Age: 3.0
Sex: F
Vaccine: FLU3
Symptoms: Blood immunoglobulin G, Blood immunoglobulin M, Borrelia burgdorferi serology negative, Conjunctival hyperaemia, Facial palsy
Clinical narrative: DATE: 10/18/08. CHIEF COMPLAINT: Unable to close left eye, unable to smile with left mouth. HISTORY OF PRESENT ILLNESS: This is a 3-year-old female who has been healthy until 2 weeks ago. She had an upper respiratory viral illness, namely coughing, sneezing, runny nose and has been rubbing her eyes, which resolved by last week. She was seen by her primary care provider 10/15/08 and received an influenza vaccination. Last night, Mom noticed that she was blinking only with her right eye. When mother asked patient to squeeze her eyes tightly, she was not able to close her left eye tightly and her left mouth did not move when she was smiling. The angle of her left mouth was dropping. Eating and drinking were as usual. Her urination and bowel movements were also as usual. She did not complain of headache, fever, nausea, or vomiting. Mom denied constipation or diarrhea. Mom also denied dribbling of fluid or liquid when she was eating or drinking. There was no history of exposure to tick bites. Of note, all the family members went out for corn picking last Sunday. They played with donkeys in the barn but Mom did not notice any tick bites or or any skin lesions. There is a family history of seizure. Patient's 11-year-old sister had a one time, generalized, tonic/clonic seizure when she was in kindergarten. It was a one-time event. She has been on seizure medication so far is being followed. The patient herself does not have any history of seizure or cardiac disease. PHYSICAL EXAMINATION:  VITAL SIGNS: Temperature 97.7, pulse rate 120, respiratory rate 32, O2 saturation 100% on room air. HEAD: Atraumatic without bruising, ecchymosis or soft tissue swelling. EYES: Slight conjunctival injection, but I did not see clear eye discharge or red eyes. The patient cannot close her left eye tightly. The left angle of the mouth is dropping. She cannot smile with the left mouth and cannot frown, no wrinkles on forehead. EARS: Clear without hemotympanum. NECK: No pain. No tenderness. No bogginess. No lymphadenopathy. CARDIOVASCULAR: No murmur. S1 and S2 are present. Rate and rhythm are regular. LUNGS: Lung sounds are clear bilaterally on auscultation. I did not hear any wheezing or crackles. SKIN: Shows no eruptions. No lesions. No erythematous changes.  NEUROLOGIC: Patient is playful, pleasant, smiling and giggling playing with her daddy. She is neurologically intact, except for the findings as described above in the history of present illness. EMERGENCY ROOM COURSE: The patient was seen, examined and discussed with senior resident and the pediatric neurologist. I explained the differential diagnosis for Bell's palsy, explained that 85% are idiopathic. Also explained that living in the tick endemic area, we need to rule out the possibility of Lyme disease. Also explained that viral illness like herpes simplex virus or Ramsay-Hunt syndrome by reactivation of a varicella due to virus can cause bell's palsy and chances for these are low. I also explained the possibility of otitis media as the probable cause, but which is unlikely as her tympanic membranes are clear. We explained the nature and course of the Bell's palsy and decided to test for Lyme disease, herpes simplex I and II and mycoplasma enzyme immunoassay. We provided a prescription for prednisone by mouth 15 mg once daily for 7-day course followed by another 2 days of tapering. We also provided information about eye care using the eye drops and eye patch during nighttime to prevent corneal abrasions. The patient was discharged from the emergency room. IMPRESSION: Left Bell's palsy, etiology unclear.