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Well welcome to another Median calm board vitals question and this one comes from the family medicine board reviewing another great question here a fifty five-year-old male presents to the ER with left-sided facial droop his symptoms started five hours ago at work and were noticed by his coworkers the patient has an elevated blood pressure at 170 over 101 he does not take any blood pressure medicines he reports excessive stress due to illness in the family he also has a headache for two weeks which mostly subsides after a good night of sleep he was sick with flu like symptoms two weeks ago what is the best test for determining the cause of his facial droop, and we've gotten some requests to not give away the answer upfront here, so we can kind of work through these, so let's do it answer choice an ask patient to frown and wrinkle his forehead be sent patient force scan of the head C obtain serology for flu infection d give to lower blood pressure or e obtain a nerve conduction test for the seventh cranial nerve so lets go through what it is that were looking at and that you mankind of tell from the answers that were going to be looking at while the seventh cranial nerve specifically because of the symptom that the patient presented with which was facial droop in the sign which shows left-sided facial droop soothe key to the answering this question is understanding the anatomy of the facial nerve so lets look at that the facial nerve is responsible for the muscles of facial expression and of course they're going to be the ones responsible for squinting and for frowning etc first thing I want you to look at is right here which is where the facial nerve nucleus comes from and toucan see there's two of them there's a right and there's a left, and it has innervation from up above in the frontal cortex which stimulates it and then from there it goes on out as a lower motor neuron to the various places and again more than two branches of the facial nerve but the ones that I want you to beware of for squinting and for frowning is the upper division here in the lower division now you'll notice that there's some interesting colors and this is to show you one point and one point specifically and that is that the upper division has dual or bilateral innervation whereas the lower has onlycontralateral innervation so let's review that again so the orange innervation coming from in this case the left side and the yellow coming from the right side and what you'll notice if we follow this through this nerve over here coming from the left frontal cortex is going to come down and its actually going to innervate both nuclei both the left and right nuclei however the innervation going contralateral so the left going over here to the right ingoing to be seen in both the upper and lower division okay however here's theta the right sided input from this upper motor neuron is going to cross and go here only to the upper okay, and then you have the flip on the other side...
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