A 4O year female presented with CHIEF COMPLAINTS of Deviation of mouth to the left side since 3years- c/o watering from the right eye since 3months- c/o Headache since 3 months

CHIEF COMPLAINTS:-

- c/o Deviation of mouth to the left side since 3           years

- c/o watering from the right eye since 3months

- c/o Headache since 3 months

Patient was apparently asymptomatic 3 years back, then developed ear discharge, insidious in onset, gradually progressive, scanty discharge, for which she didn't visited any hospital. Later on she developed deviation of the mouth to the left side, sudden in onset, non-progressive, aggrevated with talking or during eating, no relieving factors. For which she went to khammam private hospital and o/e it was grade 4 right LMN facial palsy and CT temporal bone done showing Left otomastoiditis, 
B/l reduced mastoid pneumatisation, Focal lesions in tympanic segment of left facial canal and adviced to higher centers stating chances of paralysis 
And had her ear examination done I/v/o discharge from the ear and diagnosed as left CSOM for which left  mastoidectomy and tympanoplasty done on 08/09/23. 
 -C/o inability to close right eye since 3 years 
 -H/o watering from the same eye since 3months      -no difficulty in eating / swallowing.
  -Inability to Blow/whistle, drooping of the corner of the mouth, Absence of wrinkles over the forehead.
 -c/o headache since 3 months on & off, associated with watering.

-No photophobia /phonophobia.
 -No c/o chestpain/palpitation / sob / orthopnea/PND.
PAST HISTORY :
- Not K/c/o HTN, DM2, epilepsy, thyroid disorders.

PERSONAL HISTORY :- 
Diet
Appetite
Bowel and bladder
Addictions

GENERAL EXAMINATION:
On presentation to us:
-Patient was examined in well lit room.
-Moderately built woman, well nourished, Conscious, cooperative, well oriented to time,place person.
-Pallor, icterus, clubbing, lymphadenopathy, odema    are absent.

Her vitals were stable

-Afebrile to touch,

-Blood pressure: 120/80 mmhg 

-Pulse rate: 88/min right radial artery, regular              rhythm and volume were normal.

- Respiratory rate - 16/min thoraco abdominal type.

-Sp02:98% @ RA

Systemic examination:

CVS: S1 S2 +, No murmurs

RS: BAE +

P/A: Soft, non-tender

CNS:

GCS: E4V5M6, 15/15.

MENTAL STATUS: AAOx3(awake,alert and oriented), memory intact, fund of knowledge appropriate

LANG/SPEECH: Naming and repetition intact, fluent,

follows 3-step commands

CRANIAL NERVES:
I: Sense of smell                        (Rt).        (Lt)
      Coffee                                    +             +

II: Pupils equal and reactive.
                                           
     Visual acuity -                      6/6            6/6
     Colour vision                      Normal.  Normal
       Fundus examination       normal.   Normal

III, IV, VI: EOM(extraocular movements) intact, no gaze deviation, no nystagmus.

V: i) Sensory-over face and buccalmucosa
                                                        Rt.       Lt
                                                  Normal.  Normal 
ii) Motor masseter, temporalis, pterygoids 
                                                  Normal. Normal
iii) Reflex
a. Corneal Reflex.                       N.            N
b. Conjunctival Reflex.               N.            N
c. Jaw jerk.                                  N.            N

VII: 

i) Motor –

nasolabial fold.                       Present. Present(more                                                                       Prominent)   occipitofrontalis.                       -               +

orbicularis oculi.                         -                +

orbicularis oris.                           -                +

buccinator.                                 +.                +

platysma.                                    +.               +

ii) Sensory – 

Taste of anterior 2/3rds of tongue(salt/sweet)

                                                    +.               +

Sensation over tragus.             +.              +

iii) Reflex – 

Corneal.                                 Present.      Present 

Conjunctival.                         Present.      Present 

iv) Secretomotor –

Moistness of the eyes/tongue and buccal mucosa. 

                                                Present.      Present 

VIII: 
   Rinnes                                   +.                     +
   Webers.                         Centralised   centralised 
   Nystagmus.                    Absent.           Absent 
IX, X: 

 -Uvula, Palatal arches, and movements- Centrally        placed and symmetrical.

 - Gag reflex.   Present 

- Palatal reflex. Present

XI:

i) trapezius                            N.                      N

ii) sternocleidomastoid.       N.                     N

XII

i) Tone.      Normal               

ii) Wasting.       No                      

iii) Fibrillation.      No                    

iv) Tongue Protrusion to the midline and either side

         Normal 








I  -  SPINOTHALAMIC.              Rt.               Lt

1. Crude touch.                          N.                N

2. Pain.                                        N.                  N

3. Temperature.                          N.                  N

II – POSTERIOR COLUMN

1. Fine touch.                             N.                   N

2. Vibration.                               N.                    N

3. Position sense.                     N.                     N

4. Romberg’s sign.                    N                      N

III – CORTICAL

1. Two point discrimination.    N.                     N

2. Tactile localisation.               N.                     N

3. Graphaesthesia.                     N.                     N

4. Stereognosis.                          N.                     N


TONE.                                         RT.                     LT

-UL.                                          normal.            Normal 

-LL.                                           Normal.            Normal 


POWER.

-UL.                                           5/5.                    5/5

-LL.                                            5/5.                    5/5

BICEPS.                                       +2.                    +2

TRICEPS.                                     +2.                    +2

SUPINATOR.                               +1.                     +1

KNEE.                                          +2.                     +2

ANKLE.                                       +1.                      +1

PLANTAR.                             Flexor.                   Flexor



 PROVISIONAL DIAGNOSIS:-

RIGHT LMN FACIAL NERVE PALSY SECONDARY TO ? CSOM WITH ? BELLS PALSY.


INVESTIGATIONS:-

RBC: 4.08

Hb-11.8

PLT-2.48 lakh

TC - 7,300

NCNC

CUE:

Albumin- +

Sugars- nil

Pus cells - 3-4

Epithelial cells-2 to 3

Blood urea- 24 mg/dl

Serum creatinine -0.7 mg/dl

Na+.    140

K.    4.1

Cl.    105

RBS.   108mg/dl

TREATMENT:-

1) physiotherapy

2) E/D lubrex 3./3./3./3.

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