 60-80 mg daily (or equivalent) for 7-10 days should be initiated immediately:

• Maximum benefit occurs when started within 72 hours of symptom onset
• Earlier initiation (within 24-48 hours) provides optimal outcomes
• No taper is typically required for this short duration
• Contraindications should be assessed (uncontrolled diabetes, active infection, immunosuppression)

Antiviral Therapy Consideration

While corticosteroids are the cornerstone of treatment, antiviral therapy (acyclovir 400 mg five times daily or valacyclovir 1000 mg three times daily for 7 days) may be considered in combination with corticosteroids, though evidence for benefit is less robust than for steroids alone.

Hypertension Management Context

The patient's hypertension requires monitoring but should not delay Bell's palsy treatment:

• Blood pressure should be checked to ensure this is not a hypertensive emergency (which would present differently with bilateral symptoms or altered mental status) 1
• Her chronic hypertension is a cardiovascular risk factor but does not contraindicate corticosteroid use for this acute indication
• Continue her baseline antihypertensive regimen unless contraindicated

History of Gestational Diabetes Relevance

The gestational diabetes history is relevant for two reasons:

• Increased cardiovascular risk: Women with both gestational diabetes and gestational hypertension have significantly elevated long-term cardiovascular risk 2, 3
• Corticosteroid effect on glucose: Short-term corticosteroid use may cause transient hyperglycemia, requiring glucose monitoring during treatment
• This does not contraindicate necessary corticosteroid therapy but warrants awareness

Red Flags to Exclude

Before confirming Bell's palsy diagnosis, ensure absence of:

• Bilateral facial weakness (suggests Guillain-Barré syndrome or other systemic process)
• Gradual onset over weeks (suggests tumor or chronic process)
• Other cranial nerve involvement (suggests brainstem pathology)
• Rash in ear canal or on face (suggests Ramsay Hunt syndrome, requiring higher-dose antivirals)
• Severe headache, confusion, or focal neurologic deficits (suggests stroke or other CNS pathology)

Follow-up and Prognosis

• Reassess in 48-72 hours to evaluate treatment response
• Most patients (70-80%) recover completely within 3-6 months
• Incomplete recovery at 3 weeks suggests need for electrodiagnostic testing
• Physical therapy referral if no improvement by 2-3 weeks
• Continue eye protection until complete eye closure returns

Common Pitfalls to Avoid

• Delaying corticosteroids while awaiting specialist consultation reduces efficacy
• Failing to provide eye protection can result in permanent corneal damage
• Mistaking this for a stroke because of facial asymmetry (stroke spares forehead function)
• Withholding corticosteroids due to diabetes history (short-term benefits outweigh risks with glucose monitoring)