Another interesting newbie case

[chiaroscuro27]

58 yo male presented yesterday to my ED. My attending was on the floor, so I pulled the chart and read the triage note: "facial twitching for three days." The nurse told me it was likely bell's palsy. I went in to see and interview the patient. Very pleasant man with no obvious deformities or twitching at first glance, but the more he spoke the more it became apparent.

 

His story: 3 day history of left-sided facial twitching. It began with his eye, then moved down to the corner of his mouth. Much better since yesterday, but he notices he has trouble chewing on the left side and when he drinks water he drools out of the left side of the mouth. He has no difficulty swallowing, though. Denies any other areas that twitch. Denies weakness in the arms and legs. No recent illnesses, no recent travel out of the state or country. No unfamiliar water or food sources. No coughs, sniffles, sore throat, abdominal pain, etc. Nothing. Has been feeling fine up until three days ago.

 

I do a neuro exam: facial sensation is intact, EOMI, PEERLA, TM's are clear but I see what appear to be bubbles behind the TM's bilaterally. No pain when I move the tragus or pinna. Mucous membranes moist. Something is wrong with CN VII: his smile is crooked, he can't puff out the cheeks, the left eyebrow droops when he attempts to raise them, and I can open his left eye easily but not the right eye. Peripheral motor strength is equal. Pronator and romberg are normal. Gait is normal. Speech is excellent. Patient is alert and oriented x 3.

 

I ask specifically about this happening before and he finally admits to it happening one month prior. The twitching lasted less than five minutes and never came back until 3 days ago. I ask specifically about headaches. His reply: "Now that you mention it I have had this vague, nagging HA on the right side of my head behind my eye." That was enough to scare the crap out of me.

 

I ordered a CT of the head, and presented the case to my attending while waiting for the report.

 

The report came via a phone call from the radiologist: 4.4 x 3.5 cm mass in the right frontal lobe. Consider primary lymphoma, or metastatic neoplastic process. Follow up with MRI w/wo contrast.

 

That was the hardest news I've had to give a patient to date. I transferred him to a tertiary center.

 

Pearls for new grads:

 

1. It bears repeating: respect the nurses, but don't hang your hat on a word they say. Sure bell's palsy was on my Ddx, but I'm learning more and more how much tunnel vision can get you into big, big trouble. You have license to diagnose, they don't. Try to assess each patient as if you know absolutely nothing about them.

 

2. When in doubt, always return to the HPI and the ROS. Nine times out of ten it will give you answers to questions you may not have thought to ask otherwise.

 

3. Trust your gut. Thoughts cross your mind for a reason. If you think about doing something, go ahead and do it.

 

4. Know your limitations. I work at a small, rural hospital with hardly any back-up. We transfer patients to tertiary centers all the time. There are some attendings who would have sat on this guy and wasted a lot of time. Advocate for the patient and get them to the folks who can help them.

[jmj11]

If the tumor was on the counter-lateral side then you have to assume it is motor cortex involvement (rather than indirect compression of the facial nerve) so I would assume that his forehead on the left was near normal?

[EMEDPA]

also remember that bells palsy shouldn't cause motor tics....numbness/weakness, sure.

[fuma102]

strong work.

 

anyone with mild ptosis or unilateral vision loss gets a CT and neuro consult from me. thankfully Im in a huge academic center and have such resources. Also, if neuro declines admission, I chart that neuro feels they are not in need of admission and feels a carotid sono is unnecessary - for whatever reason Ive seen two big lawsuits because a carotid sono wasnt done FROM THE ED.