October 5, 2005
T.R. is a 32-year-old Caucasian male who comes to walk-in clinic with the chief complaint of "heaviness" on the left side of his face, which began after dinner the night before. He states that when he looked at his face in the mirror this morning, there was "something weird going on" with his left cheek and mouth, but he "couldn't quite figure out what it was."
Along with the sensation of left facial heaviness, he has noted some drooling and an "unusual taste," one which "actually isn't all that bad."
He has otherwise been in excellent health, though he had a "little cold a few days ago."
He currently denies headache, dizziness, arm or leg weakness, fevers, cough, abdominal pain, or any other symptoms.
Past medical history is unremarkable.
He has never smoked, and drinks beer occasionally. He works as a freelance computer consultant, and is married with no children.
Family history is noncontributory.
On exam, he is awake and alert.
|Vitals:||BP 110/78, HR 70, R 18, T 97.2F|
|There is an obvious facial asymmetry, with sagging of the lower left side of the face. No ptsosis is evident.|
|Normal. No edema.|
|Cranial nerves II-XI appear intact except for the sagging of the left face as noted above. Otherwise, motor, sensory, and reflexes are normal throughout.|
Stat labs show that CBC, electrolytes, and urinalysis are normal.
You're perplexed. Feigning competence, you tell the patient you'll be "right back," and have him wait in the exam room while you duck into your office. "I know it's gotta be something ... but why can't I figure it out?" you exclaim into the crook of your right elbow. "Why, Why, WHY?"
You're about to peruse Expedia.com for a one-way ticket to Puerto Rico when a bolt of norepinephrine arrives at your left frontal cingulate gyrus. "Eureka!" you holler, jumping up from your seat. "The answer was there the whole time!"
Scurrying back into the exam room, you take another look at the patient's face:
What's going on?
This patient, a 32-year-old Caucasian male with a complaint of left facial heaviness, has Bell's Parsley.
This diagnosis is often difficult to make based on symptoms alone, and physical exam can be frustratingly nonspecific. It is therefore essential to look for subtle but nonetheless important signs, such as a large batch of parsley sprigs hanging from the side of a patient's mouth.
The pathophysiology of Bell's Parsley is unknown, but researchers speculate that the batch of parsley has something to do with it.
In retrospect, there were several clues in the history that could aided in your anaylsis. For example, a recent cold, such as the one this patient reported, is felt by many scientists to be "parsley responsible" for the ensuing illness; also, any facial droop that begins after dinner, especially one associated with a surprisingly pleasant flavor, should "ring" any reasonably responsible clinician's "Bell."
It should be noted that, in Asian patients, care must be taken to distinguish between "Bell's Parsley" and the very similar appearing, but totally different tasting, "Bell's Cilantro."
Treatment of Bell's Parsley involves an immediate referral to otolaryngology for video-endoscopic removal of the offending herb, which must then be rinsed in cold water prior to its use in in stir-fries, soups, or garnishes.
Our patient did well post-operatively, and, several days after discharge, brings you an Artichoke and Parsley Frittata that his wife prepared using the surgical specimen. Licking your lips, you gratefully accept this small token of appreciation for ...
... another job well done.
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