The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
A 76-year-old man presents to a clinic after a recent hospitalization for acute onset of hemicranial headache and diplopia. At the time of his hospitalization, the patient had been experiencing a left temporal headache as well as worsening double vision over several days. He states that since his hospitalization, his headaches have improved and his diplopic symptoms have slowly begun to resolve. The patient reports that the onset of these symptoms was unprovoked and occurred while he was walking in his neighborhood. He states that although he has had headaches and vision problems in the past, he has never had these specific symptoms before.
The patient has presented to the clinic twice within the past 6 years. In his initial visit, he reported the sudden onset of visual disturbances of the right eye, which were accompanied by right retro-orbital pain as well as a right hemicranial headache while he was reading a book. At the time, the patient stated that his ocular symptoms spontaneously resolved. He also reported a past medical history of type 2 diabetes, hypertension, hypercholesterolemia, iron deficiency anemia, chronic kidney disease, and prostate cancer.
Because of the transient loss of vision affecting his right eye, as well as his uncontrolled hypertension and poorly controlled diabetes, the patient was diagnosed with amaurosis fugax of the right eye and was advised to undergo transthoracic echocardiography (TTE) and a carotid Doppler study. The TTE revealed an ejection fraction of greater than 70% and left ventricular hypertrophy, with no other remarkable findings. The carotid Doppler study showed mild stenosis of the carotid arteries bilaterally, but the findings were otherwise unremarkable. The patient was advised to keep his blood pressure, cholesterol levels, and serum glucose levels under control to avoid episodes of transient blindness from reoccurring.
During this visit, the patient also reported spasms of the right facial muscles that occurred with constant frequency. He stated that the facial muscles on the left side were unaffected. The patient was referred to an otolaryngologist to receive onabotulinumtoxinA injections for relief of his hemifacial spasms.
Since his last visit 5 years ago, the patient has not returned to the clinic despite recommendations for yearly follow-up. He has not had a recent complete blood cell count or comprehensive metabolic panel.
The patient's current medications include a bone health supplement 500 mg once daily, doxazosin 4 mg once daily, atorvastatin 20 mg once daily, lisinopril 10 mg once daily, hydrochlorothiazide 25 mg twice daily, metformin 500 mg twice daily, and glimepiride 1 mg tablet once daily. He also uses one 26-gauge lancet daily and a blood glucose monitor three times daily. His surgical history includes cataract extraction and tonsillectomy; he also had radiation therapy and depot leuprolide acetate therapy for prostate cancer. He has a family history of cancer, kidney stones, and heart disease. The patient has been a heavy smoker and currently smokes between half a pack and one pack of cigarettes a day.
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Cite this: Muthunivas Muthuraj, Shailesh Rajguru. Facial Spasms in a Man Recently Released From the Hospital - Medscape - May 05, 2022.