VA Ambulatory Report 2.7.18 – Double case – Facial numbness and Arm Swelling

Morning report today was like a regular primary care clinic day – one daily ditty and two patients all in one hour no problem!  Thanks Lily for presenting two awesome cases.

Case 1: A young woman on OCPs with right sided facial numbness and facial droop sparing the forehead found to have MS.

Unilateral Facial Paralysis:

  • The key to evaluation is determining if the lesion is central vs. peripheral
    • The forehead is spared in a central process due to bilateral innervation
    • There are possible peripheral causes that spare the forehead BUT forehead sparing should raise your suspicion for a central process
    • Pearl from Jody is that forehead weakness can be subtle as patients try to overcome it with muscles of the scalp. In addition to having the patient raise their eyebrows, have them maintain raised eyebrows against your force.
    • Central
      • Stroke
      • Malignancy
      • Demyelinating diseases
      • Migraines
    • Peripheral – Facial nerve palsy
      • Infections: Herpes zoster, otitis media, lyme, HIV
      • Immune-mediated: GBS
      • Autoimmune: sarcoid, Sjogrens
      • Idiopathic (Bell’s palsy)


Case 2: A 45 yo G1P0 female with recent spontaneous abortion and RUE DVT with chronic right arm pain and skin changes found to have complex regional pain syndrome.

  • We reviewed indications for thrombophilia work-up.
    • We should not test every individual with an unprovoked VTE because for most people it will not change management.
    • Who does it change management in?
      • Women planning conception
      • Possible need to treatment with pro-thrombotic agents such as estrogen
    • In general we should consider testing in the following populations:
      • Young patients (<50) with weak provoking factors or strong family history
      • Arterial clots
      • Unusual locations: Splanchnic veins, cerebral veins
    • Check out this awesome NEJM review article.
  • And remember the Budapest criteria when considering the diagnosis of complex regional pain syndrome
    • Continuing pain, which is disproportionate to any inciting event

    • Must must report at least one symptom in three of the following four categories:

    • 1 – Sensory: hyperaesthesia (an abnormal increase in sensitivity) and/or allodynia (pain caused by usually non-painful stimuli);

    • 2 – Vasomotor: skin colour changes or temperature and/or skin colour changes between the limbs;
    • 3 – Sudomotor/oedema: oedema (swelling) and/or sweating changes and/or sweating differences between the limbs.
    • 4 – Motor/trophic: decreased range of motion and/or motor dysfunction (weakness, tremor, muscular spasm (dystonia)) and/or trophic changes (changes to the hair and/or nail and/or skin on the limb).
    • There is no other diagnosis that better explains the signs and symptoms


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